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Telepsychiatry`s benefits are HD clear
Through a telemedicine partnership arranged between ValueOptions, Verizon, and Tandberg, the David Lawrence Center (DLC) of Naples, Fla., is now delivering telepsychiatry services to residents of Immokalee. Immokalee is an agricultural community located about 45 miles from Naples and the state's southern Gulf Coast. According to Patrick Glynn, the ValueOptions vice president who heads the payer's Tampa Service Center, ValueOptions led the telepsychiatry pilot effort to evaluate the technology's ability to expand patient access statewide. “Access to care isn't just about distance or geography, but about accessibility to a relatively small pool of psychiatrists and clinical specialists who are needed to provide care over a wide area,” says Glynn. “Telepsychiatry is a very exciting move in that direction.”
ValueOptions sought to develop the pilot telepsychiatry program with DLC-one of its many provider partners-to resolve care access concerns in Collier County, which extends inland from the Gulf Coast to remote agricultural areas at the northern end of the Everglades. DLC had a satellite office in Immokalee, a community of 20,000 primarily agricultural workers where few had access to reliable transportation (DLC's Naples office was an hour's drive away) and medical facilities were limited. Providers were also limited, and language barriers were common, since most adults speak Spanish or Haitian Creole, not English.
According to Bonnie Fredeen, COO at DLC, “We got involved because ValueOptions, our pre-paid Medicaid provider for many child and some adult services, approached us. Collier County is very large and Immokalee, where we have an office, is a community with a lot of needs for physician, clinical, and therapeutic care.”
For several years, DLC had relied on a handful of Spanish and Creole speaking staff from Naples to travel to Immokalee to provide a range of care, including medication management and therapy for both adults and children.
Setup: New workflows needed
After agreeing to the pilot, Fredeen says that “the things that had to happen to deliver the service involved new workflows. We had to consider, ‘How are we going to coordinate both ends-getting the client and the physician where they needed to be? How are we going to support e-prescribing for controlled substances? Who's going to help the patient get set?’ And, we had to put in the resources to make that happen.” In all, the workflow development took about six weeks of work.
From the outset, Fredeen could see the value of the effort, since the availability of telepsychiatry meant that many details of service at Immokalee, once handled by traveling physicians, could now be performed by case managers or support staff. “It's much more efficient to have these personnel on the road … than having a physician on the road at a much higher rate.”
Glynn adds that, early on, all involved in the pilot were concerned about whether there would be any “fear factor” among physicians or patients about using the service. Would the technology pose any obstacles or impediments to treatment compared to an in-person appointment?
“Our biggest concern was for the doctors-they're on a rigorous schedule,” says Fredeen. “So, we needed to have equipment that was going to work very well-no problems. It had to be high-definition, as though you were looking into someone's eyes-and it was.”
Practical considerations
But the evaluation didn't stop there. Fredeen and her DLC colleagues considered the technology's requirements and benefits over a range of factors and talked weekly with the ValueOptions team to assess the progress of the pilot. Among the financial and service issues considered by the partners were:
Increased access, demonstrated through increased numbers seeking and receiving services.
Improved availability and utilization of specialist skills. “The technology has really expanded the different specialists that we can make available at the remote location,” says Fredeen, noting that in the past, when you had to send someone out, it was “one size fits all.”
With the new service, she notes that “we can offer maybe 10 or 15 different specialists at that location-including adult and children's psychiatrists and nurse practitioners.” Following an initial evaluation (always done in-person, per payer requirements), Fredeen says that DLC's treatment team could consider, “Who's the best person we've got for this patient? It could be that someone was sexually abused or suffered a trauma. Now, we can think outside the box as to who gets assigned to the case.”
Reimbursement. “From a cost perspective, you've got to ask, ‘Who will pay for this service?’ Right now, we're a trial [of telepsychiatry] for Medicaid in Florida. And, we're hoping that Medicaid will continue to reimburse for this service. Other payers do,” she adds, noting that the State of Florida is among those who pay for telepsychiatry services.
Asked about the apparent hesitation of Medicaid and some states to reimburse for telepsychiatry, Fredeen states, “People making the decisions to approve this service delivery want data to prove that it works.” For her, seeing is believing: “You have to see one of these sessions going on-you can see that there's really no difference with being in the room together. You can look at the body language, which is very important.
“My opinion is that CMS/Medicaid just wants to better understand this service delivery. I believe that things are moving in the right direction.” She notes that payer reimbursements for telepsychiatry are equivalent to those for in-office services.
Network investment. On DLC's end, Fredeen says that no major network improvements were needed to support the telemedicine service. “We have a pretty sophisticated IT network that connects our sites, our electronic medical records, and our e-prescriptions.”
According to Glynn, the bandwidth required to carry the encrypted, high-definition telemedicine signal is analogous to that of ordinary broadband Internet connection (i.e., DSL or cable modem line), though the Verizon service must be accessed through a secure network login.
At present, DLC is leasing the Tandberg video units from ValueOptions, who made the initial capital investment. This telemedicine technology also requires network “bridge” equipment that interfaces with the Verizon network to optimize the audio/video signals, manage encryption, and transmit the signals. Fredeen notes that DLC intends to purchase the units from ValueOptions at the conclusion of the trial.
Staffing. Fredeen says that except for the equipment, telemedicine visits are staffed similar to other office visits in Immokalee. “It's like a traditional medical office visit, with someone there to assist the patient, taking vitals, recording them for the doctor.” For medication management tele-visits, a case manager often sits in with the patient, but for therapy sessions, “staff get the session started, then exit the room.”
Delivering more services, more efficiently
Early concerns about the “acceptability” of the technology proved groundless. “We did a satisfaction survey among our providers, and they love it, 100 percent across the board,” Fredeen reports. She adds that as the clinicians conduct the appointments, they do concurrent documentation in the electronic medical record, virtually unnoticed by the client.
Satisfaction surveys from clients “are also extremely positive. We've had very few clients who didn't like working this way,” Fredeen says. “The younger population, in particular, really responds to this type of service. It's actually improved our show rate for appointments.”
Based on claims data from four-week periods before and after the service launch in June 2010, ValueOptions agrees. “Since we've started the pilot, there's been a 200-plus percent increase in services delivered in Immokalee,” notes Glynn. “In the four weeks prior to launch, the Immokalee office saw 51 unduplicated clients and delivered 162 services, mostly therapy and medication management. But in the same time period after, the office saw 94 unduplicated patients who received 375 services. And that was just in the first month of availability.”
Now that school has started in Florida, Glynn expects the service rate to rise further. And, the schoolchildren who receive telepsychiatry services locally will, for the first time, be able to receive services and return to school the same day, rather than taking much of the day off for the long drive to Naples.
Behavioral Healthcare 2010 October;30(9):25-27
