Telehealth: Virtual care for rural patients
Because of the state's geography, Children's Hospital and Medical Center in Omaha, Nebraska, recognized it was a challenge for families to travel to mental health providers—it was resulting in lost time at work and school. To provide better care, the hospital implemented a tele-psychiatry program and partners with 10 primary care clinics across the state while working to establish new sites.
The hospital establishes contracts with a primary care office, and when possible, delegated credentialing, also known as "credentialing by proxy," is arranged between Children's and the primary care site. Telemedicine providers must have licenses in the state they practice in and in the state where they see patients, so additional licensure is obtained when needed.
Coverage, reimbursement, workflow
Recognition of telemedicine as a service delivery option continues to improve, but there are nuances between states and payers. In addition to determining coverage and advocating for parity, billing specialists at Children's work with primary care clinics to identify if the clinics can bill site fees and what modifiers are the most appropriate.
Children's works with clinics to determine how referrals will be made, scheduled, and how documentation will be maintained. Each site must also identify and train a tele-presenter, a staff member who rooms patients and facilitates visits. Finally, the two entities create protocols for emergencies and outline the workflow for patient visits.
Primary care clinics obtain the intake paperwork, including the telemedicine consent forms, and send these to the Children's scheduling team. The schedule for each site is sent to the tele-presenter weekly. On the day of the appointment, the tele-presenter obtains the patient's vital signs, assists the family with signing into the computer system, and ensures the connection is made with adequate video and audio quality. Then the psychiatry provider conducts the visit, just like a face-to-face appointment.
New patient evaluations and follow-up appointments can also be conducted. Providers generate an after-visit summary and send it to the family, as well as a letter summarizing the patient's diagnosis, current medications and treatment instructions to the primary care provider. The documentation for the visit is maintained in Children's electronic medical record, with copies sent to the primary care provider.
Lessons learned
The organization's Telemedicine Operations and Steering Committee has learned several lessons.Involve the right people. The committee originally included legal counsel, billing and credentialing specialists, information technology specialists, operations directors and clinicians. Identifying an executive champion and including a telemedicine coordinator and training/education staff has been key.
Think about where telemedicine "lives." The program was part of the Information Technology department, and the chief information officer and chief medical informatics officer were responsible for championing program development. While this had advantages as the hospital determined the best platform to use, as the program developed it became clear telemedicine is a tool for clinical service rather than a service itself. The hospital repositioned the program within clinical operations.
Communication is critical. Communication between the telemedicine team and the vendor who supports the software helps troubleshoot issues and compatibility of system upgrades. It's also important to have consistent communication with patient sites to relay information about system updates, and Children's engages in routine visits with psychiatry staff and primary care providers to strengthen partnerships.
Moving forward
The organization is piloting a child and adolescent psychiatry access program, which includes two psychiatrists available for informal "curbside consults" with primary care providers in the state. The team has also begun work on building registries so the hospital can use the data in the electronic medical record more effectively for quality and process improvement projects as well as tracking outcomes.
—Jennifer McWilliams, M.D., is division chief of Psychiatry, and Michael Vance, Ph.D., is director of Behavioral Health at Children's Hospital and Medical Center in Omaha, Nebraska.
Workforce education: Technology and training in primary care
Pediatricians in the Mercy Health System in St. Louis, Missouri, identified a lack of knowledge and comfort with the diagnosis and treatment of pediatric psychiatric disorders. To help fill a gap, Mercy Kids, the pediatric arm of the Mercy Health System, assembled a psychiatry team at the Virtual Care Center to support the system, which spans five states in the Midwest.
Mercy Kids also developed a plan to increase access to basic mental health care in the primary care office. This includes training all pediatric primary care providers in the diagnosis and management of depression, anxiety, ADHD and disruptive behavioral disorders; developing electronic heath record (EHR)-based tools that allow providers to diagnose and document mental health disorders; and supporting providers with on-demand advice via phone calls or EHR emails, documented in the patient's chart.
The team designed a four-hour, in-person or online CME program. The goal of the training is to increase the comfort, confidence and competence of providers in the assessment and treatment of basic mental illnesses. The team also created a reference manual for providers, but all tools, including treatment algorithms and medication dosing charts, are built into the EHR so they are available to providers at the time of care.
To date, 280 providers have completed the training, out of an eligible 496 primary care providers—not all the primary care providers see children. One Mercy advanced practice professional commented on a recent satisfaction survey, "As a pediatric nurse practitioner working in rural health with very limited resources available to myself and my patients, Mercy Kids Virtual Mental Wellness Program allows me to see and treat these patients with confidence."
Answering questions virtually
When pediatric providers caring for patients in the medical home have a question about diagnosis, treatment, or they are looking for local treatment resources, they contact the Mercy Virtual Mental Wellness team, which consists of a child psychiatrist, psychiatric mental health nurse practitioner, licensed practical counselor and navigator. Depending on the provider's need, the team is available to help on the phone or by secure email embedded in the EHR within 15 to 30 minutes.
The goal is to answer the clinical question and provide guidance before the child leaves the office. Providers document all recommendations in the EHR for future reference. In the rare occurrence the team determines a patient requires an urgent evaluation, a low-tech telemedicine session can occur, as each office has been equipped with a camera and microphone attached to the exam room computer. Telemedicine contact has been needed in less than 1% of the patients using the service—just six times in the last two years.
Lessons learned
With the availability of interprofessional phone/internet consultation codes, billing by the primary care provider and the expert team is possible. Mercy is collecting data on the practicality of using these codes as the organization learns that dropping the charge may result in an additional co-pay. Additionally, CMS requires the primary care provider drop the code at a separate time from the office visit.
Next steps include finding ways to speed up assessments and creating a self-diagnostic algorithm incorporating screening tools and rating scales. This would allow physicians and advanced practice professionals to focus on education around illness and treatment, rather than working through diagnostic evaluations.
A small team of experts can support a large health system struggling with access to child psychiatry with an innovative program and a little bit of technology. Primary care providers, although potentially uncomfortable, can be educated and supported to provide basic mental health care in the medical home, and tools embedded in the EHR to support providers can minimize workflow disruption.
Costs can be contained by the size of the team and potentially offset by additional interprofessional consultative billing codes. Emergency room visits, psychiatric hospitalizations and wait times to see a child psychiatrist have all been improved with this model of care.
—Kyle John, M.D., is medical director of Mercy Virtual Mental Wellness at Mercy Children's Hospital-Springfield in Missouri; and Joseph Kahn, M.D., is president of Mercy Kids at Mercy Children's Hospital-St. Louis.
Chronic care model: Integrated behavioral health care
"Little did I know how much my illness affected my mood and overall well-being," shared Grace, an 18-year-old pediatric patient at NYU Langone Health's Fink Ambulatory Care Center. Grace's pediatric cystic fibrosis (CF) care team referred her for her sad mood and struggles with taking care of her health. When Integrated Behavioral Health (IBH) team psychologists met with her, Grace had dropped out of college and was not engaging with friends or family. She had not taken her CF medications or conducted her treatments, and she was reluctant to discuss her diagnosis.
She began meeting with the IBH psychologist weekly for therapy to target her depression and to better manage her medical condition. A year into treatment, she re-enrolled in college, earned a 3.7 GPA, secured a job and began a relationship with a supportive boyfriend. She shared a new awareness that CF is a permanent part of her life. Grace's story is one example from the Integrated Behavioral Health Program at Hassenfeld Children's Hospital at NYU Langone, where child life specialists, social workers, psychologists and psychiatrists partner with pediatric providers, patients and families to promote well-being and resilience.
Youth coping with a chronic medical condition are two to three times more likely to suffer from co-occurring anxiety or depression and miss twice as many school days as their peers. Rates of medical non-adherence hover around 50% and lead to increases in morbidity and mortality.
Mental health challenges affect as many of 40% of youth with a range of chronic conditions, such as diabetes, inflammatory bowel disease, cystic fibrosis and lupus. The Fink Center provides support using a stepped care model for those who are high risk for poor outcomes due to pre-existing mental health challenges that may impede chronic illness management.
As part of this support, patients and families receive education about mental health screening and common concerns facing youth living with chronic medical illness. All mental health screens are documented in the EHR. Positive screens trigger a care team huddle, risk assessment and treatment planning.
Care for the whole family
Targeted prevention is available for patients or families who experience distress, either verbally, through screening or the concern of the medical provider. The IBH team triages the referral during a weekly consultation meeting where the needs of patients and their families and a treatment plan are discussed. This plan includes co-treatment between IBH and medical team providers.
For example, a parent reporting a high level of normative distress regarding her 5-year-old daughter's reaction to a new diagnosis of diabetes may benefit from a consult with the social worker regarding community-based resources for families. Her daughter may benefit from time with a child life specialist to discuss the diagnosis in developmentally appropriate language. Once the IBH team decides on a treatment plan, it is shared with the patient, family and provider. All services are provided on-site and via the family's insurance coverage.
Intensive support
High-risk patients and families can connect with the IBH team via behavioral emergency response protocol. For example, a 14-year-old patient in the cardiology clinic may report suicidal thoughts during a routine depression screening. If the IBH professional deems the patient requires a psychiatric evaluation in the emergency room, protocol facilitates communication among the team. Since 2017, the protocol has been activated 17 times (about once a month), with 59% of patients requiring transport to the emergency room for psychiatric evaluation.
Lessons learned
Surveys indicate patients and families (85%) are interested in receiving on-site behavioral health supports at the Fink Center, with 83% preferring one-on-one support rather than group support. Medical providers rated IBH services highly on several factors, such as ease of referring, care received, and increased fulfillment in work from having the additional service on-site.
The hospital has partnered with patients, families and providers in design, implementation and evaluation and learned many lessons: Never underestimate how complicated the simplest changes can become when introducing new tools and team members. Pay attention to patient and family experiences and understand provider practice and culture. It's imperative to engage a team of champions, early adopters and senior leaders. A shared vision and strategic investment in integrated care have the power to positively affect medical, mental health and quality outcomes.
—K. Ron-Li Liaw, M.D., is director of KiDS of NYU Foundation Center for Child and Family Resilience and chief of service for Child and Adolescent Psychiatry; and Becky Lois, Ph.D., is director of Integrated Behavioral Health Programs at Hassenfeld Children's Hospital at NYU Langone in New York, New York.
