Rural Primary Care and Behavioral Health Access for Children and Adolescents Through Telepsychiatry in Hawaii - PowerPoint PPT Presentation

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Rural Primary Care and Behavioral Health Access for Children and Adolescents Through Telepsychiatry in Hawaii

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Title: Rural Primary Care and Behavioral Health Access for Children and Adolescents Through Telepsychiatry in Hawaii


1
Rural Primary Care and Behavioral Health Access
for Children and Adolescents Through
Telepsychiatry in Hawaii
  • Unheard Voices in Healthcare Access to Care
    and Communication Issues
  • Dan Alicata MD, Dan Ulrich MD, Dan Lieberman MD,
    Sara Chiu MD, Courtenay Matsu MD, Ricardo Bayola
    MD, Iwa Else PhD, Susana Helm PhD
  • University of Hawaii-Manoa, JABSOM, Department of
    Psychiatry
  • State of Hawaii, Department of Health, Child and
    Adolescent Mental Health Division
  • Mayo Clinic, Rochester Minnesota
  • Pulama I Ke Ola Healthcare Conference, Hilo,
    Hawaii
  • May 21, 2009

2
Disclosures of Potential Conflicts
3
Role of telepsychiatry in meeting the challenges
for rural Hawaii
  • Access improve access to health care in rural
    and other underserved areas.
  • Specialty care provide centralized specialty
    health care consultation to decentralized primary
    care physicians, therapists and educators.
  • Quality improve quality of care by providing
    follow-up after discharge from hospitals
    specialty services.
  • Cost provide specialty care at lower costs to
    providers and patients.

4
Factors Driving Telepsychiatry
  • Increased efficiency.
  • Increased convenience / decreased travel time
  • patients
  • providers
  • Decreased costs of care.
  • Increased access to care for underserved
    populations.
  • Increased patient compliance and follow-up.
  • Because we can!

5
Geographic isolation
  • Models of telepsychiatry on the mainland can be
    effective in Hawaii

6
Federally Designated Medically Underserviced
Areas and Populations
7
Federally Designated Mental Health Provider
Shortage Areas
8
Background Telepsychiatry in Hawaii
  • JABSOM, Department of Psychiatry
  • Administration, technical, clinical, education
    and research cores.
  • Funding State of Hawaii, Department of Health,
    Adult Mental Health Division.
  • Telepsychiatry consultation services to mental
    health clinics on Maui and Molokai.
  • - resident supervision
  • - training curriculum and research development

9
Background Telepsychiatry in Hawaii
  • JABSOM, Department of Psychiatry
  • Developing partnerships with Family Medicine and
    Bay Clinic Hawaii Island.
  • Federally Qualified Community Health Centers.

10
Background Telepsychiatry in Hawaii
  • Rural Child and Adolescent Telepsychiatry
    Molokai - JABSOM, Department of Psychiatry
  • Schools are serving children with increasingly
    broad spectrum of health care needs.
  • Remote school districts experience great
    difficulty obtaining psychiatric and
    psychological consultation within the time frames
    mandated by the IDEA.
  • Virtual office hours through telemedicine
    provides timely access.
  • School staff need ongoing in-service education to
    serve them.
  • School districts have the capacity for
    videoconferencing (Teleschool Network).

11
Child and Adolescent Telepsychiatry Molokai
  • Develop partnerships with
  • Department of Education
  • Molokai General Hospital and health clinics
  • Maui Community College School of Nursing
  • University of Hawaii Telehealth Research
    Institute
  • Hawaii Educational Treatment Interventions (HETI)

12
Child and Adolescent Telepsychiatry Teleschool
Network
  • Teleschool Network with gt 250 VTC units in
    schools and district offices.
  • 7 remote VTC sites on Molokai.
  • IP network
  • - secure, enclosed network using internet
    protocol with a data stream of 384 Kb/s.
  • Polycom VSX 7000 VTC units with monitors gt 37 in.
  • Sending / receiving sites anywhere along the hub.

13
Teleschool Network DOE goals
  • Facilitate the provision of timely and quality
    staff development activities in spite of
    geographic challenges.
  • Deliver sustained and focused support services to
    schools. 
  • Provide students with quality remedial and
    enrichment programs.
  • Reduce the time lost in traveling to workshops or
    meeting sites.

14
(No Transcript)
15
  • Moanaloa Elem.
  • Kilohana Elem.
  • DOE-LSC
  • Kaunakakai Elem.
  • Molokai General Hospital
  • Pharmacy

16
Project Parameters
  • Provide 4-direct patient care/consult hours/week.
  • Reimbursement Agency contract with DOE to
    provide Child and Adolescent psychiatric
    services.
  • Youth and their families with any psychiatric
    condition.
  • Initial evaluation, ongoing care as well as
    consultation with treatment, education and
    support staff (DOE, DOH, Family Court,
    Probations, DHHS-CWS).
  • Patients / parents agreed to receive care via
    telepsychiatry.
  • Frequency monthly visits to Molokai weekly
    telepsychiatry clinics.

17
Preliminary data
  • Telepsychiatry clinics 117
  • Total hours 392 - hours
  • Telepsychiatry encounters total 1,012
  • students total 283 (28.0 )
  • - adolescents 13-19-years-old (78.1 )
  • Parents/guardians total 355 (35.1 )
  • - staff total 374 (37.0 )

18
Pearls
  • Telepsychiatry program collaborated with the
    multiple community systems serving these needy
    youth, including primary care medicine,
    community- and school-based therapists, day
    programs, addictions programs, Family Court,
    Juvenile Corrections, Child Welfare Services, and
    the education system.
  • In this type of consultation, telepsychiatry can
    provide the glue that binds these community
    systems and youth together.

19
Future Project Goals
  • Infrastructure development.
  • Bridge Teleschool Network with medical clinics
    and health centers across the state.
  • Utilize existing Teleschool network to expand
    telepsychiatry services to other rural school
    districts (Hawaii Island, Lanai, Hana, Waianae
    and Waimanalo).
  • Recruit child and adolescent psychiatrists.
  • Develop medical student education and resident
    training curriculum.
  • Develop administration, research and technical
    cores.

20
Research Goals
  • Improve assessment of mental health outcomes.
  • Examine predictors of effective care delivered
    through telepsychiatry.
  • Evaluate the impact of cultural factors on the
    success of interventions.
  • Investigate the economic impact of access to
    services through telepsychiatry.
  • Explore the barriers to care delivered through
    telepsychiatry.
  • Assess the impact of telepsychiatry in preserving
    the rural mental health workforce.

21
Hawaii Island Telepsychiatry Initiative Project
Scope
  • Contract established with CAMHD and UH
    (Psychiatry).
  • Establish telepsyhchiatry consultation with Mayo
    Clinic.
  • Telepsychiatry case conference with Tripler Child
    and Adolescent Psychiatry resident training
    program.
  • Establish VTC linkages between UH psychiatry
    (Queens Medical Center), Hawaii Family Guidance
    Centers (CAHMD), Mayo Clinic, Tripler Army
    Medical Center and DOE.
  • Develop policies and procedures for participating
    sites, staff training, and the education and
    training curriculum for students and residents.
  • Develop administration, technical and research
    cores.

22
Child and Adolescent Telehealth (UH-DOP / CAMHD
/ Mayo Clinic) Working Group
  • Family Guidance Center
  • Mental health care coordinator clinical
    director
  • Review and completion
  • CAFAS
  • Mental health assessment
  • Qualifying diagnosis
  • Eligibility determination
  • Final approval via Division (medical director)

referral
Triage and Assembly of Patient panel
Acute hospital DOE Family Court DHS Primary care
Family
Telehealth Service
23
Family Guidance Center Levels of Care
Less intensive In-home Out-of-home More
intensive
Levels of care Intensive in home
(IIH) Multisystemic therapy (MST) Functional
family therapy (FFT) Therapeutic foster home
(TFH) Multimodal therapeutic foster care
(MTFC) Therapeutic group home (TGH) Community
based residential (CBR) Hospital based
residential (HBR)
24
Telepsychiatry Initiative Progress
  • VTC units installed at UH, Queens Counseling
    Services, and Hawaii Family Guidance Centers
    (Hilo, Waimea, Kona).
  • TeleSchool Hawaii State DOE, Pahoa HS
  • Develop policies and procedures.
  • Develop trainee curriculum and clinical
    schedules, faculty supervision
  • - first patients were seen at the Hilo FGC in
    September 2008.
  • Administration core developed (UH
    psychiatry-FGCs)
  • - provider licensing, credentialing, insurance
    (Hawaii-Mayo)
  • - clinical scheduling, registration,
    billing/tracking data

25
Telepsychiatry Initiative Progress
  • Technical core developed (Hawaii-Mayo) equipment
    / connection development, maintenance, quality
    assurance, encryption.
  • Research core evaluate program efficacy,
    quality, satisfaction, clinical outcomes and
    sustainability in rural Hawaii communities.
  • Collaboration with Mayo Clinic (monthly
    telepsychiatry case conferences started in April
    2008 consultation)
  • - provide specialized expertise for the
    evaluation of complex diagnostics,
    pharmacogenomics and cross-cultural psychiatry
    and its relevance to multi-ethnic communities in
    rural Hawaii.
  • - evaluate the role of telepsychiatry in global
    service, training and education, research and
    staff development.

26
Telepsychiatry Research
  • Overview
  • Child and Adolescent Psychiatry
  • Adult Psychiatry
  • Integrated Service System

27
Child Adolescent Research
  • Goal 1 Mental Health Outcomes
  • Measure the extent to which mental health
    outcomes are stable and improved via
    telepsychiatry
  • as compared to no treatment and comparable
    face-to-face treatment.
  • Goal 2 Service Satisfaction
  • Are people satisfied with telepsychiatry
  • Providers
  • Clients/patients and their family
  • Goal 3 Organizational Development
  • What does the Department of Psychiatry need to
    know and do to meet the psychiatric services
    needs of children and adolescents in rural areas?
  • Research and evaluation
  • Translated to action.

28
Results Service Satisfaction
  • 1. Telehealth Equipment/Technology (5 items,
    mean4.5)
  • Knowing there is help available at the UH
    provider's site made me feel comfortable using
    telepsychiatry. (mean 4.8).
  • 2. Communication Quality (7 items, mean4.4)
  • I was able to understand the client's verbal
    (mean4.5) and nonverbal communication (mean
    4.3).
  • 3. Travel/Distance (3 items)
  • 100 RT - commute time and airfare
  • I would rather provide telepsychiatry than travel
    to the client's location to provide face-to-face
    care for him/her (mean4.1).
  • 4. General Service (7 items, mean4.4)
  • Overall, I was satisfied with the quality of the
    services provided by telepsychiatry (mean4.3).
  • The participation of the distant site provider
    was essential to obtain an adequate history or
    information (mean4.7).
  • 5. Training (4 items, mean3.4)
  • I feel confident in using telepsychiatry after
    training (as a result of this rotation)
    (mean3.5).

29
Future Directions
  • Research evidence-based data driving culturally
    sensitive training and education, clinical
    service and work force development and
    sustainability.
  • Linking all Hawaii FGCs through telepsychiatry.
  • Strengthening the continuity of care of youth in
    transition to/from hospital-based and
    community-based treatment programs.
  • Providing child and adolescent psychiatric
    services to military families living in rural
    Hawaii.
  • The role of telepsychiatry in bridging the FGCs,
    primary care clinics and the local school
    districts.

30
Collaboration/Partnerships
  • JABSOM A. Guerrero, C. Bell, J. Huh, C.
    Koyanagi, M. Fukuda, I. Else, S. Helm, M. Horton,
    T. Unten
  • Hawaii Family Guidance Centers (CAMHD) D.
    Lieberman, S. Chiu, K. Acquaro, P. Azevedo
  • Mayo Clinic D. Mrazek, C. Swintak, B. Koplin,
    M. Williams
  • Community Child and Adolescent Psychiatrists
    (Hilo) Drs. Ching, Eaglin, Kagawa
  • Tripler Army Medical Center S. Uthiol (Program
    Director, Child and Adolescent Psychiatry)
  • TeleSchool (Hawaii State DOE) D. Miyamoto, S.
    Miyazono

31
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