Rural TeleCon Rural TeleCon ''07071010thth Annual Conference of the Rural Annual Conference of the Rural

Telecommunications CongressTelecommunications CongressOctober 14 – 17, 2007October 14 – 17, 2007

Rural TeleMental HealthRural TeleMental Health

Rural TeleMental HealthRural TeleMental Health

F. Rose Rexroat, R.N.,C., MSN, Manager Community Services, Saint Joseph HealthCare,

Inc. a Market Based Organization of Catholic Health Initiatives

Carol L. Ireson, R.N., PhD, Associate Professor, College of Public Health, University of Kentucky

Rural TeleMental HealthRural TeleMental Health

• Understand how telehealth technology is utilized in a rural primary care setting

• Understand how telehealth technology can support provision of mental health services in rural areas

• Understand achievements, barriers, and future objectives

Why rural telemental health?Why rural telemental health?

Economic ChallengesEconomic Challenges.. • 25% to 39%, in area served, live in poverty

compared to 18.7% in Kentucky and 16.3% nationally

• 80 - 100% of children at the targeted schools are on National Free and Reduced Lunch Program

• 7.8% to 12.6% of residents are unemployed

• 18 - 37% of residents qualified for Medicaid

Gaps in the Health SystemGaps in the Health System

81 of 120 Kentucky Counties are officially designated as a Health Professional Shortage Area (HPSA)

• Wolfe County has 1 PCP per 100,000, • Morgan County has 4.8 PCPs per 100,000 • Lawrence County has 11 PCPs per 100,000

(primarily located in the far eastern border in Louisa.)

Health Care ChallengesHealth Care Challenges

• 37.4% to 42.6% of residents reporting fair or poor health

• Over 6% of the population have diabetes higher than the Kentucky rate of 4.5%

• Obesity and overweight rates are among the highest in the state

• Over 5% of residents suffer from major depression

The BeginningThe Beginning

• Work as chair of the Kentucky Association of Free Health Clinics allowed the opportunity to educate two State Representatives and a Senator about a Mobile Health Service

• This discussion lead to implementation of the Eastern Kentucky Mobile Health Service (EKMHS)

Know your own strengths and Know your own strengths and weaknesses in developing the project!weaknesses in developing the project!

Identified and collaborated with experts…– Clinical experts –always focus on the clinical

needs of patients– Technical experts – always have a technical

consultant that can develop a plan to support your clinical needs

– Research experts – help with assessment, analysis, outcome measurement

CollaboratorsCollaborators

• Saint Joseph HealthCare, Inc.• Catholic Conference of Kentucky • Appalachian Regional HealthCare, Inc.• Saint Claire Regional Medical Center• Cabinet of Health Services, Dept. of Public

Health

Collaborating Agency RolesCollaborating Agency Roles

SJHCHolds a personal service vendor contract with the DPH

for: • provision of services• development and administrative oversight• billing and medical record management

Appalachian Regional HealthCare: • Provides care regardless of ability for payment• Referral for ancillary service

Collaborating Agency RolesCollaborating Agency Roles

St. Claire Regional Medical Center• Second line of referral for care regardless of ability for

payment• Serves as hub manager for the five EKMHS sites and SJH • Annual management fees of approximately $12,000 -15,000

paid by St. Claire for EKMHS / SJH

Cabinet for Health Services / Department of Public Health

• Representatives John Will Stacy and Rocky Adkins, Senator Walter Blevins

• Service provider relationship for continued funding to support operation

Collaborating Agency RolesCollaborating Agency Roles

Catholic Conference of Kentucky

Collaboration in carrying out the mission of the Catholic Church, Catholic Health Care.

• Lead role with legislative process to assure continued funding for the EKMHS

• Relationship building• Continued presence and communication

with state legislature

SupportSupport

• State Service Provider Contract - $325,000 for annual operations subsidy

• Budget 2007-2008 increase of $34,000 – FTE replacement factor for ARNP

• Bill for Services: Medicare, Medicaid, other third party payers

• SJHC has no expense subsidy for operations

The Goal of the EKMHSThe Goal of the EKMHS

To improve access to primary and specialist care for residents of five extremely rural communities located in Eastern Kentucky and

To build a provider referral network

Role of College of Public HealthRole of College of Public Health

Kentucky Commissioner of Health designated the University of Kentucky, College of Public Health to conduct a community needs assessment to provide baseline data for use in:– Planning focused health promotion – Disease prevention programs– Future evaluations of the impact of the

EKMHS on health status of clients served

Community Health AssessmentCommunity Health Assessment

• 75 item questionnaire assessing disease burden, health risk behavior, access to care

• Administered at the county fair, homemaker groups, senior center

Needs Assessment FindingsNeeds Assessment Findings

• Disease burden– Heart disease, cancer, diabetes, injury,

depression• Health behaviors

– Poor nutrition, lack of exercise• Access to health care

– No insurance, no money, not enough doctors

Service DeliveryService Delivery

• The Eastern Kentucky Mobile Health Service EKMHS) started seeing patients on May 6, 2003.

Communities ServedCommunities Served

• Blaine in Lawrence County

• Hazel Green in Wolfe County

• Ezel, Cannel City, and Crockett in Morgan County

Output: Patient VolumeOutput: Patient Volume

Visits Average/dayFYE 06/2003 73 3FYE 06/2004 970 4FYE 06/2005 2132 9FYE 06/2006 2528 11FYE 06/2007 2360 10

23.3% New patient76.7% Two or more visits

Income By Reimbursement SourceIncome By Reimbursement Source

FYE 06/04 FYE 06/05 FYE 06/06 FYE 06/07

MEDICARE 13.0% 19.0% 20.0% 11%

MEDICAID 5.0% 3.0% 3.0% 5%

SELF PAY 57.0% 55.0% 69.0% 66%

ALL OTHER 25.0% 24.0% 8.0% 18%

self pay includes self pay and other charity (DSH and St. Joseph Charity)

Bill for Services: Medicare, Medicaid, other third party payers

SJHC has no expense subsidy for operations

Patient ProfilePatient Profile

FYE 06/04 FYE 06/05 FYE 6/06 FYE 6/07

Female 64.9% 60.6% 58.2% 58.1%

Male 35.1% 39.4% 41.8% 41.9%

Pediatric 5.9% 2.5% 1.9% 1.3%

Caucasian 99.5% 100% 100% 99.5%

Native Am. 0.5% 0% 0% 0.5%

Disease BurdenDisease Burden

MEDICATION AS AN INDICATOR

HEALTH KY P.A.P.

FYE 06/03 $6,495 $9,078 FYE 06/04 $108,202 $323,898 FYE 06/05 $109,649 $765,242 FYE 06/06 $176,076 $1,174,954

FYE 06/07 $196,461 $1,014,639

H.K.: Health Kentucky, Inc.PAP: Patient Assistance Programs

Disease BurdenDisease Burden

MEDICATION AS AN INDICATOR

TOTAL AMOUNT / VISITFYE June 2003 $15,572 $213FYE June 2004 $432,100 $445FYE June 2005 $874,891 $410FYE June 2006 $1,351,029 $534FYE JUNE 2007 $1,211,101 $513

TOTAL $3,884,693 $423 AVG

The Role of Telemedicine for EKMHSThe Role of Telemedicine for EKMHS

Remote Access:

• To Specialists

• For follow up visits

• Referrals to or from any of the sites in the Kentucky TeleCare Network

Kentucky TeleHealth Network (KTHN) Sites

Telehealth Clinical ConsultationsTelehealth Clinical Consultations

2003 2004 2005 2006

• EKG 3 10 43 67• Internal Medicine 2 2 3

• Pulmonary 1 1 • Conferencing 4• Education Programs 2• Peds Gastroenterology 2• School Nurse access for primary care 3• November 2005 started laying foundation with KRCC for

mental health clinic(s)

Role Of Grants / Funding SourcesRole Of Grants / Funding Sources

1. OCTOBER 2002: USDA-RUS GRANT of $90,300.00to add telemedicine technology to the MHS and to SJH

2. JUNE 2004: STEELE-REESE GRANT of $47,880.00to provide cancer and diabetic screening for early detection

3. OCTOBER 2004: USDA-RUS GRANT of $235,636.00 to expand present telemedicine network

Need for Mental Health ServicesNeed for Mental Health Services

• Analysis of diagnoses after one year of EKMHS operation found that number of women diagnosed with mental health disorders exceeded the sum of all other diagnoses

• Residents of the targeted communities do not

use the local mental health service provider because of the stigma of going to a mental health clinic

Rural TeleMental Health ProjectRural TeleMental Health Project

Purpose• To develop a comprehensive network of health

care services by expanding the existing primary care and bringing mental health diagnostic and treatment expertise to residents of local rural communities

Role Of Grants / Funding SourcesRole Of Grants / Funding Sources

2006

Appalachian Regional Commission of $303,882

and

USDA-RUS Grant of $326,893

to expand the Kentucky Telehealth Network

SAINT JOSEPH HEALTHCARESAINT JOSEPH HEALTHCARE SERVICE AREA WITH EKMHS SERVICE SERVICE AREA WITH EKMHS SERVICE

AREA AREA (Morgan, Wolfe and Lawrence (Morgan, Wolfe and Lawrence Counties)Counties)

Primary Service Area

Secondary Service Area

Tertiary Service Area

FloydPike

Living

sto

n Ho

pkins

Ch

ristia

n

Webster

Logan

Simpson

Carlisle

AllenMonroe

Calloway

McCrackenBallard

Trigg

Lyon

Caldwell

Crittenden

FULTON

Hickman

MarshallTodd

Union

HendersonDavies

McLe

an

MuhlenbergButler

Ohio

Warren

Edmonson

Marion

Grayson

Breckinridge

Meade

Hardin

Hart

Barren

Green

LaRue

Metcalfe

TaylorCasey

Adair

Cum

berland

Wayne

Clinton

Russell

McCreary

Pulaski

Lincoln

Boyle

MercerWashington

Nelson

Bullitt

Jefferson

Oldham

Trim

ble Carroll

Boo

ne

Ken

to

n

Cam

p

bell

Gallatin

Henry

Shelby

Spencer

Anderson

Owen

FranklinScott

Grant

Pe

rry

Garrard

Wo

odf

ord

Pendleton

Fayette

Bourbon

Harrison

RobertsonBracken

Nicholas

Clark

Rockcastle

Madison

Jessamine

Knox

Whitley

Laurel

Knott

Leslie

Harlan

Letcher

Bell

Clay

Lee

Jackson Owsley

Wolfe

Breathitt

Johnson

Magoffin

Estill

Morgan

Lawrence

Martin

Menifee

RowanElliott

Powell

BathMontgom

ery

Lewis

Fleming

Mason

BoydCarter

Greenup

GravesHancock

2006 Grant Goals2006 Grant Goals

Appalachian Regional Commission Grant $303,882

• Expand EKMHS telemedicine network adding mental health diagnostic and treatment clinic(s)– 4 school sites served by MHS– 3 Kentucky River Community Care sites of Jackson,

Hazard and Campton– St. Claire Regional Medical Center Mental Health Services– 6 county impact area of Perry, Breathitt, Wolfe, Morgan,

Lawrence and Rowan

Saint Joseph HealthcareSaint Joseph Healthcare Service Area With EKMHS Service Area & ARC Grant Service Area With EKMHS Service Area & ARC Grant

Primary Service Area

Secondary Service Area

Tertiary Service Area

FloydPike

Living

sto

n Ho

pkins

Ch

ristia

n

Webster

Logan

Simpson

Carlisle

AllenMonroe

Calloway

McCrackenBallard

Trigg

Lyon

Caldwell

Crittenden

FULTON

Hickman

MarshallTodd

Union

HendersonDavies

McLe

an

MuhlenbergButler

Ohio

Warren

Edmonson

Marion

Grayson

Breckinridge

Meade

Hardin

Hart

Barren

Green

LaRue

Metcalfe

TaylorCasey

Adair

Cum

berland

Wayne

Clinton

Russell

McCreary

Pulaski

Lincoln

Boyle

MercerWashington

Nelson

Bullitt

Jefferson

Oldham

Trim

ble Carroll

Boo

ne

Ken

to

n

Cam

p

bell

Gallatin

Henry

Shelby

Spencer

Anderson

Owen

FranklinScott

Grant

Pe

rry

Garrard

Wo

odf

ord

Pendleton

Fayette

Bourbon

Harrison

RobertsonBracken

Nicholas

Clark

Rockcastle

Madison

Jessamine

Knox

Whitley

Laurel

Knott

Leslie

Harlan

Letcher

Bell

Clay

Lee

Jackson Owsley

Wolfe

Breathitt

Johnson

Magoffin

Estill

Morgan

Lawrence

Martin

Menifee

RowanElliott

Powell

BathMontgom

ery

Lewis

Fleming

Mason

BoydCarter

Greenup

GravesHancock

2006 Grant Goals2006 Grant GoalsUSDA-RUS (DLT) Grant $326,893

• Expand Access by expanding the network to:– 4 Health Departments (Menifee, Morgan, Rowan &

Lawrence)– 5 Schools (Owingsville Elementary, Bath County High

School, Morgan County Middle and High School and Menifee Co.Complex K-12)

– 3 SJHC Emergency Departments (SJ Berea, SJH, SJ East)

– First Clinical Application for Sleep Wellness Center in Lexington and Berea

– 8 County impact area (Fayette, Madison, Bath, Menifee, Wolfe, Rowan, Morgan and Lawrence)

Technology Plan for EKMHS for the USDA RUS DLT Grant

SAINT JOSEPH HEALTHCARESAINT JOSEPH HEALTHCARE SERVICE AREA WITH EKMHS SERVICE SERVICE AREA WITH EKMHS SERVICE

AREA & USDA-RUS GRANTAREA & USDA-RUS GRANT

Primary Service Area

Secondary Service Area

Tertiary Service Area

FloydPike

Living

sto

n Ho

pkins

Ch

ristia

n

Webster

Logan

Simpson

Carlisle

AllenMonroe

Calloway

McCrackenBallard

Trigg

Lyon

Caldwell

Crittenden

FULTON

Hickman

MarshallTodd

Union

HendersonDavies

McLe

an

MuhlenbergButler

Ohio

Warren

Edmonson

Marion

Grayson

Breckinridge

Meade

Hardin

Hart

Barren

Green

LaRue

Metcalfe

TaylorCasey

Adair

Cum

berland

Wayne

Clinton

Russell

McCreary

Pulaski

Lincoln

Boyle

MercerWashington

Nelson

Bullitt

Jefferson

Oldham

Trim

ble Carroll

Boo

ne

Ken

to

n

Cam

p

bell

Gallatin

Henry

Shelby

Spencer

Anderson

Owen

FranklinScott

Grant

Pe

rry

Garrard

Wo

odf

ord

Pendleton

Fayette

Bourbon

Harrison

RobertsonBracken

Nicholas

Clark

Rockcastle

Madison

Jessamine

Knox

Whitley

Laurel

Knott

Leslie

Harlan

Letcher

Bell

Clay

Lee

Jackson Owsley

Wolfe

Breathitt

Johnson

Magoffin

Estill

Morgan

Lawrence

Martin

Menifee

RowanElliott

Powell

Bath

Montgom

ery

Lewis

Fleming

Mason

BoydCarter

Greenup

GravesHancock

SAINT JOSEPH HEALTHCARESAINT JOSEPH HEALTHCARE SERVICE AREA WITH EKMHS SERVICE SERVICE AREA WITH EKMHS SERVICE

AREA & USDA-RUS AND ARC GRANTAREA & USDA-RUS AND ARC GRANT

Primary Service Area

Secondary Service Area

Tertiary Service Area

FloydPike

Living

sto

n Ho

pkins

Ch

ristia

n

Webster

Logan

Simpson

Carlisle

AllenMonroe

Calloway

McCrackenBallard

Trigg

Lyon

Caldwell

Crittenden

FULTON

Hickman

MarshallTodd

Union

HendersonDavies

McLe

an

MuhlenbergButler

Ohio

Warren

Edmonson

Marion

Grayson

Breckinridge

Meade

Hardin

Hart

Barren

Green

LaRue

Metcalfe

TaylorCasey

Adair

Cum

berland

Wayne

Clinton

Russell

McCreary

Pulaski

Lincoln

Boyle

MercerWashington

Nelson

Bullitt

Jefferson

Oldham

Trim

ble Carroll

Boo

ne

Ken

to

n

Cam

p

bell

Gallatin

Henry

Shelby

Spencer

Anderson

Owen

FranklinScott

Grant

Pe

rry

Garrard

Wo

odf

ord

Pendleton

Fayette

Bourbon

Harrison

RobertsonBracken

Nicholas

Clark

Rockcastle

Madison

Jessamine

Knox

Whitley

Laurel

Knott

Leslie

Harlan

Letcher

Bell

Clay

Lee

Jackson Owsley

Wolfe

Breathitt

Johnson

Magoffin

Estill

Morgan

Lawrence

Martin

Menifee

RowanElliott

Powell

Bath

Montgom

ery

Lewis

Fleming

Mason

BoydCarter

Greenup

GravesHancock

How telemental health services will be How telemental health services will be delivereddelivered

• Patients needing mental health services will be referred by the EKMHS Primary Care ARNP to a psychiatric nurse practitioner and psychiatrists located at St. Claire Regional Medical Center or Kentucky River Community Care

• Students with behavior or mental health problems will be referred by school nurses employed by the Gateway Regional Health Department to the Mental Health Nurse Practitioner or Psychiatrists specializing in child and adolescent psychiatry via the Kentucky Telehealth Network

Benefits for the PatientBenefits for the Patient• Linked to physicians in a regional medical center

and a metropolitan hospital(s) via a telemedicine connection – real time audio and video consultation

• Connected to any agency / organization on the KTHN

• Patients will not have to travel long distances to be seen

• Eliminates the stigma of “going to the psychiatrist office”

Benefits for the CommunityBenefits for the Community• Will impact the economic development of the region

by reducing the absenteeism and decreased productivity of workers suffering from mental health problems

• Early intervention for mental health problems will enhance their successful growth and development and prevent these problems from following them into adulthood

• Through access to obtain mental health services for the EKyMHS, the end sites obtained access to primary care and other services

Evaluation PlanEvaluation Plan

• Number of adults and children receiving mental health services in their local communities

• Distance and costs required to travel to receive mental health services vs. using technology

• Satisfaction of patients with the telemedicine mental health services

• Satisfaction of health care providers with the telemedicine technology for providing mental health service

Cost effectivenessCost effectiveness

• We believe the program will be the most cost effective way to address the mental health needs of the rural population served– Reduces travel for the patient– Reduces travel for practitioners– Brings services to rural communities that can

not support a FT or PT health care provider or specialist

SustainabilitySustainabilityLooked at how we could develop

partnerships with our collaborators to build a network that can support the program– All end sites are responsible for T1 installation

and ongoing costs– All end sites are responsible for all equipment

repair / replacement after the first year warranty period

– Education of end sites users on value of new delivery model to their clinical practice

Future GoalsFuture Goals

Expansion of the TeleMental Health Network through an Appalachian Regional Commission Grant

• To connect 3 rural CHI hospitals to the Network• To expand mental health services by adding 5

more KRCC clinics to the Network• To provide primary care services to the 5 new

KRCC clinics• 8 county impact area

Lessons learned Lessons learned • Working with two federal granting agencies

requires a lot of communication• Important to identify champions in each agency

who can help with interagency communication, interpretation of regulations and correct processes

• Pay very close attention to the guidelines for definitions of in-kind and matching funds of each agency

• Patience and persistence are needed

Recommendations for joint federal Recommendations for joint federal grantsgrants

• Written guidelines • Clear identifiers on application for joint grant with

another federal agency• Don’t try to maintain integrity of parts of one or

both grants (scope of work) and then try to consolidate other parts (budget)

• When one grantee allows for funding to be used as match, all agents reviewing the grants need to know that provision

Recommendations for joint federal Recommendations for joint federal grants (continued)grants (continued)

• Point of contact for each organization for questions

• Joint federal grants should require different documents than those for a traditional grant

• Clarify reporting requirements and report cycle

• Clarify process for fiscal allocations and management

QuestionsQuestions

Discussion