BEHAVIORAL TELEHEALTH

Matthew E. Lambert, Ph.D.Senior Director for Rural ResearchF. Marie Hall Institute for Rural and Community HealthTexas Tech University Health Sciences Center

Behavioral Telehealth

Telehealth is the use of electronic information and telecommunications

technologies to support long-distance clinical health care, patient and

professional health-related education, public health and health

administration. (HRSA)

Behavioral Telehealth focuses on using telecommunications

technologies for the provision and support of behavioral healthcare

and education.

The types of technologies used in Behavioral Telehealth include:

telephone audio connections, video teleconferencing, web audio or

video conferencing, web-chatting, e-mail, et cetera.

Benefits of Behavioral Telehealth

Increased access and availability of behavioral health providers and

specialists at reduced cost

Reduced barriers to care from disparities (e.g., geographic,

financial, ethnic/cultural, gender, scheduling)

Improved crisis management and support

Increased opportunities for supervision, training, and consultation

Greater support when using augmented self-help care

Type of Behavioral Telehealth Services

Psychiatry Diagnostic Evaluation

Medication Management

Psychotherapy and Medication Management

Consultation and Supervision

Training

Psychology and Counseling Diagnostic Evaluation

Psychotherapy and Counseling

Cognitive-Behavior Therapy

Group Therapy and

Psychoeducational Groups

Psychological Testing

Biofeedback

Critical Incident Stress

Debriefing/Crisis

Intervention

Consultation and Supervision

Training

Value of Behavioral Telehealth

Demonstrated to be equivalent to face-to-face behavioral healthcare encounters

Can reduce length of hospital stays Can produce better medication adherence Reductions in symptoms Emphasizes “Evidenced-Based” care Can treat special populations (e.g., PTSD, autism, ADHD,

children, geriatrics, those of culture) Reduced costs of care

Issues Impacting Behavioral Telehealth

Regulatory Issues – State by State Psychiatry and the practice of

medicine

Psychology and Counseling board

rules

Interstate commerce - location of

service, liability, licensure

HIPPA compliance

Provider familiarity with telehealth

Reimbursement

Technology requirements

All video conferencing software is

not HIPPA compliant (e.g.. Polydor,

Microsoft Lync, Skype)

Most secure connection is hardware

based with video codex – costly

Cameras have different fidelity

levels

Bandwidth affects fidelity of

interaction (DSL, Cable, Fiber

Optics, Wi-Fi, etc.)

Managing technology glitches and

interruptions

What Is Needed

Revamping of regulatory restrictions on behavioral telehealth

Broader interstate compacts to allow services to cross state

boundaries

Clear delineation of HIPPA rules governing telemedicine in

general and behavioral telehealth specifically

Technology guidelines consistent with HIPPA requirements

Educate health care providers about telehealth as part of their

training

Advocate for telemedicine/behavioral telehealth to be covered

insurance services without conditions

Changes Are Coming Slowly

New Texas Medical Board Telemedicine Rules (on hold) Patients can interact with their physicians via telemedicine beyond the traditional

office visit including receiving appropriate care from their homes, between multiple health care settings, and from other medical sites like a school nurse’s office, a fire station or even an oil rig.

Once a physician has made an initial diagnosis of a patient through a face-to face visit held either in person or via telemedicine, the physician can treat a patient for their preexisting condition, via telemedicine, for up to one year in their home. The presence of another medical provider to assist in communicating the patient’s diagnostic information to the physician is only required for the initial consultation.

A physician can provide mental health services to a patient via telemedicine at the patient’s home, which can include a group or institutional setting where the patient is a resident. No other health care provider is required to be with the patient to present the patient’s symptoms to the physician unless there is a behavioral emergency.

Texas State Board of Examiners of Psychologists The delivery of psychological services by telephone, teleconferencing,

and the Internet is a rapidly evolving area. Board rules do not specifically address telepractice, teletherapy, teleconferencing, or electronically providing services. No rules currently prohibit such services. (Fall 1999)

Telehealth: Chapter 111 of the Occupations Code This statute requires a health care professional obtain informed consent before providing telehealth services (§111.002) and take appropriate steps to ensure confidentiality (§111.003). (Winter 2013)

Internet Activity: Chapter 106 of the Occupations Code Pursuant to §106.001, the fact that an activity occurs through the use of the internet does not affect a licensing authority’s power to regulate the activity or person.

Telemedicine Payments to Expand Under New Breed of ACOs March 15, 2015 waiver of telemedicine restrictions to

only patients in rural areas for Next Generation Accountable Care Organizations

Telemedicine visits will qualify for payment if the patient is at home, not just at a hospital, a physician office, or one of six other "originating sites" specified by Medicare.

Building a Behavioral Telehealth Psychotherapy and Counseling Program

Personnel Needed One to three behavioral health providers needed depending on the

number of clinics being served: Recommend at least one Ph.D.

Psychologist while other providers could be a mix of Licensed

Professional Counselors and/or Licensed Clinical Social Workers.

Only Psychologists and Licensed Clinical Social Workers can bill

Medicare. All providers can bill Medicaid.

Originating site communicator: Staff personnel who arranges

appointments, initiates telehealth sessions, insures necessary

forms are completed, and collects co-payments if appropriate.

Telehealth technical support personnel: Manages technical component of telehealth session

Billing and Collection personnel: Complete billing and submit claims for reimbursement

Types of Services Individual psychotherapy and counseling

Evidenced-Based Cognitive Behavioral Therapy

Family Counseling

Marital Counseling

Psychological Testing

Frequency and Duration of Services Initial Diagnostic Interview: First session

Psychotherapy and Counseling Sessions: Total duration of sessions dependent upon presenting problem/diagnosis and evidenced-based treatment guidelines. Typical course of treatment is 12-16 sessions.

Telehealth Codes for Psychotherapy and Counseling

Individual and group health and behavior assessment and intervention

Individual and group health and behavior assessment and interventionCPT codes 96150–96154

 

Individual psychotherapy Individual psychotherapy CPT codes 90832–90834 and 90836–90838  

Telehealth Pharmacologic Management Telehealth Pharmacologic Management HCPCS code G0459

Psychiatric diagnostic interview examination Psychiatric diagnostic interview examination

Neurobehavioral status examination CPT code 96116  

Smoking cessation services HCPCS codes G0436 and G0437 and CPT codes 99406 and 99407  

Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services

HCPCS codes G0396 and G0397 

Annual alcohol misuse screening, 15 minutes HCPCS code G0442  

Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes

HCPCS code G0443 

Annual depression screening, 15 minutes HCPCS code G0444  

High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes

HCPCS code G0445

 

Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes

HCPCS code G0446

 

Face-to-face behavioral counseling for obesity, 15 minutes

HCPCS code G0447 

Psychoanalysis (effective for services furnished on and after January 1, 2015)

CPT codes 90845 

Family psychotherapy (without the patient present) (effective for services furnished on and after January 1, 2015)

CPT code 90846

 

Psychological testing (includes psychodiagnostic assessment of emotionality, intellectual abilities, personality and psychopathology, eg, MMPI), administered by a computer, with qualified health care professional interpretation and report)  

CPT Code 96103

 

Neuropsychological testing (eg, Wisconsin Card Sorting Test), administered by a computer, with qualified health care professional interpretation and report  

CPT Code 96120

 

Administrative Needs Comprehensive sets of forms: Clinic Information, Consent to Treatment,

Release of Information, Billing Authorizations, Limitations to Treatment, et

cetera

Case Management/Triage of Cases

Emergency Crisis Protocol/After Hours Needs

Electronic Health Record/Practice Management Software

Education for Clinics and Providers

Ongoing Supervision at All Levels

IT Requirements HIPPA Compliant Videoconferencing Software

High Fidelity Video/Audio Equipment

High Speed Internet Bandwidth

Other specific equipment tied to treatment provided

Two Behavioral Telehealth Projects

Telemedicine Wellness Intervention Triage and Referral Project (TWITR)

Vision 21, Building State Technology Capacity Telemedicine Psychiatric Services for Children’s Advocacy Centers of Texas (TPSCAC)

Telemedicine Wellness, Intervention, Triage and Referral Project (TWITR)

The TWITR Project is a demonstration project grant funded by the Office

of the Governor of the State of Texas and is a proposed cooperative effort

between the F. Marie Hall Institute for Rural and Community Health at

TTUHSC and public school entities in Lubbock and surrounding

counties.

The primary purpose of the project is to promote school safety by

providing assessment and referral services to students who may be

struggling due to behavioral and mental health issues.

Telemedicine is leveraged to provide psychiatric services to those

students in schools deemed to have violence risk and suffering

behavioral health problems.

TWITR Results

Over the first two years of the TWITR Project, those students receiving psychiatric services via telemedicine had a 37% reduction in referrals for truancy and discipline problems.

Vision 21, Building State Technology Capacity Telemedicine Psychiatric Services for Children’s Advocacy Centers of Texas (TPSCAC)

To provide support for technology improvements to enhance current systems, build new systems to increase access to technology, increase victims access to resources, and increase the accuracy of administrative reporting.

Builds on the TWITR model to provide psychiatric services via telemedicine to sexually and physically abused children seen at several Children’s Advocacy Centers across Texas without access to psychiatric services.

The project is in its early stages and outcome data are not yet available.

Questions