IDD and Behavioral Health: A Local and National View of Trends and Outcomes - PowerPoint Presentation

IDD and Behavioral Health: A Local and National View of Trends and Outcomes Luke Reynard, MBA Chief of Disability Services My Health My Resources (MHMR) of Tarrant County Clara Daniel, MA Director for IDD Services-Authority Lakes Regional MHMR

Systemic Challenges IDD : a disability that involves impairments of general mental abilities that impact adaptive functioning in three domains 1.5% to 2.5% of the population has an intellectual or developmental disability (IDD) 30% to 35% of people with IDD have mental health conditions, too Incidence/prevalence of mental health conditions is 2 to 3 times that of general population 2

Systemic Challenges: Barriers in IDD & BH Systems “ Troublesome” behaviors considered unacceptable in many support and service venues The last and least served Stigma Much more likely to use emergency room (ER) services Lack of training (diagnostic overshadowing) Lack of expertise Medication issues Believed that challenging behavior was a result of developmental issues alone “Did not have IQ for depression” Primary vs. secondary diagnosis instead of presenting issue MH “language” vs. IDD “language” The person’s perspective vs. the provider’s perspective 3

MHMR Tarrant Needs Assessment and Gap Analysis Need f or crisis prevention services 20%-30% of people with IDD and Autism Spectrum Disorder (ASD) have co-occurring mental health diagnosis or behavioral issues People with IDD have difficulty accessing services Providers lack expertise in how to treat people with co-occurring disorders Professional consensus for need of effective MH services for people with IDD/ASD Reduce ER utilization 4

MHMR Tarrant START Program START Systemic, Therapeutic, Assessment, Resources, & Treatment Developed in 1988 by Joan Beasley, Ph.D. Designed to serve people with co-occurring IDD and BH needs Strengthen communication and collaboration with existing systems of support5

MHMR Tarrant START Program: Core Components Enrich the system (avoid strain) Promote linkages (i.e. the use of a linkage "team") Fill in service gaps Services provided across systems and needs ( bio-psycho-social) Expertise, training, mentoring improves capacity OutreachPositive psychology/strength-based approach Develop a common language Data-driven approach6

MHMR Tarrant START Program Services 24-hour , 7-day-a-week crisis response capability Therapeutic emergency respite facility to provide short-term planned and emergency respite services Psychological/behavioral support services In-home mobile supports Intensive service coordination 7

MHMR Tarrant START Program 8

MHMR Tarrant START Program: Data Collection and Analysis Data c ollection START Information Reporting System (SIRS) Collect and report on various data to provide evidence-informed information to stakeholders and community members Web-based data collection system Provides services outcome feedback to PMs and administrators Captures de-identified information and can report by: Case load Region State Supports a continuous quality improvement approach 9

MHMR Tarrant START Program: What We Gather Services provided Clinical Education Teams (CETs) Assessment Aberrant Behavior Checklist (ABC) Recent Stressors Questionnaire Family experiences with mental health services for people with IDD Matson Evaluation of Drug Side Effects Comprehensive Service Evaluations (CSEs) Systemic consultation 24-Hour crisis response Therapeutic Resource Center In-home support services 10

MHMR Tarrant START Program People We Serve 84 % of START referrals come from Service Coordination, almost half of those are from the HCS Waiver 77% of individuals are referred to START because of aggression 36% are diagnosed with ASD 57 % have a speech/communication disability 77% have a psychiatric diagnosis 65% of callers who used the on-call crisis line were able to be maintained in their current setting 3 people went to the hospital in June and July, twice each. After START, NONE of them have been back to the hospital 11

MHMR Tarrant START Program People enrolled and received services since the program began, August 2014 (N=604). Tarrant County serves children (6-17) and adults (18 and older). 12

START Data: How Tarrant Compares to other START Programs 13

MHMR Tarrant Source or Referrals Tarrant Other START Programs (122) (2,104) Case Manager 94% 69% Emergency Department/mobile crisis 2% 6% Family Member 1% 6% Residential/Day Provider - 8% Mental Health Practitioner 2% 2% Other (Behavior Analyst, School) 1% 8% 14

Reason for Referral: Children 15

Reason for Referral: Adult 16

Reasons for Enrollment   Children Adults Tarrant Other START Tarrant Other START 55 568 67 1536 Aggression 91% 91% 84% 81% Family Needs Assistance 76% 75% 43% 34% Risk of losing placement 2% 20% 9% 24% Decreased Daily Functioning 0% 23% 3% 26% Dx and Treatment Planning 2% 25% 4% 24% Mental Health Symptoms 13% 39% 18% 57% Leaving Unexpectedly 16% 24% 19% 18% Suicidality 15% 11% 16%19% Self-Injurious Behavior25%31%28%30% Sexualized Behavior 9%15%12%10% Transition from Hospital 4%10%6%8% 17

Demographics   Children Adults Tarrant Other START Tarrant Other START 55 568 67 1536 Mean Age (Range) 13 (6-17) 14 (6-17) 30 (18-60) 31 (18-77) Gender (% male) 69% 76% 66% 61% Race         White/Caucasian 71% 49% 61% 64% African American 15% 24% 27% 20% Asian 2% 3% 3% 2% Other 4% 9% 1% 6% Unknown/Missing 9% 14% 7%8%Ethnicity (% Hispanic)27%14%18%10%Level of Intellectual Disability (%)     No ID/Borderline7%12%9%7% Mild53% 33% 49% 48% Moderate25%29%19%32% Severe-Profound7%8%16%8% None Noted4%15%4%4% Missing4%3%1%2% 18

Living Situations   Living Situation (%)   Children Tarrant Children Other START Adult Tarrant Adult Other START Family 93% 90% 43% 52% Group Home and Community ICF/DD 4% 5% 42% 28% Independent/Supervised - - 3% 11% Psych. Hospital/IDD Center - 3% 1% 4% Other (Jail, Homeless, “Other”) 2% 1% 6% 3% Missing 1% 1% 4% 2% 19

Mental Health Conditions   Children Adults Variable Tarrant Other START Tarrant Other START N 55 568 67 1536 Mental Health Conditions (%) At least 1 diagnosis Mean Diagnoses (range)   93% 2.3 (1-5)   89% 2.1 (1-7)   96% 2.5 (1-7)   88% 2.1 (1-7) Most Common MH Conditions (%)         Anxiety Disorders 18% 16% 11% 19% ADHD 73% 48% 34% 25% ASD 69% 70% 42% 30% Bipolar Disorders 16%8%30%23% Depressive Disorders20%21%50%28% Disruptive Disorders27%30%28%27% OCD10%6%5%9% Personality Disorders-0%11%10% Schizophrenia Spectrum Disorders 2% 3% 28%23% Trauma/Stressor Disorders10%12%11%14%20Table IV: Mental health conditions

Frequency of Mental Health Conditions for Enrolled C hildren 21

Frequency of Mental Health Conditions for Enrolled Adults 22

Medical Conditions   Children Adults Tarrant Other START Tarrant Other START 55 568 67 1536 Medical Conditions (%) At least 1 diagnosis Mean Diagnoses (range)   56% 2.0 (1-7)   43% 1.7 (1-7)   79% 1.8 (1-6)   64% 2.0 (1-11) Most Common Medical Conditions (%)         Cardiovascular 10% 6% 9% 21% Endocrine 16% 10% 30% 25% Gastro/Intestinal 29% 26% 17% 26% Genitourinary 13% 6% 8%6% Immunology/Allergy19%14%8%10% Musculoskeletal13%7%8%7% Neurologic42%41%32%40% Obesity10%7%6%13% Pulmonary disorders 23% 18% 8%10% Sleep Disorder13%4%9%7%

Frequency of Mental Health Conditions for Enrolled Children (Trend A cross START Nationally) 24

Frequency of Mental Health Conditions for Enrolled Adults (Trend Across START Nationally) 25

Emergency Service Utilization   Children Adults Tarrant Other START Tarrant Other START 55 568 67 1536 Psychiatric Hospitalization         Prior to enrollment, N (%) 17 (31%) 188 (33%) 26 (39%) 560 (36%) Mean Admissions (range) Missing During START, N (%) Mean (range) Emergency Department Visits Prior to enrollment, N (%) Mean Visits (range) Missing During START, N (%) Mean (range) 1.6 (1-4) - 4 (7%) 1.3 (1-2)   24 (44%) 1.7 (1-4) - 4 (7%) 1.3 (1-2) 1.8 (1-12) 39 (7%) 54 (10%) 1.3 (1-3)  204 (36%)2.5 (1-24)45 (8%)67 (12%)1.9 (1-10)2.3 (1-5)1 (1%)7 (10%)2.1 (1-8)  32 (48%)2.2 (1-6)2 (3%)5 (7%)1.0 (1)2.0 (1-20)63 (4%)200 (13%)1.9 (1-13)  723 (47%)3.4 (1-30)96 (6%)330 (21%)2.8 (1-43)26

Change in frequency of pre and post START enrollment emergency service utilization(children) 27

Change in Frequency of pre and post START enrollment emergency service utilization(adults) 28

Aberrant Behavior Checklist Significance (Since Jan. 2017) 29

MHMR Tarrant START: Where We Spend Our Time 30

MHMR Tarrant START: Where We Spend Our Time 31

MHMR Tarrant START: Where We Spend Our Time 32

MHMR Tarrant START: Crisis Contacts 33

MHMR Tarrant START: Planned Resource Center Utilization

Life After DSRIP HB 13 Community Mental Health Grant Community partnership with Mental Health ConnectionMental Health America of Greater Tarrant CountySupport community mental health programs and coordinate mental heath care for people with mental illness and other needed supports, such as IDD 35

Life after DSRIP Cont’d HHSC Crisis Respite FundsHHSC Crisis Intervention Specialist 36

MHMR Tarrant START: Next Steps Data analysis to improve services Review longitudinal trends to proactively address systemic needs Continue outreach and education activitiesWork collaboratively with community partners to address gaps Continue to compare ourselves to other programs to identify services that provide the greatest impact 37

Using Telehealth to Address Barriers to Serving Dually Diagnosed Individuals 38 IDD and Behavioral Health: A Local and National View of Trends and Outcomes:

DUAL DIAGNOSIS PREVALENCE RATES Definition of dual diagnosis : the co-existence of the symptoms of both intellectual or developmental disabilities and mental health problems A few decades ago, it was believed that ID could not co-occur with mental illness Behavioral issues were associated with the ID diagnosis and were learned behaviors to be addressed with behavior management alone Emerging research has shown that the prevalence level of dual diagnosis for this population is estimated to be higher than the general population (Florida DD Council Guidelines for Dual Diagnosis, 2009) The estimates range from 15% (Cadman, Boyle, Szatmari, & Offord, 1987) to 41% (Einfeld & Tonge, 1996). A more recent summary of the research indicates a 30% prevalence rate (Fletcher,Loschen, Stavrakaki, & First, 2007) Baker et al. (2003) found the same level of emotional issues in children younger than 4 years of age with mild intellectual disabilities 39

40 Prevalence Factors : Why the increased vulnerability to mental health problems in persons with IDD ? Stress due to stigma and negative social conditions throughout the lifespan, language difficulties, social rejection and inadequate social supports, high frequency of nervous system impairment Behavioral phenotypes, genetic syndromes with characteristic behavior and emotional patterns

National Core Indicators (NCI)–(NCI Data Brief: Issue 6, December 2012) NCI (data from an adult consumer survey of 8796 adults from 15 states in 2010-11) tells us about adults with IDD taking prescribed medications for anxiety, behavior challenges, mood disorders or psychotic disorders In the study, adults with intellectual and developmental disabilities taking medications for one of the three mental health conditions or behavior differed from those who did not take any medications in several ways 41

NCI Study Participants were : Slightly less likely to be profound ID and more likely to be mild ID Slightly older and slightly less racially diverse More likely to be living in a group home and less likely to be living at home with family Significantly more likely to have a diagnosis of autism spectrum disorder and slightly less likely to have cerebral palsy, a physical disability, or Down syndrome More likely to smoke More likely to be obese or overweight 42

43 Of NCI Study Participants . . . 8% taking prescribed medications did not show a need for additional supports 49% needed supports in addition to prescribed medications for one or all three mental health conditions and challenging behaviors 88% of people with a psychiatric diagnosis were taking meds for mood, anxiety or psychotic disorders 30% of participants with no psychiatric diagnosis took medications for one or all of three mental health conditions

44 Comprehensive Community Health Support Standards (AAIDD 11 th Edition Definition and Best Practices Manual) The seven standards are meant to “…optimize health and the well- b eing of persons with ID. . .” (135 -8): Intellectual Disability: Definition, Classification and Systems of Supports), and include the understanding that: “. . . [a] ll needed health supports [should be] obtained from the same s ources as those provided to everyone else in the community. . .” Standard #7 states: “People with IDD will have access to comprehensive mental health and behavioral health services/supports and other allied services/supports to meet their needs within the community.”

45 Regarding health outcomes in AAIDD standards : Improved quality of daily living may be a tangible result of treating chronic conditions, such as taking medications for psychiatric illness (147) The integration of health-related supports is difficult to measure and requires: Identification of sources of health supports Assessment of access to health care to determine if it is timely and appropriate Evaluation of insurance-related barriers and supports Health services be provided in a consistent manner with clear and measurable goals consistent with the individual’s goals and values

46 NASDDDS – National Association of State Developmental Disabilities Directors -- Guidelines for Understanding and Serving People with Intellectual Disabilities and Mental, Emotional, and Behavioral Disorders :“. . .when working with individuals with intellectual disabilities and challenging behaviors, it is essential that a functional assessment be completed. . .” (Putnam, 2009, p 22) “Recent studies have shown that psychotherapy can be effective with persons with mild developmental disabilities. Prout and Nowak-Drabik (2003) found a moderate level of effectiveness of psychotherapy and concluded that psychotherapeutic interventions should be considered as part of overall treatment plans for persons with ID.” (Putnam, 2009, 24) Aman et al (2004) found that cognitive behavioral therapy is recommended for some persons with ID to address thought processes, biased perceptions and unrealistic expectations, attitudes and emotions (Putnam, 2009, 25).

47 Best Practice for Psychopharmacology (NADDDS, Putnam, 2009, 24) Medication should not be used in isolation of other treatment,and should be implemented only with the guidance of an interdisciplinary team using the biopsychosocial model of care, and only after the following areas have been reviewed: • Medical conditions • Psychosocial and environmental conditions• Health status and history• Current medications • Psychiatric diagnosis • History of previous interventions and their results • Functional analysis of behavior

48 Dual Diagnosis and Obstacles to Care (NADDDS, Putnam, 2009): Increased visibility of dually diagnosed individuals is due to deinstutionalization and integration of IDD individuals in the community Obstacles to appropriate care for this population is possibly due to:Diagnostic overshadowing (overlooking or minimizing psychiatric disturbance in individual who is IDD)Minimizing the psychiatric disorder as the result of intellectual deficits (issue of primary diagnosis) Funding of mental health and IDD administratively separate – each expects the other to serve the person who is dually diagnosed Staff may feel ill-equipped (lack of appropriate training) to provide adequate diagnosis and/or services to individual with needs in both areas Lack of physical access to mental health clinics & psychiatrists in rural areas 6. Insufficient provider network in managed care

49 Possible solutions to care for dually diagnosed individuals based in recommended best practices (NADDDS, Putnam, 2009): Psychopharmacology using a biopsychosocial model Psychotherapy – individual and group Behavioral Management Skills training Residential services Physical/speech/occupational therapies Crisis Intervention Services

50 Telehealth/Telemedicine can address barriers to access to a psychiatrist/prescriptions for the dually diagnosed population in a cost-efficient delivery system : “Telehealth offers one potential strategy to help achieve the triple aim of better health care, improved health outcomes and lower costs. . .new projects estimate that health care spending in the US will increase by an average of 5.8 per cent per year . . .through 2024(National Conference of State Legislatures, 2015. (p 6).. . .[t] elehealth is a tool – or means – of delivering care that capitalizes on technology to remotely provide health care and other health services. It brings the services directly to the patient, changing the way patients and their families can interact with providers and the health care system” (NCSL, 2015, p6).

51 Defining Telehealth/Telemedicine Health Resources and Services Administration (HRSA) defines Telehealth as “the use of electronic information and t elecommunications technologies to support and promote long-distance clinical health care, patient and professionalhealth-related education, public health, and healthadministration” (NCSL, 2015, p 6).Telemedicine refers to “. . .clinical services” specifically deliveredthrough Telehealth (6), and means “. . .the practice by a dually l icensed physician or other health care provider acting within t he scope of such provider’s practice, of health care delivery, d iagnosis, consultation, treatment, or transfer of medical data by m eans of audio, video or data communications which are used d uring a medical visit with a patient or which are used to transfer m edical data obtained during a medical visit with a patient. Standard telephone, [faxes], unsecured email, or a combination t hereof do not constitute telemedicine services” (NCSL, 2015, 7).

52 Telepsychiatry: C an be used as a real-time or live video between a patient and/or family member and provider. Its popularity is considered “high ”(Review of Trends in Research And Practice, NCBI, p 6). 2. Is defined by Wikipedia as:“. . .[t]he delivery of psychiatric assessment and care through telecommunications technology, usually videoconferencing,” and can involve “. . .providing a range of services including psychiatric evaluations, therapy (individual, g roup, family), patient education and medication management” (APA Website). Can involve “. . .direct interaction between a psychiatrist and the patient.. .[m] ental health care can be delivered in a live, interactive c ommunication. . .[and can involve] recording medical information (images, video) and sending this to a distant site for later review” (American Psychiatric Association website).

53 Advantages of Telepsychiatry to patient and provider Equivalent to in-person care in diagnostic accuracy, treatment effectiveness, quality of care and patient satisfaction (American Psychiatric Association website) Individuals with autism or severe anxiety or severe physical limitations may prefer this format for treatment to in –person care (APA website)Has been found effective in treatment of PTSD, depression and and ADHD (APA website) APA has published a Best Practices in Video-Conferencing Based Telemental Health Guide

54 Telepsychiatry and Mental Health: Addressing the Barriers to Care The World Health Organization has estimated that 450 million people are affected by mental or behavioral disorders worldwide; five of ten leading causes of disability and premature death are associated with psychiatric conditions ( Recent Directions in Telemedicine: Review of Trends in Research and Practice, NCBI, p 6)Telepsychiatry is a promising approach to delivery of mental health services that is needed to increase access to evidence-based care in rural areas, and to address the increasing shortage of psychiatrists nationally, [and in Texas] (Review of Key Telepsychiatry Outcomes, NCBI, P 2) The US is suffering from a dramatic shortage of psychiatrists and other mental health providers; the shortfall is worse in rural areas, some urban neighborhoods, and community mental health centers that serve the severely mentally ill (Addressing the Escalating Psychiatrist Shortage, AAMC News, Weiner, 2018).

55 The growing psychiatrist shortage The need for treatment is expected to rise as the number of psychiatrists falls (AAMC News, Weiner, 2018)By 2025, demand may outstrip supply by 6,090 to 15,600 psychiatrists, according to a National Council for Behavioral Health 2017 report The number of psychiatrists in more than half of US counties is 0 according to a 2016 Health Affairs report People in the US living in mental health shortage areas: 111 million (US Dept. of Health and Human Services) 2 out of 3 primary care physicians reported having difficulty referring patients for mental health care (Health Affairs report 2016) Over a recent 3 year period, a 42 percent increase in visits to ER for psychiatric services (National Council for Behavioral Health)

56 Telepsychiatry in Texas addressing shortage of psychiatrists Like the 1 in 5 statistic for incidence of mental illness nationally, 1 in 5 Texans or 5.4 million people will experience a mental health concern at some point this year (Iris Telehealth website) Nearly 20% of children ages 9 to 17 have a diagnosed mental Illness in Texas (Iris Telehealth website)There are only 8 psychiatrists per 100,000 children (Iris Telehealth Website) The shortage is more pronounced in rural areas (Iris Telehealth) Medicaid reimbursement is available for the following Telemedicine services: consultations, office or outpatient visits, psychiatric diagnostic interviews, medication management, psychotherapy and data transmission. Reimbursable practitioners are: Psychiatrist, Nurse Practitioner, LCSW and LPC (Iris Telehealth).

57 Nearly 1 in 5 US Residents lives in a rural area (SAMHSA In Brief, Fall 2016, Volume 9, Issue 2) Individuals living in rural locations experience mental and substance use disorders at rates similar to and sometimes higher than those of their urban counterparts Mental health and mental disorders were ranked as the 4 th priority in a list of 10 rural health prioritiesDespite having a similar need for services, people in rural areas have less access to the behavioral health continuum of care than do people in rural areas People in rural areas face additional barriers such as a lack of adequate internet infrastructure, having to travel long distances to see specialty providers, and a lack of anonymity about receiving treatment Two major concerns facing individuals in rural areas: lack of privacy and a lack of culturally appropriate care (and cultural taboos around seeking treatment)

58 Addressing Acceptability Barriers (Rural Behavioral Health: Telehealth Challenges and Opportunities, Fall 2016, Vol. 9, Issue 2) Telehealth clearly has the potential to provide confidential t herapies, enabling individuals in rural communities to access treatment and services Treatment relying on telehealth systems could be accessed from hospitals, clinics, educational institutions, professional offices and other settings that offer privacyBurke Center was mentioned in this national study for offering comprehensive emergency psychiatric services entirely by Telepsychiatry, covering 400,000 people dispersed over 11,000 Square miles. . .within 1 hour of arrival, patients are assessed and engaged via videoconference by phone within 5 minutes. . .the center contracts with psychiatrists at a private behavioral health Telemedicine practice in Houston.

59 Lack of practitioners and Telehealth – the single area where improved p atient care could be realized is in the significant expansion and activeuse of telehealth (In Brief, Fall 2016, Volume 9, Issue 2) More than 75 percent of all US counties are mental health shortage areas, and half of all US counties have no mental health professionals at allHRSA estimates that more than 7,700 professionals are needed to fill existing behavioral health workforce gaps due to low pay, professional isolation, difficulty for spouses to find work, few social outlets and educational opportunities, and difficulties adjusting to rural life Telehealth can bridge the rural-urban treatment gap by linking rural clients to high –quality behavioral health services and providers located in more populated areas Video telehealth provides the intervention most similar to office-based treatment, with satisfaction levels and outcomes similar to those of clients receiving in person therapy

60 Accessibility Barriers and Telehealth (In Brief , Rural Behavioral Health: Telehealth Challenges and Opportunities, Fall 2016, Vol. 9, Issue 2 ) Many individuals in rural areas are not able to drive due to not having a driver’s license, a reliable car or public transportation options More than 1.6 million families living in rural locations do not have a car according to the US Agriculture Economic Research Service –These individuals living in rural locations without a car may not want to be away from their families or leave children with others to take a long trip to see a provider. Indigent individuals may not be able to afford transportation or the cost of care Telehealth can offer clients and providers more convenient ways to access services, resulting in reduced travel time and expense, less time away from families and fewer missed appointments Telehealth also saves institutions the expenses associated with their practitioners’ travel to distant sites More insurance carriers are recognizing that telehealth is able to provide evidence-based care in a cost-effective way that is also HIPAA compliant

61 Reported benefits of telehealth for residents in rural and remote areas : In Australia in 2010 (Australian Health Review 2010 Aug: 34 (3): 276-81), The reported benefits of telehealth for rural Australians found the following benefits to offering telehealth for people living and professionals working in rural and remote areas of Australia: Lower costs and reduced inconvenience, improved access to services and improved quality of clinical health services Improved access and quality of clinical care contributing to decreasing urban-rural health disparities

62 Community Center Telemedicine and Telehealth Survey – Texas Council of Community Centers, July, 2016 Collective responses from 39 community centers in Texas Representing providers in both urban and rural service areas 97% provide psychiatric services through telemedicine and 33% provide counseling through telehealth Common Advantages Reported in Survey Centers indicated that telehealth is an effective means of delivering mental health services, particularly in rural areas with provider workforce shortages, clients are able to access specialty services more quickly in their own communities, avoiding long commutes to distant sites. Providers are able to shorten or eliminate travel time from their homes to offices. . . Favorable quality and quantity outcomes like improved access to care, more frequent visits, less client no-shows, shorter wait times, 24/7 access for clients in crisis, better coordination and continuity of care, i ncreased client and provider satisfaction

63 Common Barriers Reported in Survey – Community Center Telemedicine And Telehealth Survey, July 2016 High cost of providing service reported by 51%; insufficient reimbursement 38% High cost attributed to hiring or contracted with qualified providers, developing technology infrastructure and electronic medical records, using external IT support and maintaining sufficient connectivity Low Medicaid reimbursement rates create financial challenges –in particular, fee for service and managed care rates are significantly lower than the hourly rates centers pay contracted telemedicine providers like psychiatrists Some issues with collecting fees from private insurers, who may choose not to contract for telehealth services; some barriers with Medicaid claims denials and disputes (10%) Lack of qualified providers and workforce shortages (33%) Other barriers: sporadic internet connectivity, challenges with audio and visual quality in rural areas, inadequate equipment, added scheduling and presenter costs, MCO prior authorization processes, provider turnover and client no shows (still have to pay providers’ hourly rates)

64 Lakes Regional Community Center Telemedicine/Telehealth Project – Data from 2013 for 1115 Waiver Needs Assessment Key Personnel and Processes for Telemedicine Implementation– Well-trained, licensed clinician to meet individual program needs before, during after Telehealth encounters 2. Agreements to assure licensing and credentialing, training and authentication of individuals and practitionersQuality Assurance process to assure privacy and confidentiality, provision of systematic quality improvement and performance management process Essential clinical and performance data analysis processes Expansion of network infrastructure with high speed connectivity from Lakes Regional HQ in Kaufman County to internal and external specialists Clinical – hire licensed QMHP or nurse to oversee sessions; Quality Assurance to monitor QI processes, HIPAA compliance, and performance management (use of existing staff); Data Analysis – conduct and monitor clinical data analysis and tracking; IT – technical support team members to m onitor and assist with Telehealth implementation

65 Lakes Regional Community Center’s current IDD Telehealth/ Telemedicine Program Technology Platform: Skype for Business is the cloud-based software used as part of Microsoft Office 365 Suite – HIPAA compliant Psychiatrist is based in Houston; sees clients quarterlyA presenter must be in the room (a QMHP or nurse) for medical questions/data like BMI’s; presenter monitors the session and the equipment; looks up labs – nurse has to call in scripts for controlled substances and the nurse explains things to the individual and family The doctor bills for the session and the presenter bills (managed care) Sometimes kiddos don’t get prescribed meds but behavior therapy or other specialized therapies Referral sources: #1 from Service Coordination at Lakes Regional; #2 outside programs; #3 Lakes Regional MH Clinics;#4 Psychiatric inpatient facilities like Terrell State Hospital, Green Oaks, etc. #5 Doctors at East Texas Medical Center Criteria – must have previous records, a DID, a diagnosis or previous diagnosis in records; autism or IDD, but some referrals with ADHD E Scripts go from Cerner to pharmacy of choice which then mails out to individual/family if the family chooses that service

66 Lakes Regional IDD Telehealth/Telepsychiatry : Initial Evaluation is one hour, then follow up sessions for IDD usually last half an hour, typically once per quarter (and priority scheduling within 7 days for individuals discharging from inpatient psychiatric hospital care)Presenter reviews and informs doctor of patient vitals, BMI, recent significant events or behaviors, monitors Telemed equipment, ensures client understanding of D r’s orders, reviews medication instructions with individual/family, orders doc requested lab work, completes prior authorizations for meds that MCO’s frequently require Scheduler/coordinator maintains clinic schedule, makes appt. reminder calls, takes vital signs and prepares consents, scans labs and enters info into Cerner EHR, monitors billing compliance Locations for IDD Telehealth: Kaufman, Hunt, Lamar, Ellis and Navarro counties; additional access For IDD individuals at MH Telehealth clinics in rural counties in Hopkins, Lamar and Titus counties

67 Telemedicine/Telehealth Studio Systems Service Delivery Equipment Doctor’s and Homebased Systems Dual Monitors – One for Video Session, One for the EHR Application Camera-Codec, Single PC or Dual PC’s

68 Headsets Microphone/ Speakers

69 Lakes Regional - Microsoft Office 365

70 1115 Telemedicine/Telehealth Expansion Project Expanded Telemedicine Services to Individuals in Need Across Our Counties Services Provided for Mental Health Clients and Dually Diagnosed IDD Individuals Kaufman County : Brown Building IDD Programs, MH Clinic, IDD Crisis Respite Cottage Rockwall County: MH Counseling Center, IDD Day Program Navarro County: Navarro IDD Programs, MH Counseling Center, IDD Crisis Respite Home Ellis County: Executive Court and IDD Day Programs Other Counties: MH Clinics, IDD Day Programs, MH Counseling Centers, Integrated Care Mobile Bus

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73 Lakes Regional Client Satisfaction Questionnaire Data on IDD Telemedicine/Telehealth – measures and assesses c onsumer satisfaction with mental health, health care, and h uman services (self-administered, with data collected at end of services)Region 9 overall score 2016-17 – 92.10 (high satisfaction) Regional 10 overall score 2016-17 – 92.52 (high satisfaction) Region 18 overall score 2016-17 – 91.86 (high satisfaction) Satisfaction with IDD Telemedicine/Telehealth is currently measured v ia satisfaction surveys evaluated by QM staff with items such as: Were you able to schedule an appointment easily? Was the office staff courteous and helpful? Were you satisfied with the amount of time spent with the doctor? Did the doctor fully explain all medications and side effects? Did the medical staff answer all of your questions? Was the service you received helpful? An opportunity to give suggestions is available as item #10

74 IDD Telemedicine Testimonials answered by IDD Service Coordinatorsregarding individuals on their caseloads “The individual and I talked a lot about how he could trust Dr. ---and that it is Ok to tell him anything and that it is confidential. He wanted me to go in with him to help him tell the Dr. about his depression that he was afraid to talk about. They do a good job monitoring his medication. Karen (Telemedicine Coordinator) even came to his SPT meeting that we had and we discussed making sure that he is taking his correct medications for the correct thing at the right time. Dr. -- took the time to listen to everything that was REALLY going on with the individual once he started actually talking about it.” _____________________________________________________________________ “The doctor took extra time to talk to an individual about her traumatic h istory. She had never talked to anyone about her past. He took e xtra time with her and was very compassionate. She was comfortable e nough to talk with him about this painful subject. He did a wonderful job listening to her.”

75 IDD Telemedicine Testimonial Lakes Regional from a parent . . . “In the past 2 years the IDD Telemedicine psychiatrist at Lakes has assisted my son with changing meds and helping us find the right treatment. . .He is almost a completely different child. We have been able to take him out to eat as a family again and to the store shopping. He has helped us be more as a family in the community and not keep him shut up at his group home missing family functions or dinner events due to his behaviors . Another thing the doctor assisted with is out of 3 doctors seeing him, h e was the first one to recognize a health problem with our son and assisted us with pursuing additional testing due to his extreme weight loss and increased seizures. Once we took the doctor’s concerns to his PCP and she sent our son for an endoscopy to find out that he had a severe stomach bacterial infection. He just received a clean bill of health today and is doing amazing.”

76 Lakes Regional IDD Telemedicine testimonials ctd . “1. We do not have to drive 65+miles to see a Dr ; 2. We do not have to sit in a waiting room full of people beforeseeing the Dr and he is always on time. Most do not understand the importance of this, unless they too have a child with little to no patience; 3 . Dr ___speaks to my son with respect and encouragement and then he is able to leave with my parents so I can fully utilize the time with the Dr discussing meds, weight, sleep patterns , etc. As with any medication, I like to know exactly what I’m giving him, how it works and what to look out for as far as side effects; 4. I have seen more success in my son the past couple of years thanI have in many years. I would like to THANK any and all who have helpedus out during this time. Without this program I’m not sure where we would be now.”

77 Telemedicine/Telehealth Expansion Project Delivering an Array of Telemedicine/Telehealth Services: Psychiatric Evaluations, Medication Management, Skills Training, Nursing, Counseling, Behavioral Support, Nutritional Training, and more… Delivering Services that are Satisfying the Needs of our Client/Individuals (CSQ-8 Satisfaction Surveys – Positive Results)

78 Next Steps for IDD Telemedicine at Lakes Regional: Expand IDD Telemedicine access to the rural IDD Counties – some individuals and families still have to travel a distance to receive IDD Telemedicine at available locations if they may have a wait to get an appointment the MH Clinic Telemedicine unit closest to themImprove on technology in rural areas to make this access achievable Improve on cost-efficiency of the service? Look at the possibility of home-based Telemedicine?