NFAR TOT Administrators Manual

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Administrators Instructor Manual

Te l e h e a l t h Te c h n o l o g i e s Training of Trainers

Telehealth

Telehealth Technologies Training of Trainers Administrators Manual www.nfarattc.org July 2013

This publication was made possible by Grant Number TI024TT9 from SAMHSA. The views and opinions contained in the publication do not necessarily reflect those of SAMHSA or the U.S. Department of Health and Human Services, and should not be constructed as such.

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Introduction It is essential that organization administrators be able to access accurate information about implementing telehealth technologies to make informed decisions. This TOT provides you with the resources to introduce administrators telehealth: trends; outcomes; costs; reimbursement; technologies; and an agency-focused Telehealth Capacity Assessment Tool.

Learning Objectives At the end of the TOT, participants will be able to: • List three telehealth trends and/or research outcomes • Identify two types of telehealth counseling services and three web-based support activities • List and describe the five types of telehealth readiness • Implement scoring procedures for the Telehealth Capacity Assessment Tool.

• Illustrate how the types of telehealth readiness interact with the domains of innovation implementation to influence implementation effectiveness • Describe two foundational tenets of organizational change management • Discuss the three levels of individual resistance to change • Demonstrate an understanding of the decision-making processes associated with implementation • Access a telehealth reimbursement map • Understand the current reimbursement policies, practices and coding requirements for the use of addiction treatment services delivered via telehealth • Review at least four “lessons learned” related to successful implementation of telehealth technologies

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Slide 2.1 Finding a way to fund telehealth services is a vital component to offering and maintaining treatment services.

Reimbursement through Medicaid, Medicare and/or Commercial Private payors • They are transforming and beginning to reimburse for some telehealth services; not all telehealth costs are reimbursed.

• There have been and will be a number of changes that will need to occur in the addiction treatment field as the Affordable Health Care Act increases the need and demand for behavioral health services.

• Medicare, to some extent, has set the standard and decides telehealth reimbursement based on where the patient is located.

• If you or your agency currently accepts Medicare, Medicaid, or private insurance benefits, you are aware that the rules change almost daily.

Slide 2.2 The intent of this presentation is not to give you hard and fast answers about reimbursement, but rather provide a general understanding of the current policies, practices and requirements for providing addiction treatment services using telehealth technologies.

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Slide 2.3 Key terms will be defined as we move along. However, keep in mind that • definitions are different based on the context in which they are being used; • understanding the “lingo” is an “art form”; • definitions and other key phrases are important for understanding the ways in which telehealth services can be delivered, billed, and reimbursed.

Slide 2.4 As a reminder: • For the purpose of this presentation, we are using the Institute of Medicine’s (IOM) 2012 definition of telehealth, which states that telehealth is • ‘the use of telecommunications and information technologies to provide access to health information and services across a geographical distance’.

• The decision to use the IOM definition of telehealth is based on the broad aspect of the definition as it applies across disciplines, including education as the access to health information.

• Many of the “formal” definitions and explanations used in healthcare delivery systems often use the word “medical.”

• Many, but not all, mental health and substance use services are intended to be covered by the term “medical” in this presentation.

• For example, CMS (Centers for Medicare and Medicaid Services) does not provide a definition of telehealth and therefore mostly refers to telemedicine.

• As you can see, IOM’s definition of Telemedicine differs slightly from CMS’s definition of Telemedicine. Although similar in meaning, it is important that you are aware of the differences as it relates to reimbursable service via telehealth.

Source http://www.cms.gov/apps/glossary/

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Slide 2.5 The next two slides provide terms that you will encounter when researching reimbursement for telehealth services.

Fee-for-service • Refers to a healthcare delivery and payment system where health care providers are paid for each service provided.

• In Part A and Part B Medicare, providers are paid via a fee-for-service payment system.

Managed Care • Includes any arrangement for health care in which an organization acts as an intermediate between the person seeking care and the physician, for example: A Health Maintenance Organizations (HMO), another type of doctorhospital network, or an insurance company • This can be fiscal, contractual or other techniques in which payors (you, me or agency) contract with health plans and work with health care providers and medical facilities to provide care for members at reduced costs.

• Managed care approaches often prepay the health care delivery system in exchange for providing preventive services, quality management and utilization strategies, and assurances of network sufficiency.

• Federal law allows Centers for Medicare & Medicaid Services (CMS) to implement managed care implementation through Medicare Part C and in the States through Medicaid 1115 (demonstration) and 1915 managed care waivers.

Sources http://www.cms.gov/apps/glossary/ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ telehealthsrvcsfctsht.pdf

Slide 2.6 Remote Patient Monitoring (RPM) Healthcare Provider • Uses telehealth technologies to collect medical data from patients in one location and electronically transmit that information to health care providers in a different location.

• Health professionals monitor patients remotely and, when necessary, implement medical services on their behalf.

Think of it like this: health (patient) data are collected, the data are transmitted and evaluated, the patient is notified and an appropriate intervention is decided.

Example Texting Portable Contingency Management is a study about instructing clients on how to take a video of themselves while conducting a self-administering Blood Alcohol Content (BAC) reading and sending the results to their treatment provider. In the study, some clients received a minimal reward for completing the task regardless of result of the BAC (negative or positive). The clients in the experimental design group who reported negative BACs got vouchers and a thank you text had better outcomes than the control group.

Source www.cchpca.org/what-is-telehealth/patient-monitoring

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Slide 2.7 Asynchronous and Synchronous Communication: As an administrator of your agency, it is important to understand the difference between Asynchronous (Store and Forward) and Synchronous forms of communication, especially as it pertains to Medicare reimbursement.

• Asynchronous (store and forward technology): • Store and Forward Technology is the acquisition and storage of clinical information (e.g. data, image, sound, video) that is then forwarded to or retrieved by another site for clinical evaluation at any time.

• Asynchronous enables communication and collaboration over a period of time through a “different timedifferent place” mode.

• Examples of Asynchronous communication are: discussion boards, web blogs, email, narrated slideshows, streaming videos, databases, web books, surveys or polls, and shared calendars.

• Synchronous: • Synchronous tools possess the advantage of being able to engage people instantly through real-time communication and collaboration in a “same time-different place” mode.

• These tools allow people to connect at a single point in time, at the same time.

• Examples of synchronous communication are: audio, web or video conferencing, chat, instant messages, and whiteboards.

These definitions should remain as an important concept as you decide to implement telehealth services and deliberate on which forms or tools to utilize in providing the service, e.g., videoconferencing vs. discussion boards.

Sources The Center for Association Leadership, By: Julia Ashley, iCohere julialynn@icohere.com Executive Update Online; Published: December 2003 http://www.asaecenter.org/Resources/articledetail.cfm?itemnumber=13572 http://www.hrsa.gov/ruralhealth/about/telehealth/glossary.html

Slide 2.8 Medicare looks at location/geography as a factor relating to reimbursement

Originating Site • Refers to the delivery of telehealth services where the beneficiary (patient) is located at the time the service is being rendered via a telecommunications system occurs.

• The originating site must be located in a rural HPSA or in a county outside of a Metropolitan Statistical Area (MSA).

• There are exceptions to the rural HPSA and non-MSA requirement in Alaska and Hawaii.

Distant Site Practitioner • Refers to the practitioners at the distant site, away from the beneficiary (patient), who may furnish and receive payment for covered telehealth services (subject to State law).

Sources www.medicaid.gov www.telehealth.va.gov/sft/ www.cchpca.org/what-is-telehealth/patient-monitoring http://www.hrsa.gov/ruralhealth/about/telehealth/glossary.html www.census.gov/populations/metro/ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf

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Slide 2.9 In understanding the originating site eligibility, a person needs to understand the definitions of a Metropolitan Statistical Area (MSA) and a Health Provider Shortage Area (HPSA).

• A Metropolitan Statistical Area refers to geographic entities delineated by the U.S. Office of Management and Budget (OMB) for use by Federal statistical agencies in collecting, tabulating, and publishing Federal statistics.

• The MSA is a geographical region with a relatively high population density at its core and close economic ties throughout the area.

• A Health Provider Shortage Area (HPSA) is designated by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA) as having shortages of primary medical care, dental or mental health providers and may be geographically-, demographically- or institutionally based.

Sources http://bhpr.hrsa.gov/shortage/hpsas/ http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/designationcriteria.html

Slide 2.10 Note to Trainer Introduce the Center for Medicare and Medicaid Services. The acronym CMS is used quite a lot throughout this presentation and it is important participants know what CMS is.

CMS is responsible for Medicare and parts of Medicaid to include and not limited to: • oversight of HIPAA administrative simplification transaction and code sets • health identifiers • security standards Source http://www.cms.gov/

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Slide 2.11 Medicare: • A federal system of health insurance administered by the U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services (CMS).

• Medicare follows federal rules and guidelines that are different than Medicaid.

• Medicare typically reimburses telehealth services at the same rate as face-two-face.

• The use of telehealth services in Medicare is restricted by geography, facility type, practitioner and services (procedure type).

• Many states (depending on state law) provide some level of reimbursement for interactive services delivered via telehealth technologies.

Considering the expansion of service offerings utilizing telehealth, it’s important to know that state policies, rules and laws are constantly changing.

Sources http://www.cms.gov/Medicare/Medicare.html http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf

Slide 2.12 There are 4 parts to Medicare • Generally, people who are over age 65 and getting Social Security automatically qualify for Medicare Parts A and B. • Typically, telehealth services can be reimbursed under Medicare Parts A & B for outpatient services if covered by certain practitioners in certain settings • Providers should pay particular attention to the Medicare advantage plans (i.e., part C Advantage Plans) • There is more flexibility to cover addiction treatment services via telehealth technologies in Medicare part C • Medicare Part C, also known a Medicare Advantage, is a combination of hospital and medical insurance provided by health plans that allow individuals to choose to receive all health care services through a provider organization.

• These plans may help lower Medicare recipient’s cost of receiving medical services and may provide extra benefits for an additional monthly fee.

• In order to be enrolled in a Medicare Part C Medicare Advantage Plan, a member must have both Medicare Parts A and B.

Note to Trainer Below is a review of Medicare parts A, B, C, D that might be useful • Medicare Part A is hospital insurance and is paid for by a portion of the Social Security tax. It helps pay for inpatient hospital care, skilled nursing care, hospice care and other services.

• Medicare Part B is medical insurance (physician and outpatient services) paid for by the monthly premiums of people enrolled and by the general funds from the U.S. Treasury. It helps pay for doctors’ fees, outpatient hospital visits, and other medical services and supplies that are not covered by Medicare Part A. • Medicare Part C, also known a Medicare Advantage, is a combination of hospital and medical insurance provided by health plans that allow individuals to choose to receive all health care services through a provider organization.

These plans may help lower Medicare recipient’s cost of receiving medical services and may provide extra benefits for an additional monthly fee. In order to be enrolled in a Medicare Part C Medicare Advantage Plan, a member must have both Medicare Parts A and B. • Medicare Part D is prescription drug insurance coverage and is a voluntary program whereby individuals’ monthly premiums pay for the program. Unlike Part B in which an individual is automatically enrolled and must opt out of if the coverage is not wanted, Part D requires an individual to opt in by filling out a form and enrolling in an approved plan. Many Part C Medicare Advantage Plans offer Part D prescription drug coverage.

Source http://ssa-custhelp.ssa.gov/app/answers/detail/a_id/167/~/differences-between-medicare-parts-a,-b,-c-and-d

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Slide 2.13 Providers need to pay attention to the conditions for reimbursement. The use of telehealth services in Medicare is restricted by: • type of services (procedure type) & must be in real time • facility type • practitioner • geography • allowable codes Specific requirements for addiction treatment service coverage: • Benefits and Covered Services • A service must be covered by an individual’s health insurance plan in order to bill and reimburse for the service. For example, under the Affordable Care Act there is a list of federally-required benefits called essential health benefits (EHBs) that certain types of health plans will be required to cover and include as a benefit in 2014. Mental health and addiction treatment services are included in the list of EHBs. • Practitioner and Provider Requirements • An addiction treatment service is provided by an allowable provider and practitioner type and/or in a place of service that is authorized by the payer.

• Depending on the payer of the service (Medicare, Medicaid, private insurance), this latter requirement could be stated in contract, state policy, administrative rule, federal law, or a state’s scope of practice act.

• Eligibility, Enrollment or Patient/Beneficiary Participation • A person receiving a covered service must be “enrolled” or eligible to participate in a health plan or government sponsored program.

• “Enrollment” is a term often used when healthcare is covered by a managed care organization.

• Safety net/public programs that are block purchased or are reimbursed on a fee-for-service basis have their own eligibility requirements.

• Allowable Codes • CPT and HCPCS codes with appropriate modifiers are “open” (billable) in pursuant to a contract or covered in the health plan.

• Often the modifier “GT” is used to provide further clarification that a service was provided via telehealth Sources http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html http://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html

Slide 2.14 Telehealth services and Medicare coverage: • Although limited in the number of services that can be provided via telehealth technologies, there is opportunity for addiction treatment providers and their clients.

• The use of telehealth in Medicare began January 1, 1999 to provide coverage of professional consultation services delivered via telecommunications systems, previously requiring “hands on” or “face to face” interaction with the patient.

• Medicare does not reimburse for “store and forward” technology, so the interaction must be real-time between a beneficiary (patient) and the practitioner.

• There have been exceptions made for Alaska and Hawaii.

Source http://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html

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Slide 2.15 Professional services can be furnished to a Medicare beneficiary (patient) who is located in a covered Originating Site, by a covered physician or practitioner located at a Distant Site.

There are restrictions on which type of originating sites are Medicare eligible. (next slide).

Source http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ downloads/telehealthsrvcsfctsht.pdf

Slide 2.16 Originating Sites • Medicare has a list of defined eligible originating sites that may bill Medicare for a facility fee related to an eligible telehealth encounter.

• The patient must have been seen from one of the following authorized originating sites • Physicians and Practitioners offices 1. Hospitals 2. Critical Access Hospitals (CAH) 3. Rural Health Clinics 4. Federally Qualified Health Centers (FQHC) 5. Skilled nursing facilities 6. Hospital-based or CAH-based Renal Dialysis Centers (including satellites) 7. Community Mental Health Center • In addition to the eligible list of originating facility sites, the originating site must be located in a rural-Health Provider Shortage Area (rural-HPSA) or a county outside an Metropolitan Statistical Area (MSA). These terms will be described in more detail later on in the presentation.

Source CMS Rural Health Fact Sheet, Telehealth Services: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/downloads/telehealthsrvcsfctsht.pdf

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Slide 2.17 Distant Site Practitioners • The following practitioners who perform the telehealth encounter may receive payment for covered telehealth services: • Physicians, Nurse Practitioners and Physician Assistants; Nurse Midwives; Clinical Nurse Specialists; Registered Dietitians or nutrition professionals; Clinical Psychologists (CP); and Clinical Social Workers (CSW) • Note: there are restrictions – CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicaid).

• Note. There are no Licensed Addiction Counselors listed above.

Source http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf

Slide 2.18 As mentioned earlier, the Originating Site authorized must be • located in a rural-Health Provider Shortage Area (rural-HPSA) or • a county outside an Metropolitan Statistical Area or • in a federal telemedicine demonstration project (Alaska and Hawaii).

• HPSAs may be designated as having a shortage of primary medical care, dental or mental health providers. They may be urban or rural areas, population groups or medical or other public facilities.

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Slide 2.19 Number of Metropolitan and Metropolitan Statistical areas: • Based on the definition of rural in use, a rural HPSA cannot be located within a MSA county.

• According to the Office of Management and Budget (OMB), as of February 2013, there are 381 metro and 536 micro areas in the United States and 7 metro and 5 micro areas in Puerto Rico.

• This map above indicates where these areas are located. For example, Nevada has 6 Micro areas and 2 Metro areas.

Note to Trainer Find the state you are presenting in and use that states information when presenting.

Source http://www.census.gov/population/metro/files/metro_micro_Feb2013.pdf http://www.hrsa.gov/shortage/ HPSA defined http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/designationcriteria.html http://www.americantelemed.org/news-landing/2013/03/27/97-counties-to-lose-telehealth-medicare-benefits

Slide 2.20 • HRSA develops shortage designation criteria and uses them to decide whether or not a geographic area, population group or facility is a HPSA or a Medically Underserved Area (MUA) or Population.

• HPSAs may be designated as having a shortage of primary medical care, dental or mental health providers.

• They may be urban or rural areas, population groups or medical or other public facilities.

• The Mental Health HPSA category definition: • Core mental health professionals or core professionals and includes psychiatrists, clinical psychologists, clinical social workers, psychiatric nurse specialists, and marriage and family therapists who meets the definition as defined by the HRSA for Health Professions.

• The chart indicates the number of currently-designated HPSAs, by discipline.

• Mental Health is 26.53% or 3,741 professionals short in HPSA indicated areas.

• The criteria for designation varies from one discipline to another, and there is no intrinsic relationship between them: an area may be considered to have a shortage of practitioners in any or all of the disciplines independently.

Note to Trainer It is recommended that you visit the HRSA’s Data Warehouse and change the states indicated on this slide to best fit your target audience as well as check for the latest Maps and numbers reported by HRSA for the Mental Health shortage areas by discipline. This can be done at: http://datawarehouse.hrsa.gov/hpsadetail.aspx Sources HRSA Data Warehouse: http://datawarehouse.hrsa.gov/hpsadetail.aspx HRSA HPSA Definition/Criteria: http://bhpr.hrsa.gov/shortage/hpsas/designationcriteria/mentalhealthhpsacriteria.html

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Slide 2.21 The Health Professional Shortage (HPSA) Area map shows the currently-designated HPSAs. • As of June 26, 2013, there are a total of 3,880 HRSA designated Health Professional Shortage Areas (HPSA) for Mental Health.

• Mental Health HPSAs are based on a psychiatrist to population ratio of 1:30,000.

• In other words, when there are 30,000 or more people per psychiatrist, an area is eligible to be designated as a mental health HPSA. • Applying this formula, it would take approximately 2,200 additional psychiatrists to eliminate the current mental HPSA designations.

Source http://datawarehouse.hrsa.gov/hpsadetail.aspx

Slide 2.22 The HRSA website has a search feature that can be used to find designated shortage areas (http://hpsafind.hrsa.gov/) This can be a useful resource for programs that use HPSAs to determine eligibility.

Source How to Determine if your Originating Site is Rural: http://ctel.org/2013/01/how-to-determine-if-yourtelehealth-originating-site-is-rural/

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Slide 2.23 In addition to the shortage area locator, agencies may be wondering if they are considered rural or not.

• The Rural Assistance Center has an online tool where an individual can input their agency/organization information to find out if their telehealth originating site is located in a rural area making them eligible for reimbursement.

• The Am I Rural? service can be used to help determine whether a specific location is considered rural based on various definitions of rural, including definitions that are used as eligibility criteria for federal programs.

According to HRSA staff, by definition, it is impossible to have a rural HPSA within a Metropolitan Statistical Area. A site within a MSA cannot be located within a rural HPSA. Please check with the program contacts directly to verify your eligibility for specific federal programs.

Sources RAC: http://www.raconline.org/amirural/ Am I Rural tool: http://ims2.missouri.edu/rac/amirural

Slide 2.24 Coding Definitions CPT Codes (Current Procedural Terminology Code) • maintained by the American Medical Association • describes medical, surgical, and diagnostic services and is designed to communicate uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers • identified by the Center for Medicare and Medicaid Services (CMS) as Level 1 of the Health Care Procedures Coding System (HCPCS) HCPCS (pronounced “hick pick” or “hicks picks”) • refers to the standardized coding system for describing the specific items and services not included in CPT codes.

• State Medicaid and mental health/substance use agencies often categorize these services as rehabilitation or support services (as opposed to treatment or medical services) • HIPAA, Medicare, Medicaid and private insurance carriers are required to use HCPCS for transactions involving health care information with implementation • HCPCS includes two levels of codes: • Level 1 – numeric CPT codes • Level 2 – alphanumeric and primarily includes non-physician services and durable medical equipment.

Source http://www.cms.gov/apps/glossary/default.asp?Letter=C&Language=English

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Slide 2.25 • CMS has provided a simplified sheet to assist providers in understanding Medicare and telehealth.

• With respect to the delivery of telehealth services for addiction treatment, the following services (procedures) are allowed under Medicare Fee-for-Service program (excerpt from the CMS Telehealth Services Rural Health fact sheet): • Individual and group health and behavioral assessment and intervention • Individual psychotherapy (some CPT code restrictions for CP and CSWs) – new for dates of service on or after January 1, 2013 • Psychiatric diagnostic interview examination (some CPT code restrictions for CP and CSWs)- new for dates of service on or after January 1, 2013 • Neurobehavioral status examination • Smoking cessation services • Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services – new for dates of service on or after January 1, 2013 • Annual depression screening, 15 minutes – new for dates of service on or after January 1, 2013 • Keep in mind, there can be limitations on the number of times the service is permitted and/or the amount of time spent with the client.

• The focus is on Medicare CPT codes because it defines the telehealth codes as it pertains to the services covered and many insurance carriers follow Medicare guidelines.

• Please remember, these codes are only for Medicare and only a small sample set.

Source CMS Telehealth Services Rural Health Fact Sheet - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNProducts/downloads/telehealthsrvcsfctsht.pdf

Slide 2.26 There are very specific guidelines detailed by Medicare that must be followed to ensure proper reimbursement.

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Slide 2.27 Rate of Reimbursement • Medicare claim via telehealth is the same as the rate for a non-telehealth service.

• The originating sites are paid an originating site facility fee and can bill for site fee reimbursement separate to part B payment.

• Interactive telecommunications systems (audio and video) allowing real-time communication is required as a condition of payment.

• In addition, the patient must be present at the originating site and participating.

An example…. A Federally Qualified Health Center located in a rural area contracts with a specialty addiction treatment provider to provide SBIRT services by a Licensed Clinical Social Worker.

• Using HIPAA Compliant video-conferencing equipment a patient is screened for Risky Drinking… and receives a brief intervention • CPT codes are the same for SBIRT services delivered in person or through telecommunications Source CMS Telehealth Services Rural Health Fact Sheet - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/ MLNProducts/downloads/telehealthsrvcsfctsht.pdf

Slide 2.28 Since Medicare has the most prescriptive policies for telehealth, it tends to be less flexible than Medicaid. It is a good rule of thumb to always check your Medicare Manual as well the Medicare.gov website for the most up to date information.

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Slide 2.29 The resources listed in this slide are specific to Medicare and telehealth.

Source http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ downloads/telehealthsrvcsfctsht.pdf

Slide 2.30 Next we will cover Medicaid reimbursement, which is very different from Medicare.

Medicaid is • a State operated program that provides health coverage for lower-income people, families and children, the elderly and people with disabilities • funded by a combination of federal, state and sometimes local funds • eligibility rules for Medicaid are different in each state; however each state Medicaid plan has mandatory and optional eligible populations and covered services • the most common path being taken by states is to cover telehealth services in the Medicaid program.

• 42 states now provide some form of Medicaid reimbursement for telehealth services.

Note to Trainer It is recommended that you check the number of states that offer some type of reimbursement as this changes often.

Source National Conference of State Legislature (NCSL): http://www.ncsl.org/issues-research/health/state-coverage-for-telehealth-services.aspx

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Slide 2.31 According to Medicaid.gov: • “Telemedicine is viewed as a cost-effective alternative to the more traditional faceto-face way of providing medical care (e.g. face-to face consultations or examination between provider and patient) that states can choose to cover under Medicaid.”

• This definition is modeled on Medicare’s definition of telehealth services (42 CFR 410.78).

• Note that the federal Medicaid statute does not recognize telemedicine as a distinct service; definitions are different yet the same for telehealth and telemedicine.

Medicaid’s definition of telehealth: • Telehealth (or Telemonitoring) is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.

• Telehealth includes such technologies as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices, which are used to collect and transmit patient data for monitoring and interpretation.

• While they do not meet the Medicaid definition of telemedicine they are often considered under the broad umbrella of telehealth services.

• Even though such technologies are not considered “telemedicine,” they may be covered and reimbursed as part of a Medicaid coverable service, such as laboratory service, x-ray service or physician services (under section 1905(a) of the Social Security Act).

Source http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html

Slide 2.32 For purposes of Medicaid, telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment. States have the option/flexibility to define: • which telehealth services (i.e., counseling) are eligible for reimbursement; • which populations are eligible to receive telehealth services; • which practitioners are qualified to provide a reimbursable telehealth service as long as such practitioners are “recognized” and qualified according to Medicaid statute/regulation; • where telehealth services can be provided (location); and • how much to reimburse for telehealth services, offering different services delivered via telehealth in managed care arrangements when compared to fee for service arrangements.

Reimbursement for Medicaid covered Telehealth services and applications: • Must satisfy federal requirements of efficiency, economy and quality of care.

• States are encouraged to use the flexibility inherent in federal law to create innovative payment methodologies for services that incorporate telehealth technology; for example: • States may reimburse the physician or other licensed practitioner at the distant site and reimburse a facility fee to the originating site.

• States can also reimburse any additional costs such as technical support, transmission charges, and equipment.

• These add-on costs can be incorporated into the fee-for-service rates or separately reimbursed as an administrative cost by the state.

• If they are separately billed and reimbursed, the costs must be linked to a covered Medicaid service.

Source http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html

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Slide 2.33 Medicaid’s reimbursement can be thought of as a three legged stool

Slide 2.34 Note to Trainer Allow time for participants to read the slide, then review the three components of Medicaid: • Person must be covered and currently enrolled in Medicaid eligible program • Type of Service covered – both audio and video interactions • The provider (professional offering services) is practicing within the states scope Source http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html

Slide 2.35 • The type of coverage, the healthcare (insurance) carrier, federal laws, and state laws and policies decide an organization’s or practitioner’s ability to provide addiction treatment services via telehealth and be reimbursed for those services.

1. For Medicaid, Medicare and many other payers, telehealth services must include a practitioner and a beneficiary (patient).

2. An actual service that can be billed using a CPT or HCPCS code must be provided when delivered using an interactive video and audio telecommunications system.

3. The time a patient spends using a web-based support is not reimbursable by Medicaid or Medicare and most other payers.

4. Interactive video and audio telecommunications system, or telehealth, is a vehicle to deliver services.

5. Some payers do allow for reimbursement to the originating site (where the patient is located) known as an Originating Site Facility Fee. • Counselors will receive information regarding billing and reimbursement practices in Medicare and Medicaid.

• Medicare and Medicaid are the two largest insurance programs for the poor and offer greater access to addiction treatment services than private insurance carriers.

• Keep in mind that states define Medicaid services. It is widely held, that State Medicaid programs should remove artificial barriers (like those barriers currently in place in Medicare) such as beneficiary residence restrictions, where a patient is served, the provider type, and what type of technology is allowed.

Sources http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf National Conference of State Legislature (NCSL): http://www.ncsl.org/issues-research/health/state-coverage-for-telehealth-services.aspx http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html

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Slide 2.36 Coverage of telehealth services under private insurance is either • mandated in state law; or • up to the insurance company to decide whether or not to reimburse for telehealth services.

There are no consistent standards that govern private commercial payers.

More and more private payers are starting to recognize the benefits of telehealth and electing to cover for selected telehealth services.

• 16 states now require private insurers to pay for telehealth delivered services at the same rate as in-person services (subject to the limitations of their policies) • 29 states have pending legislation to create this mandate • Managed care plans, both public and private, are also beginning to incorporate telehealth into the services that are covered.

Note to Trainer According to the Telemental Health Institute, sixteen (16) states mandate some form of Private Payer Telehealth Coverage • California, Colorado, Georgia, Hawaii, Kansas, Kentucky, Louisiana, Maine, Maryland, Michigan, New Hampshire, Oklahoma, Oregon, Texas, and Virginia.

The covered services could be telehealth, telemedicine, or both services depending on the state.

Four states recently passed new legislation that impact private payers and go into effect July 2013-January 2015: Arizona, Mississippi, New Mexico and Montana.

Legislation is consistently evolving and changing everyday. It is important to maintain up to date information in your state or where you plan on offering a form of telehealth services.

Sources TMH Institute – 11/2012 http://telehealth.org/mandated-states The National Telehealth Policy Resource Center project is made possible by Grant #G22RH20214 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS: Telehealth Reimbursement Policy: http://telehealthpolicy.us/telehealth-policy

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Slide 2.37 Telehealth Policy Resource Center: • Provides continuous updates on telehealth legislation • Has a user-friendly interactive map to state laws and reimbursement policies.

• Simply click on a state to view telehealth-related laws, regulations, and Medicaid programs.

• Another important characteristic of this particular website is you can also view a list of pending laws and complete advance searches.

Note to Trainer It is suggested, prior to presenting this slide, that you complete a search and get the most recent information for the state(s) in which you will be presenting. This slide has a hyperlink included, so you can click on the map and be taken directly to the website to provide a demonstration to participants.

Source National Telehealth Policy Resources Center: http://telehealthpolicy.us/state-laws-and-reimbursement-policies

Slide 2.38 Center for Connected Health Policy: • Comprehensive State Telehealth Laws and Reimbursement Policies Report released February 2013 • Information available about how each of the 50 states (and the District of Columbia) defines, governs, and regulates the use of “telehealth” or “telemedicine” technologies in the delivery of health care services.

• CCHP completed research on 11 policy areas which included reimbursement, consent, service location, online prescribing and licensure.

Source http://telehealthpolicy.us/state-laws-and-reimbursement-policies

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Slide 2.39 The Center for Connected Health Policy (CCHP) Report highlights telehealth laws related to Medicaid and the private sector in all states as of December 2012.

The survey focused on 11 policy areas, including reimbursement, consent, service location, online prescribing and licensure.

Key findings: • 44 states have some form of telehealth reimbursement for Medicaid programs; • Live video was the most prominent form of reimbursed telehealth services, with 44 states paying for live video sessions; • Seven states provide Medicaid reimbursement for remote patient monitoring; • 10 states require informed consent; • 9 state medical boards issue special licenses or certificates for telehealth; and • 13 states have legislation pending on telehealth.

The report, launched in March 2013, will be continually updated on the Telehealth Policy Resource Center website.

In addition, a link to this report will be on the NFAR-ATTC website (www.nfarattc.org).

Source http://telehealthpolicy.us/state-laws-and-reimbursement-policies Read more at http://www.ihealthbeat.org/features/2013/states-not-keeping-up-with-telehealth-advances.aspx#ixzz2QphzLgc3

Slide 2.40 Mario Gutierrez, Executive Director of the Center for Connected Health Policy, stated that “no two states are alike in how telehealth is defined and regulated” (http://cchpca. org).

Nuanced System • State health care laws, statutes and policies payer requirements are nuanced or have subtle differences or distinctions in meanings. These nuances can represent important differences in health care design, delivery and reimbursement depending on your location.

• All the new telehealth technology that are up and coming, e.g., mobile applications, computer-based interventions, interactive voice response, may not be reimbursable through traditional means as of yet.

Disclaimer • Information contained in this workshop is up to date at the time it was presented.

• Please note, information is subject to change following action taken by your state’s legislature, state agencies and other applicable government or regulatory body.

Each counselor/provider is encouraged to understand the telehealth allowances and restrictions covered in their state’s Medicaid program: • How those allowances and restrictions are passed down through contracts with their counseling center or community mental health center • What their counseling centers or community mental health center’s ability is to provide telehealth services.

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Slide 2.41 Take home point The biggest drivers of drivers behind an organization’s or practitioner’s ability to provide addiction treatment services via telehealth and be reimbursed: • The type of insurance (payer) • Insurance (patients health care provider, i.e., Medicare) carrier, • Federal laws • State laws and policies

Slide 2.42 Take home point • Live (videoconferencing), interactive (audio/telephone) is the most commonly reimbursed form of services where the patient and doctor are in “real time”.

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Slide 2.43 ALTHOUGH, there are some private insurers that are paying for telehealth and some state agencies are contracting for these types of services, there is increased public demand. Customer demand is starting to drive telehealth technologies which in turn is changing insurance company reimbursement policies.

According to an article posted by the Wall Street Journal, “Virtual doctor visit services— which connect the patient from their homes with physicians whom they meet via online video or phone—are moving into the mainstream, as insurers and employers are increasingly willing to pay for them.”

Source Mathews, A.W., Wall Street Journal (Online), New York, N.Y. December 21, 2012

Slide 2.44 For example: • WellPoint Inc., the nation’s second-biggest health insurer, plans to offer a new service in all of its employer and individual plans that will allow people to consult with physicians on-demand, using laptop webcams or video-enabled tablets and smartphones.

• Appealing to clients looking for convenience and accessibility of care.

• Saving money by avoiding costly ER visits with virtual visits estimated at $40-$45 a visit.

• Aetna Inc. and UnitedHealth Group Inc., offer virtual-visit services as an option for certain employers.

Source Mathews, A.W., Wall Street Journal (Online), New York, N.Y. December 21, 2012

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Slide 2.45 Let participants review slide. Additional comments listed below: • Mercer is a consulting unit of Marsh & McLennan Companies who provide advice and solutions in risk, strategy and human capital.

• The ability to communicate with a doctor via the internet at any time without an appointment is attractive to most people.

• Employers and insurers agree this could be the answer to the shortage of primary care doctors and mental health counselors.

• By 2014, WellPoint Insurance will have LiveHealth Online Program offered for employer plans in Ohio and California and its success will depend on regulatory status in those states.

• 2014 they will launch with a webcam video, then add a smartphone and tablet capabilities.

• Virtual visits will be available everyday – 7a.m. to 11p.m.

• Same co-pay will be required as in “in-office” face-to-face visit.

• Companies include Home Depot and Westinghouse Electric Company Source Mathews, A.W., Wall Street Journal (Online), New York, N.Y. December 21, 2012 Marsh & McLennan Companies: http://www.mmc.com/index.php

Slide 2.46 Treatment providers need to be creative and find a way to expand services and enhance care. As providers of behavioral health/addition treatment services, we need to find a way to access the clients who are not seeking treatment from a variety of reasons.

Agencies are doing this work AND getting reimbursed for it.

For example, Gateway Connect and Operation Par (on the next slide) are Early Adopters of Telehealth Services: • Gateway Connect was launched in October 2006 with a SAMHSA grant awarded September 2007 and has served a total of 400 clients over a 3-year period.

• In September 2010, Gateway received another grant award with the goal to serve a total of 400 clients over a 3-year period (total intakes through 5/30/13 is 363) in alliance with three (3) other agencies: • Operation PAR in Largo, FL • Center for Drug-Free Living in Orlando, FL; and • DISK Village in Tallahassee, FL. • These agencies were part of a group that approached the State of Florida to have Standards for Telemental health or as PAR calls it eServices.

• Numerous client services are provided through a password protected web portal using a variety of technologies (e.g., telephone, Internet, computers, web cams, mobile phones).

Source http://www.gatewaycommunity.com/

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Slide 2.47 Operation PAR eServices and Gateway Connect services include, but are not limited to: 1. client services; 2. education for client; 3. families and loved ones; 4. family sessions 5. discharge sessions with new providers before clients leave the facilities; 6. training for clinical staff, Clinical Supervision; 7. EBP Training and Certification; 8. Contingency Management; 9. involvement of family and support system for client.

Operation Par and Gateway Connect’s Goal: making services blend with everyday life so not to attach the stigma that many fight with attending treatment for substance abuse, mental health Source http://www.operationpar.org/

Slide 2.48 As we strive to expand access and enhance treatment services to frontier and rural areas, NFAR ATTC believes that telehealth is in the best interest of clients AS WELL AS providers. It is imperative that addiction treatment agencies look at offering services via telehealth technologies to address barriers to treatment and reach those who need help and are not receiving it.

For example: NIDA and the Addiction Technology Transfer Centers (ATTCs) are working together to create web-based applications to add to already existing client services (NIDA-CTN-0044; Web-Delivery of Evidence-Based, Psychosocial Treatment for Substance Use Disorders (TES.) Source Clinical Trials Network, Dissemination Library: http://ctndisseminationlibrary.org/protocols/ctn0044.htm

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Slide 2.49 Catch the Wave: • It’s your choice! There is a wave of technology and it is beginning to crest.

• You can stay on the beach or grab your surf board and ride the wave.

• We are moving forward with the new way of offering treatment services you don’t want to miss the ride.

Next, we will begin to discuss organizational change management, levels of individual resistance to change, types of telehealth readiness, influence implementation effectiveness of telehealth, and the Telehealth Capacity Assessment tool to engage organizations into adopting telehealth services.

Slide 2.50 Telehealth Readiness and Capacity Development

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Slide 2.51 The practice of telehealth challenges the conventional perception of the health care professional-patient/client relationship. This raises many questions before and during the foray into using telehealth technologies, such as: 1. Do we have a need to expand services beyond our usual array?

2. How do we know that telehealth technologies are a viable option for our organization and our patients/clients?

3. What do we need to know to move forward?

4. What is the best way to proceed?

Slide 2.52 Readiness is a necessary requirement for successful implementation of an innovation.

Lack of readiness can result in the inability to adopt telehealth projects or to maintain successful services.

Understanding telehealth ‘readiness’, i.e., the degree to which public users, health care organizations and their staff, and the health system itself are prepared to participate and succeed in telehealth implementation is essential for the successful adoption of new, innovative technologies in the health care field. Since some telehealth innovations can be costly and/or difficulty to implement, it is important that telehealth stakeholders have the tools and mechanisms to understand the readiness concept, and to determine the readiness status of their organization before undertaking telehealth innovations.

The Canadian Health has been one of the leaders in increasing the understanding of readiness and its factors, particularly in rural and remote communities. The Canadian National Initiative for Telehealth guidelines project (NIFTE, 2003), investigated: 1) What are the elements within the concept of readiness? 2) Is there more than one type of readiness? and 3) What are the factors within those types of readiness?

The study provided a readiness assessment framework highlighted facilitators and barriers that can be addressed during the implementation / diffusion process.

Source Jennet, P., Jackson, A., Ho, L., Healy, T., Kanzajian, A., Woollard, R., Haydt, S., & Bates, J. (2005). The essence of telehealth readiness in rural communities: An organizational perspective. Telemedicine Journal and e-health, 11(2), 137-145.

National Initiative for Telehealth Guidelines (2003). National initiative for telehealth (NIFTE) framework of guidelines. Ottawa: NIFTE.

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Slide 2.53 Understanding readiness is a critical first step towards the successful adoption of telehealth. Administrators, planners, and stakeholders require clear mechanisms to determine the readiness status of organizations before investments are made to help avoid failure rates associated with telehealth projects.

In planning a telehealth project, a readiness assessment can help to improve the chances of successful implementation by identifying the stakeholders and the factors that should be targeted. The term readiness embraces preparedness, receptiveness, and the willingness to achieve something.

Slide 2.54 Here are a few examples of the types of readiness elements that will be explored.

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Slide 2.55 As early as 1998, Jennett reported on a meeting of the Canadian and international telehealth communities where the key barriers to adoption of technology-mediated healthcare were identified as: Fear of depersonalization; loss of privacy; poor readiness and preparation (people, environment); human resource needs (skilled personnel); lack of models and frameworks for evaluation; implementation processes; and issues ethical, moral, and legal (licensure, remuneration). All these barriers are still valid.

More recently, Brooks, Turvey and Augusterfer (2013) stated that several developments have paved the way for broader use of telehealth technologies, particularly for mental health services. In the past, equipment was often prohibitively expensive, was technologically complex, and often had unreliable performance.

Third-party payer reimbursement, particularly from private payers, was unknown. Research was limited to small pilot studies, and best practices had yet to be developed. They note that several obstacles that once inhibited the use of telehealth services have been significantly improved. In particular, training opportunities have increased, technological changes have made the delivery of telehealth services more convenient and of a better quality, and there is a growing evidence base supporting positive telehealth outcomes.

Although many barriers have diminished considerably in the past 25 years, these researchers found several factors that continue to exist that limit the utilization and growth of this healthcare delivery platform.

1. personal barriers (provider characteristics that influence one’s acceptance and use of telehealth services; lack of training in this area; and apprehension that successful treatment outcomes may be inhibited by the lack of proximity between the clinician and the patient/client) 2. clinical workflow barriers (additional procedures not found in face-to-face encounters, such as equipment set up; scheduling and documenting changes; telehealth protocols that can spiral in complexity) 3. technology barriers (bandwidth difficulties and questions about network security; lack of knowledge about advancements in low cost, state-of-the-art encryption technology; and 4. licensure, credentialing, and reimbursement barriers (clinical practitioners need to be licensed in each state in which they practice telehealth services as well as a license in the state in which they physically offer clinical services; services are covered by a patchwork of third-party payers and government payers; 5. patient/client concerns about privacy and confidentiality such as HIPPA-related issues when medical information is digitized and transmitted over the Internet or through other electronic means. The degree of anxiety varies according to the type of medical condition and the type of information being collected and transmitted (CETC, 2009).

We will discuss these more as we move through this module.

Source California Telemedicine and eHealth Center (2009, January). If you bill it, they will come: A literature review on clinical outcomes, costeffectiveness, and reimbursement for telemedicine. Retrieved from http://www.caltrc.org/sites/main/files/file-attachments/literaturereview.pdf Brooks, E., Turvey, C. & Augusterfer, E. F. (2013). Telemental health - Provider barriers to telemental health: Obstacles overcome, obstacles remaining. Telemedicine and e-Health, 19(6), 433-437.

Jennett, P. (1998). Sante Interactive Health. Ottawa: Industry Canada.

Slide 2.56 (Continuation of the notes from the previous slide)

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Slide 2.57 The Canadian National Initiative for Telehealth guidelines project (NIFTE, 2003) focused their work on defining readiness in organizations and communities and gathering evidence to support the development of measures of e-health (telehealth) readiness.

Four types of readiness were described: “core readiness” where a need for change is identified; “engagement readiness” expressed by questioning and needs assessment; “structural readiness” where there is need for development of the human and technical infrastructure to operate the system; and “non-readiness” which means a lack of need or failure to recognize need.

Readiness was explored across patient, practitioner, organizational, and public groups in order to examine groupspecific factors of readiness. Factors of readiness were evident in each target group within each type of readiness.

Source Jennet, P., Jackson, A., Ho, L., Healy, T., Kanzajian, A., Woollard, R., Haydt, S., & Bates, J. (2005). The essence of telehealth readiness in rural communities: An organizational perspective. Telemedicine Journal and e-health, 11(2), 137-145.

National Initiative for Telehealth Guidelines (2003). National initiative for telehealth (NIFTE) framework of guidelines. Ottawa: NIFTE.

Slide 2.58 Core readiness elements for organizations include having a recognition of the need for service and dissatisfaction with the existing context and available services. This necessitates attention to a comprehensive needs assessment and determinants of accessibility to existing services.

In Jennet’s research (2005), isolation was identified as being a strong factor in creating needs, contributing to the strength of core readiness in rural and remote communities.

However, isolation in and of itself was found to be insufficient in creating readiness for implementation of telehealth services. Readiness also requires community members viewing the current conditions as unacceptable and in need of change. Therefore, dissatisfaction with the status quo and the willingness to try telehealth, along with the conditions of isolation were seen as fundamental to a successful telehealth service.

Source Jennet, P., Jackson, A., Ho, L., Healy, T., Kanzajian, A., Woollard, R., Haydt, S., & Bates, J. (2005). The essence of telehealth readiness in rural communities: An organizational perspective. Telemedicine Journal and e-health, 11(2), 137-145.

National Initiative for Telehealth Guidelines (2003). National initiative for telehealth (NIFTE) framework of guidelines. Ottawa: NIFTE.

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Slide 2.59 This level of readiness encompasses processes in which people are actively engaged with the idea of telehealth, weighing its perceived advantages and disadvantages. The involvement of key stakeholders representing professionals, health care organizations, and the community in the planning and development of telehealth technologies appear essential for achieving the increased acceptance of such services. Many on telehealth adoption highlight the importance of engagement (Legare, E. et al., 2010; Jennet, et al., 2005; Chau, et al., 2002; Gannon, et al., 2003).

In the Canadian study and others, an important concept has emerged - this is the importance of innovators or champions; i.e., people who are enthusiastic promoters of an innovation. Readiness among individuals varies from absolute refusal to cautionary interest, and innovators are often thought to be essential to the successful implementation of projects. In organizational settings, innovators have an important role in building readiness through education and awareness. Innovators have been found to be helpful to the diffusion of information to others within the organization and providing an example through experimentation and demonstration. This, in turn, was considered important in alleviating fears and encouraging participation (Jennet, et al., 2005).

While continual refinements to clinical practices are viewed as necessary for effective service delivery by many, some individuals (and organizations) may be more reserved and cautious about what it means to adopt a new practice. While frequently juggling overwhelming practice, clinical, and administrative responsibilities, taking on new and different job tasks may be seen as a difficult endeavor with questionable rewards. Additionally, changing attitudes about the adoption of telehealth technologies involves a shift from expecting short-term results to viewing telehealth as a long-term project, with utilization itself indicating success.

Source Chau, P. Y. K., & Hu, P. J. (2002). Investigating healthcare professionals’ decision to accept telemedicine technology: An empirical test of competing theories. Information Management, 39, 297-311.

Gagnon, M. P., Duplantie, J., Fortin, J. P., & Landry, R. (2006). Implementing telehealth to support medical practice in rural/remote regions: what are the conditions for success? Implementation Science, 1(18), e 1-8.

Gagnon, M. P., Godin, G., Gagne, C., Fortin, J. P., Lamothe, L., Reinharz, D., & Cloutier, A. (2003). An adaptation of the theory of interpersonal behaviour to the study of telemedicine adoption by physicians. International Journal of Medical Informatics, 71(2-3), 103-115.

Helitzer, D., Heath, D., Maltrud, K., Sullivan, E.,& Alverson, D. (2003). Assessing or predicting adoption of telehealth using the Diffusion of Innovations Theory: A practical example from a rural program in New Mexico. Telemedicine Journal and e-Health, 9(2), 179-187.

Jennet, P., Jackson, A., Ho, L., Healy, T., Kanzajian, A., Woollard, R., Haydt, S., & Bates, J. (2005). The essence of telehealth readiness in rural communities: An organizational perspective. Telemedicine Journal and e-health, 11(2), 137-145.

Slide 2.60 The adoption of telehealth as a mode of care delivery bears structural challenges related to financing the innovation, and organizational and technical infrastructures to support new clinical protocols and quality control mechanisms. As was noted in “Core Readiness” it is critical that the organization conduct a robust planning process that looks at the needs of the community, the gaps in services for potential patients/clients and how well a telehealth strategy will align with the organization’s vision and mission. This process also includes performing a comprehensive literature search so organizations don’t try to “reinvent the wheel” when they don’t need to. Getting a feel for what has been previously tried in the type of service desired and acquiring guidance on evidence-based or “best practices” for the telehealth technology provide valuable lessons for needed organizational structures for success, as well as information about pitfalls that can help minimize implementation difficulties.

The organization has an important role in supporting telehealth integration. Fiscal, human, material, and logistical resources need to be provided to ensure the functioning of telehealth services.

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Slide 2.60 Cont.

Clinical workflow procedures can be challenging with telehealth technologies as these entail additional procedures not found in typical clinical encounters. Added processes, such as making appropriate technical arrangements and new types of documentation, can provide disruptions that can lead to clinician resistance. Written protocols for new clinical service flows for each telehealth technology to be used will be important. In addition, integrated technologies that improve the workflow for clinicians who would otherwise have to juggle multiple technologies (such as videoconferencing, electronic health records and scheduling).

Leveraging the human potential of the organization by selecting those who are the “early adopters” of new service innovations and dedicating resources to staff training (initial and ongoing) are critical to helping solve programmatic implementation issues. These staff also are effective in serving as ambassadors for promoting the initiative throughout the organization and in the community.

Source Broderick, A. & Lindeman, D. (2013, January). Scaling telehealth programs: Lessons from early adopters. Commonwealth Fund Publication, Vol.1, 1-10.

California Telemedicine and eHealth Center (2009, January). If you bill it, they will come: A literature review on clinical outcomes, costeffectiveness, and reimbursement for telemedicine. Retrieved from http://www.caltrc.org/sites/main/files/file-attachments/literaturereview.pdf California Telemedicine and eHealth Center (2009, April). Telemedicine reimbursement: A national scan of current policies and emerging initiatives. Retrieved from http://www.caltrc.org/report/telemedicine-reimbursement-national-scan-current-policies-and-emerging-initiatives Jennet, P., Jackson, A., Ho, L., Healy, T., Kanzajian, A., Woollard, R., Haydt, S., & Bates, J. (2005). The essence of telehealth readiness in rural communities: An organizational perspective. Telemedicine Journal and e-health, 11(2), 137-145.

Shore, J. (2008). Telepsychiatry Developmental Model: Telemental Health Guide. University of Colorado. Retrieved from www.tmhguide.org

Slide 2.61 There are several different aspects of structural readiness related to the actual technology. The first is to understand technological requirements (hardware, software and connectivity) which are determined by what type of service that is desired. For example, if the organization is setting up a videoconferencing system: • they need to determine whether they are going to do this over an IP system and their Net-based system or a phone line, • whether there are existing phone lines or IP systems in the community that could be utilized as part of the program, or • whether they are going to need to work with a local telecom company to create technological infrastructure (Shore, 2009).

At the technological level, the various components of telehealth systems must correspond to users’ expectations in terms of reliability, mobility, and user-friendliness. Below are five areas that should be considered when looking at any telehealth technology (Gannan, et al, 2004): 1. Compatibility - Not only should the technologies be compatible in terms of interoperability, but newer versions of technology must also be compatible with earlier versions of a similar technology.

2. Interoperability - In order to develop telehealth networks that interface with one another, organizations should strongly consider the purchase of technologies that meet the recommended guidelines.

3. Scalability - Technology purchased for telehealth should be capable of migrating into expanded capabilities without total replacement.

4. Accessibility - The level of the vendor’s accessibility in terms of sales, timely delivery, and equipment maintenance should be a purchasing/selection criteria.

5. Reliability - Telehealth programs should consider issues such as the reliability that the network and equipment will work consistently as intended and that the technologies can be reliably serviced with minimum downtime.

Source

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Gannan, F., Phillips, R., Patterson, M., et al. (2004). Telehealth technology. In: Telemedicine Technical Assistance Documents: A Guide to Getting Started in Telemedicine (pp. 314-342). University of Missouri School of Medicine. Retrieved from http://www.netrc. org/docs/Telehealth%20Technology.pdf.

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Slide 2.62 Written policies are important as a means to build the structural readiness of organizations in the adoption of telehealth. Codified policy at the organizational level is considered essential in the areas of service provider reimbursement, liability, cross-jurisdiction credentialing/licensing, and issues of privacy—which often become complicated in rural areas. Organizations should seek legal opinions, as necessary.

Slide 2.63 Non-readiness for telehealth may occur in a number of ways. Non-readiness may be characterized by a lack of awareness of the benefits that technology can offer to health care delivery, and by avoidance of addressing the topic with any real consideration.

At times a telehealth service has failed as a result of a lack of a genuine need to use it. There is also the potential for indifference toward telehealth applications in larger communities, where adequate resources already exist.

Slide 2.64 Earlier it was noted that a core readiness element is when there emerged a felt or expressed dissatisfaction with current conditions or the status quo, so strong that members of a community or organization are willing to adopt new practices to create change.

Leading and effectively managing change is at the heart of adopting and implementing telehealth technologies. Let’s take a little step backward and address change management theory and how it informs this process.

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Slide 2.65 Note to Trainer Refer participants to their handout – Personal Experience with Change Everyone has experienced change in all aspects of their lives. Let’s take a minute to think about a couple of your experiences in being a part of a change process at your place of work. Using your handout form, take 5 minutes to jot down your responses to the questions posed.

The first set of questions ask about a time when you were involved in a successful change effort - What do you think made this change initiative successful? Also, think about and record how you felt during the change process and how you think others felt.

The second scenario asks you to consider a time when the change process was unsuccessful. As you think about what went awry, imagine that you had been given three wishes that, when fulfilled, would have likely resulted in a more successful change initiative.

Note to Trainer Ask participants to share responses to each scenario and facilitate a discussion about the elements they identified that were successful and those that needed more attention. Take about 5-10 minutes for this part of the activity.

Slide 2.66 In years past, perhaps, leaders could simply order changes. Even today, many view change as a straightforward process: establish a task force to lay out what needs to be done, when, and by whom. Then all that seems left for the organization to do is simply implement the plan. Many leaders imagine that to make a change work, people needed only to follow the plan. It is not that easy. What is the leader supposed to do when they “just don’t do it” -- when people do not make the changes that need to be made, when deadlines are missed, costs run over budget, and valuable workers get so frustrated that they “just leave.”

We could spend days on addressing change theory and change management, but let’s take a few minutes to explore two theses that are consistently embedded in prevailing theories about leading change: 1. Undertaking large-scale change is a process that has distinct stages or steps.

2. All change is personal – meaning, organizations have to attend to the people as well as the process.

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Slide 2.67 The Stages of Change Model was originally developed to describe the process people go through in a series of stages when they change health behavior. The stages are cognitive and behavioral. In the early phases, people tend to focus on thinking about change-whether change is something they need to consider. In later stages, people are actively doing things to change or maintaining the changes that they have been able to make.

The Stages of Change Model has five phases: 1. Pre-contemplation: Avoidance. That is, not seeing a problem behavior or not considering change.

2. Contemplation: Acknowledging that there is a problem but struggling with ambivalence. Weighing pros and cons and the benefits and barriers to change.

3. Preparation/Determination: Taking steps and getting ready to change.

4. Action: Actively making the change and living the new behaviors.

5. Maintenance: Actively working to prevent relapse and consolidate the gains attained during action.

The Stages of Change Model describes five stages of readiness and provides a framework for understanding the change process. While these stages are presented and discussed in a linear fashion, one does not necessarily have to proceed through them in order. It is entirely possible and natural to jump around and shuffle back and forth. By identifying where a person is in the change cycle, interventions can be tailored to the individual’s “readiness” to progress in the change process. Interventions that do not match the person’s readiness are less likely to succeed and more likely to damage rapport, create resistance, and impede change. Anything that moves a person through the stages toward a positive outcome should be regarded as a success.

These same stages and concepts are also applicable to organizational change. Additionally, the stages-of-change dimension can be applied by leaders to reduce resistance, increase participation, reduce dropout, and increase change progress among employees.

Source Prochaska, J. O, , DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory Research and Practice , 19, 276–88.

Prochaska, J. O, , DiClemente, C. C. & Levesque, D. A. (2001). A transtheoretical approach to changing organizations. Administration and Policy in Mental Health, 28(4), 247-261.

Slide 2.68 William Bridges, an international expert and author on change, says that failure to manage the transition, which occurs in the course of every attempt at change, most often results in failed attempts in leading change initiatives. Bridges the makes a distinction between concepts of transition and change. He says if you want to lead successfully in times of change, you will have to help people through the process of change that your vision implies.

Bridges distinguishes between “changes” and “transitions.” Change is an event; transition is a psychological process. Changes are things that happen in the physical environment: we get a new computer, we move to a new location, our office is restructured, etc.

Transitions are the psychological adjustments we have to make when the world changes around us. Change is easy to do; transitions are tougher. Often we make plans for managing change in organizations but don’t make implementation plans for managing transitions.

Source Bridges, W. (2009). Managing Transitions: Making the Most of Change, Third Edition. DeCapo Press.

William Bridges and Associates: http://www.wmbridges.com/

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Slide 2.69 One of the most important differences between a change and a transition is that changes are driven to reach a goal, but transitions start with letting go of what no longer fits or is adequate to the life stage you are in. Leaders need to figure out what exactly that no-longer-appropriate thing is...but whatever it is, it is internal. The transition itself begins with letting go of something that you have believed or assumed, some way you’ve always been or seen yourself, some outlook on the world or attitude toward others.”

In the model shown above, William Bridges suggests that there are three phases to the psychological process of transition. The phases overlap; we can actually experience more than one of them simultaneously. Movement through transition is marked by a change in the dominance of one phase as it gives way to the next. Illustrate the phases with examples such as moving from one location to another, mergers, developments in the field, etc.

Ending the old means giving something up, losing something. Even with self-initiated change, endings often bring feelings of sadness, remorse, and nostalgia. A common failure in organizational change is to fail to adequately consider who will lose something of value when a change is implemented. Sometimes losses are identified but the grief is not acknowledged.

The Neutral Zone between the end of the old and the start of the new is often a time of chaos and confusion.

This uncertainty can lead to great creativity and innovation, however. If you are a manager, this is a good time to encourage training to learn new skills and experimentation to see how the new world will work. Expect the uncertainty to create anxiety and stress, however.

The new Beginning builds on things that happened in the ‘neutral zone;’ it involves adopting a new mindset or new identity and cannot be scheduled. People go through transitions at different paces. Some people may still be wrestling with ending losses while others are already excited about new beginnings. In organizations, this sometimes happens because people get information at different times. Senior managers may have thought about a change quite a bit before they present it to people below them. As a result, managers may be in the beginning phase while their subordinates are still in an ending phase. The Beginning phase can be disconcerting -- it puts people’s sense of competence and value at risk. Particularly in organizations that have a history of punishing mistakes, people hang back during the final phase of transition, waiting to see how others are going to handle the new beginning.

Exploration of these concepts can be found in Bridges’ Managing Transitions, third edition book (2003) or on his website.

Source Bridges, W. (2009). Managing Transitions: Making the Most of Change, Third Edition. DeCapo Press.

William Bridges and Associates: http://www.wmbridges.com/

Slide 2.70 Note to Trainer: As you go through these steps, weave in as many examples as you can from the issues discussed during the Personal Reflection on Change activity (particularly, the Wish Lists) to anchor the material.

These eight steps on leading change were developed through extensive research in the business world by professor and author, John P. Kotter. Kotter is internationally known and widely regarded as the foremost expert on the topics of Leadership and Transformation. He is a Professor of Leadership, Emeritus at the Harvard Business School and a graduate of MIT and Harvard. This eight-step process for implementing successful transformations were first penned in Kotter’s international bestseller Leading Change. His recent book and website, Our Iceberg Is Melting, puts the eight-step process within an allegory involving penguins whose iceberg is melting, thus making the concepts and principles accessible to a broad range of people.

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Slide 2.70 Cont.

Step 1. Create a Sense of Urgency. Kotter says that, in their rush to make a plan and take action, most companies ignore this step —close to 50% of the companies that fail to make needed change make their mistakes at the very beginning. Leaders may underestimate how hard it is to drive people out of their comfort zones, or overestimate how successfully they have already done so, or simply lack the patience necessary to develop appropriate urgency.

Leaders who know what they are doing at this step will “aim for the heart.” They will connect to the deepest values of their people and inspire them. They will make their “business case” come alive with human experience, and create messages that are simple and imaginative. (Kotter has a book devoted entirely to this first step.)

Step 2. Create the Guiding Team. Kotter has found that putting together the right coalition of people to lead a change initiative is critical to its success. That coalition must have the right composition, a significant level of trust, and a shared objective. In the complex business environment now facing organizations, they are forced to make decisions more quickly and with less certainty than they would like. Teams of leaders, managers, and other staff, acting in concert, are the most effective way to make productive decisions under these circumstances.

Source Kotter, J.P. (1996). Leading Change. Watertown, MA: Harvard Business School Press.

Kotter International Website: http://www.kotterinternational.com/

Slide 2.71 Step 3. Develop a Vision and a Strategy. Kotter says that a clear vision serves three important purposes. First, it simplifies hundreds of more detailed decisions. Second, it motivates people to take action in the right direction even if the first steps are painful.

Third, it helps to coordinate the actions of different people in a remarkably fast and efficient way. A clear and powerful vision will do far more than an authoritarian decree or micromanagement can ever hope to accomplish.

Sources Same as above

Slide 2.72 Step 4. Communicate the Change Vision. Kotter has found that most companies undercommunciate their visions by at least a factor of 10. To be effective, the vision must be communicated in every effective communication channel often.

Step 5. Empower Broad-Based Action. Many times the internal structures of companies are at odds with the change vision. Strategies such as realigning organizational structures, incentives, and performance appraisals to reflect the change vision can have a profound effect on the ability to accomplish the change vision. Kotter says that another barrier to effective change can be troublesome supervisors. Often these managers have habits and a style of management that inhibits change. They may not actively undermine the effort, but they are simply not “wired” to go along with what the change requires. This is not an easy problem to “fix.”

Sources Same as above

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Slide 2.73 Step 6. Generate Short-term Wins. With long-term change effort, short-term wins are essential. The Guiding Coalition becomes a critical force in identifying significant improvements that can happen between six and 18 months. Getting these wins helps ensure the overall change initiative’s success. Kotter’s research shows that companies that experience significant short-term wins by fourteen and twenty-six months after the change initiative begins are much more likely to complete the transformation. To ensure success, short term wins must be both visible and clearly related to the change effort. Such wins provide evidence that the sacrifices that people are making are paying off, boosts morale and increases optimism. Short-term wins also tend to undermine the credibility of cynics and self-serving resistors.

Step 7: Don’t Let Up. The consequences of letting up can be very dangerous. Whenever you let up before the job is done, critical momentum can be lost and regression may soon follow. People who have been resistant are often “waiting in the wings” for a break in the momentum to declare failure. The new behaviors and practices must be driven into the culture to ensure long-term success. Once regression to former behavior begins, rebuilding momentum is a daunting task.

Source Kotter, J.P. (1996). Leading Change. Watertown, MA: Harvard Business School Press.

Kotter International Website: http://www.kotterinternational.com/

Slide 2.74 Step 8. Create a New Culture. Kotter emphasizes that new practices must grow deep roots in order to remain firmly planted in the culture. Culture is composed of norms of behavior and shared values. These social forces are incredibly strong. Changes – whether consistent or inconsistent with the old culture – are difficult to ingrain.

Kotter provides some general rules about cultural change include: • Cultural change comes last, not first (as it takes time to ingrain) • You must be able to prove that the new way is superior to the old • The success must be visible and well communicated • You will lose some people in the process • You must reinforce new norms and values with incentives and rewards • Reinforce the culture with every new employee Source Kotter, J.P. (1996). Leading Change. Watertown, MA: Harvard Business School Press.

Kotter International Website: http://www.kotterinternational.com/

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Slide 2.75 Step 8. Create a New Culture. Kotter emphasizes that new practices must grow deep roots in order to remain firmly planted in the culture. Culture is composed of norms of behavior and shared values. These social forces are incredibly strong. Changes – whether consistent or inconsistent with the old culture – are difficult to ingrain.

Kotter provides some general rules about cultural change include: • Cultural change comes last, not first (as it takes time to ingrain) • You must be able to prove that the new way is superior to the old • The success must be visible and well communicated • You will lose some people in the process • You must reinforce new norms and values with incentives and rewards • Reinforce the culture with every new employee Source Kotter, J.P. (1996). Leading Change. Watertown, MA: Harvard Business School Press.

Kotter International Website: http://www.kotterinternational.com/

Slide 2.76 Note to trainer: Don’t review each behavior that is a sign of resistance. Just make a general comment about the signs as shown below.

Most of us are very familiar with these behavioral signs of resistance. The behaviors can be less overt and more easily addressed (as shown in the first column) or very overt and potentially damaging to the change initiative (second column).

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Slide 2.77 Resistance is in the eye of the beholder. The people resisting don’t see what they are doing as resistance – they often see it as survival. Resisting change helps to preserve balance in our lives by relegating habitual responses to the unconscious.

Resistance also protects people from harm. It’s resistance that keeps people from getting into dangerous situations. In an organization, resistance can be beneficial; for instance, if a manager wants to institute a change that is not well thought out or could have serious repercussions that have not been considered.

Resistance to change is a reaction to the way a change is being led. There are no born “resistors” out there waiting to ruin otherwise perfect plans. People resist in response to something.

Source Maurer, R. (2009). Resistance to change – Why it matters and what to do about Ii. Author. Retrieved from http://www.rickmaurer.com/wp/ resistance-to-change-why-it-matters-and-what-to-do-about-it-2

Slide 2.78 In dealing with resistance, be sure to show respect to others by making sure people know why the change is needed, be honest and engage others in the process, and build relationships within the team.

Source Maurer, R. (2009). Resistance to change – Why it matters and what to do about Ii. Author. Retrieved from http://www.rickmaurer.com/wp/resistance-to-change-why-it-matters-and-what-to-do-about-it-2

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Slide 2.79 Level 1 – I Don’t Get It Level 1 involves information: facts, figures, ideas. It is the world of thinking and rational action. It is the world of presentations, diagrams, and logical arguments. Level 1 may come from . . .

• Lack of information • Disagreement with data • Lack of exposure to critical information • Confusion over what it means Many make the mistake of treating all resistance as if it were Level 1. Well-meaning leaders give people more information – hold more meetings, and make more PowerPoint presentations – when, in fact, something completely different is called for. And that’s where Levels 2 and 3 come in.

Sources Maurer, R. (2002). Why don’t you want what I want? How to win support for your ideas without hard sell, manipulation or power plays. Austin, TC: Bard Press.

Maurer, R. (2009). Resistance to change – Why it matters and what to do about it. Author. Retrieved from http://www.rickmaurer.com/wp/ resistance-to-change-why-it-matters-and-what-to-do-about-it-2

Slide 2.80 Level 2 is an emotional reaction to the change. Blood pressure rises, adrenaline flows, pulse increases. It is based on fear: People are afraid that this change will cause them to lose face, status, control – maybe even their jobs.

Level 2 is not easy to change as these fundamental feeling run deep. When they kicks in, people can feel like their very survival is at stake.

When Level 2 is active, it makes communicating change very difficult. When adrenaline shoots through the body, people can move into fight-or-flight mode and stop listening.

Consider the example of an organization that has to downsize some of it’s operations. No matter how terrific the leader’s presentation is, once people hear “downsizing” their minds (and bodies) go elsewhere. And this is uncontrollable. They are not choosing to ignore the leader, it’s just that they have more important things on their minds – like their own survival.

Organizations usually don’t encourage people to respond emotionally, so employees limit their questions and comments to Level 1 issues. They ask polite questions about budgets and timelines. So it may appear that they are with “the program”, but they’re not. They are asking Level 1 questions while hoping that leadership will read between the lines and speak to their fears, and they may not even be aware that they are operating on such a basic emotional level.

This level relates closely to the Stages of Change model in which the person undergoing the change has to resolve ambivalence to making the change, has to see the change as important, and believe in his/her ability to make the change (confidence/self-efficacy).

Sources Maurer, R. (2002). Why don’t you want what I want? How to win support for your ideas without hard sell, manipulation or power plays. Austin, TC: Bard Press.

Maurer, R. (2009). Resistance to change – Why it matters and what to do about it. Author. Retrieved from http://www.rickmaurer.com/wp/ resistance-to-change-why-it-matters-and-what-to-do-about-it-2

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Slide 2.81 This level of resistance is a “hard pill” for most leaders to swallow. But lack of attention to Level 3 is a major reason why resistance flourishes and changes fail. And it is seldom talked about. Books on change talk about strategies and plans (all good stuff, to be sure) but most of this advice fails to recognize a major reason why change fails.

This level of resistance involves: lack of trust in person implementing the change, lack of trust of overall management, and/or deep entrenchment in beliefs, experiences and biases. In Level 3 resistance, people are not resisting the idea – in fact, they may love the change that is being presented. Maybe their history with the organization or certain leaders/managers makes them wary. Perhaps they are afraid that this will be “a flavor of the month” like so many other changes, or that leaders won’t have the fortitude to see this through.

Whatever the reasons for this deeply entrenched resistance, it can’t be ignored. It is actually the most difficult level of resistance to turn around. Even if people understand the idea being suggesting (Level 1), and they have a good feeling about the possibilities of this change (Level 2) – but they won’t go along if they don’t trust the people leading the change.

Rick Maurer offers specific strategies to turn resistance at each level into support for change in his book - Why Don’t You Want What I Want? How to Win Support for Your Ideas Without Hard Sell, Manipulation or Power Plays (2002) and on his comprehensive website at rickmaurer.com.

Source Maurer, R. (2002). Why don’t you want what I want? How to win support for your ideas without hard sell, manipulation or power plays. Austin, TC: Bard Press.

Maurer, R. (2009). Resistance to change – Why it matters and what to do about it. Author. Retrieved from http://www.rickmaurer.com/wp/ resistance-to-change-why-it-matters-and-what-to-do-about-it-2

Slide 2.82 Changing practices to incorporate telehealth technologies – or any other new practice – is multi-level and multi-faceted. Not only do organizations need to have a commitment and shared resolve for change and an effective strategy for managing the change process, organizations need to pay attention to the components of adoption and implementation of a telehealth technology.

The new field of implementation science studies the effects of individual, organizational, and systemic characteristics on the process of implementation of new programs or practices. There is now an open source (free access) online journal called “Implementation Science” that is devoted to this type of research.

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Slide 2.83 The process and the factors that affect the spread of innovations are described in several well-known research-based frameworks. There not enough time during this training to go into detail of these theories; however, in the resources shown on this slide can provide comprehensive information and/or tools to assist with implementation science knowledge or implementation processes.

One of these frameworks, the Consolidated Framework for Implementation Research (CFIR) is a “meta-theory” – meaning researchers conducted a meta-analysis of the prevailing implementation theories to arrive at an overarching theory of theories. We will quickly review the constructs of the CFIR as it provides a reference for the key components for effective implementation of new practices and reinforces the many elements we have discussed today.

Sources Aarons, G. A., Hurlburt, M., & Horwitz, S. M. (2011). Advancing a conceptual model of evidence-based practice implementation in public service sectors. Administration and Policy in Mental Health, 38(1), 4-23.

Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., & Lowery, J.C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4:50. Retrieved from http://www.implementationscience.com/content/4/1/50.

Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M. & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231).

Meyers, D. C., Durlak, J. A., & Wandersman, A. (2012, Dec.). The quality implementation framework: a synthesis of critical steps in the implementation process. American Journal of Community Psychology, 50(3-4), 462-23.

Slide 2.84 The CFIR comprises five major domains - the intervention, inner and outer setting, the individuals involved, and the process by which implementation is accomplished. These domains interact in rich and complex ways to influence implementation effectiveness.

Source Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., & Lowery, J.C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4:50. Retrieved from http://www. implementationscience.com/content/4/1/50.

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Slide 2.85 The first major domain of the CFIR is related to characteristics of the intervention being implemented into a particular organization. Without adaptation, interventions often come to a setting as a poor fit, resisted by individuals who will be affected by the intervention, and requiring an active process to engage individuals in order to accomplish implementation.

Different innovations have different characteristics which result in various probabilities of adoption and adoption rates. These are particularly applicable to telehealth technologies because understanding the potentially complex characteristics of the selected technology device can help to alleviate barriers to implementation.

Intervention source – stakeholders’ perception about the legitimacy of the source of the intervention Evidence strength and quality – stakeholders’ perceptions of the quality and validity of evidence supporting the belief that the intervention will have desired outcomes Relative advantage – stakeholders’ perception of the advantage of implementing the intervention versus an alternative solution; the perception that it is significantly better than current practice Adaptability - the degree to which an intervention can be adapted, tailored, refined, or reinvented to meet local needs Triability – the ability to test the intervention on a small scale in the organization, and to be able to reverse course (undo implementation) if warranted Complexity – the perceived difficulty of implementation, reflected by duration, scope, radicalness, disruptiveness, centrality, and intricacy and number of steps required to implement Design quality and packaging – the perceived excellence in how the intervention is bundled, presented, and assembled Cost – the costs of the intervention and costs associated with implementing that intervention, including investment, supply, and opportunity costs Source Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., & Lowery, J.C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4:50. Retrieved from http://www.implementationscience.com/content/4/1/50.

Slide 2.86 Patient needs and resources - the extent to which patient needs, as well as barriers and facilitators to meet those needs, are accurately known and prioritized by the organization. Research has shown that patient-centered organizations are more likely to implement change effectively because of the importance of accounting for patient outcomes.

External Networks - the degree to which an organization is networked with other external organizations Peer pressure - competitive pressure to implement an intervention, typically because most or other key peer or competing organizations have already implemented or in pursuit of a competitive edge External policies and incentives – these broad constructs encompass external strategies to spread interventions, including policy and regulations (governmental or other central entity), external mandates, recommendations and guidelines, pay-for-performance, collaboratives, and public or benchmark reporting Source Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., & Lowery, J.C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4:50. Retrieved from http://www.implementationscience.com/content/4/1/50.

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Slide 2.87 Structural characteristics - the social architecture, age, maturity, and size of an organization. The stability of staff on implementation teams are (members are able to remain with the team for an adequate period of time; low staff turnover), the more likely implementation will be successful.

Networks and communications - the nature and quality of webs of internal social networks and the nature and quality of formal and informal communications within an organization Culture – the norms, values, and basic assumptions of a given organization. Most change efforts are targeted at visible, mostly objective, aspects of an organization that include work tasks, structures, and behaviors. One explanation for why so many of these initiatives fail centers on the failure to change less tangible organizational assumptions, thinking, or culture Implementation climate - the capacity for change, shared receptivity of involved individuals to an intervention, and the extent to which use of that intervention will be ‘rewarded, supported, and expected within their organization Source Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., & Lowery, J.C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4:50. Retrieved from http://www.implementationscience.com/content/4/1/50.

Slide 2.88 The fourth major domain of the CFIR is the individuals involved with the intervention and/or implementation process.

Knowledge and beliefs about the intervention - individuals’ attitudes toward and value placed on the intervention, as well as familiarity with facts, truths, and principles related to the intervention. The degree to which new behaviors are positively or negatively valued heightens intention to change, which is a precursor to actual change.

Self-efficacy – the individuals’ belief in their own capabilities to execute courses of action to achieve implementation goals. Self-efficacy is a significant component in most individual behavior change theories.

Individual stage of change - characterization of the phase an individual is in, as he or she progresses toward skilled, enthusiastic, and sustained use of the intervention Individual identification with organization – this is a broad construct related to how individuals perceive the organization and their relationship and degree of commitment to that organization. These attributes may affect the willingness of staff to fully engage in implementation efforts or use the intervention.

Source Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., & Lowery, J.C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4:50. Retrieved from http://www.implementationscience.com/content/4/1/50.

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Slide 2.89 The fifth major domain is the implementation process. The fundamental objective of planning is to design a course of action to promote effective implementation by building local capacity for using the intervention, collectively and individually.

Successful implementation usually requires an active change process aimed to achieve individual and organizational level use of the intervention as designed. Individuals may actively promote the implementation process and may come from the inner or outer setting (e.g., local champions, change agents). The implementation process may be an interrelated series of sub-processes that do not necessarily occur sequentially. There are often related processes progressing simultaneously at multiple levels within the organization.

Quantitative and qualitative feedback about the progress and quality of implementation accompanied with regular personal and team debriefing about progress and experience is important.

Source Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., & Lowery, J.C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4:50. Retrieved from http://www.implementationscience.com/content/4/1/50.

Slide 2.90 To facilitate the telehealth implementation process, NFAR-ATTC has designed a Telehealth Capacity Assessment Tool (TCAT) to help behavioral health organizations: 1) measure their capacity in accordance with these factors; 2) identify capacity building needs and plan for development in strategic areas; and, 3) monitor and evaluate the impact of their capacity building efforts.

Note to Trainer Have participants take out the TCAT and follow along as you go through Slides 2.90 2.103.

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Slide 2.91 The successful implementation of a telehealth program requires attention to the interplay among technical, organizational, regulatory, financial, clinical and social factors – as well as how this interplay is managed through effective organizational change processes.

The TCAT helps organizations assess their readiness to adopt telehealth technologies.

Slide 2.92 The TCAT helps organizations assess their readiness to adopt telehealth technologies.

It can provide a starting place discussions, and for keeping them focused through the series of questions in the capacity assessment.

Determining organizational readiness is the initial step an organization should take to assure that the desired technology can be fully implemented and utilized. The approach to assessment may be as simple as leaders in the organization completing the steps in this guide to assure that critical areas have been considered, or as involved as a formal facilitated process among the organization’s key personnel, the Board of Directors, and other stakeholders.

By using the TCAT, organizations can identify their strengths and weaknesses—where they are meeting essential components and where they do not—as well as define activities that can strengthen the organization’s ability to refocus programs and continually improve the quality of their telehealth efforts. In addition, the TCAT can be used as a measurement tool over time to allow the organization to assess its increased competency and capacity in the areas that support telehealth.

The TCAT is not a validated assessment instrument, but has been adapted/modified to fit the needs of behavioral health organizations from other validated telemedicine or telehealth readiness instruments (shown below). Items in the TCAT are also based on the prevailing research on readiness elements and predictors of adoption of telehealth technologies. There are only a few related telehealth readiness assessments: 1. Telehealth Readiness Assessment Tools (for organizations, practitioners, and the public) (Jennet, 2005) 2. e-Health Readiness Assessment Tools for Healthcare Institutions in Developing Countries (Khoja, 2007) 3. Assessing Organizational Readiness (2009) from the California Telemedicine and eHealth Center Sources Jennet, P.A., Ganon, M.P. & Brandstadt, H.K. (2005). Preparing for success: Readiness models for rural health. Journal of Postgraduate Medicine, 51:4, 279-285.

Khoja, S., Durani, H., Schoot, R. E., Sajwani, A. & Piryani, U. (2013). Conceptual framework for development of comprehensive e-health evaluation tool. Telemedicine and e-Health, 19(1), 48-53.

Khoja, S., Scott, R. E., Casebeer, A. L., Mohsin, M., Ishaq, A. F. M., & Gilani, S. (2007). e-Health readiness assessment tools for healthcare institutions in developing countries. Telemedicine and e-Health, 13(4), 425-431.

Legare, E., Vincent, C., Lehoux, P., Anderson, D., Kairy, D., Ganon, M. P. & Jennett, P. (2010). Telehealth readiness assessment tools. Journal of Telemedicine and Telecare, 16, 107-109.

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Slide 2.93 The TCAT considers capacity as a function of various factors that enable an organization to work towards its desired telehealth technologies solutions. Capacity is viewed as the ability of individuals, organizations, or organizational units to perform specific functions effectively, efficiently, and sustainably.

For the purposes of the TCAT, capacity building is an evidence-driven process of strengthening the abilities of organizations and individuals to deliver the desired telehealth services, and continue to improve and develop over time. Having an established plan helps ensure that capacity continues to develop in strategic areas.

The TCAT emphasizes important factors in six key domains that have been shown in previous research to complement and reinforce each other, and together combine to enhance the implementation, quality, integrity, sustainability, and impact of telehealth initiatives.

Slide 2.94 Note to Trainer: For the following six slides that address each domain in the TCAT, refer participants to the corresponding scoring table in the TCAT. Review the subcomponents and the scoring statements associated with each.

Slide 2.95 Domain 2: Technology

Slide 2.96 Domain 3: Regulatory and Policy

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Slide 2.97 Domain 4: Financing and Reimbursement

Slide 2.98 Domain 5: Clinical

Slide 2.99 Domain 6: Workforce

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Slide 2.100 The TCAT can be used by any behavioral health organization interested in improving the planning process, design, implementation, and monitoring of its telehealth initiatives.

The assessment tool should be completed by as many people as possible to help prevent bias in either a positive or a negative direction. Likewise, the organization should create an environment that is participatory and equitable, where all participants feel comfortable contributing their opinions and do not feel they are being steered toward a certain score or outcome. It is helpful if the persons completing the TCAT are familiar how the organization functions in all or some of the six capacity assessment domains.

The level of formality of the assessment process depends on the organization’s needs and culture. No matter how extensive the review, the capacity assessment is a critical component of a successful telehealth initiative. The TCAT provides worksheets for documenting answers to important organizational readiness questions and provides a summary template that can be used to discuss your proposed program with stakeholders and decision makers within the organization.

The organization should clearly understand the purpose of the TCAT and note that the assessment tool encompasses a three-step process: • The first step requires the use of the capacity assessment tool to guide discussions and scoring.

• The second step gathers evidence through a review of telehealth materials.

• The third step concludes the process with the development of a Capacity Strengthening Plan.

After completing the entire three-step process, organizations will be able to take action to increase their telehealth capacity in a systematic and evidence-based manner.

Slide 2.101 The first step in the assessment process is to determine organizational readiness. The readiness assessment phase may be as simple as leaders in the organization completing the TCAT to ensure that critical areas have been considered, or as complex as a formal facilitated process among the organization’s key personnel, Board of Directors, and other stakeholders.

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Slide 2.102 Participants completing the Step 1 process should rate the organization on each of the six capacity domains using the TCAT. This should be a ‘blind’ assessment, meaning that each individual should base their assessment on what they know or believe about the organization as it relates to each of the six domains. Each readiness item will be assessed using the following 6-point scale: 0 = Don’t Know/Not Applicable; 1= No, never considered; 2 = No, but have considered; 3 = Yes, in progress; 4 = Yes, nearly completed; 5= Yes, in place. The total score for each domain component should be calculated and entered on the Domain Scoring Summary.

Slide 2.103 The mean score for each domain can then be calculated and used to visualize the organization’s overall readiness for implementing telehealth. Tallying and averaging the scores for each domain will provide a baseline from which the organization can build and begin planning changes regarding the implementation of telehealth technologies.

Once areas showing a less than adequate degree of organizational readiness to implement client services using telehealth technologies have been identified, it will be helpful to gather information on ways to address those deficiencies. For example, if the TCAT results show that the organization does not have the technology capacity to deliver client services using telehealth, looking at current resources on how to develop that infrastructure will provide information on the type of equipment, Internet access, and room setup needed to move forward with planning for telehealth implementation.

After reviewing external resources such as those shown in the TCAT, it is recommended that the organization examine the status of its currently available internal resources. For example, going back to the previous illustration regarding a low TCAT score on technology capacity, it could be helpful to look at the organization’s current telephone service, Internet provider/broadband connection capacity, and computer hardware/software resources to determine the type and extent of the changes that would need to be made in order to have the technology capacity to implement telehealth services. By comparing the information gathered from the internal resource ‘inventory’ to what was learned from the external review will help inform the planning process.

The final step in this initial process is the create a Capacity Strengthening Plan. The template follows the domains and components of the TCAT provides a convenient format that can be used by organizations to detail needed actions and support current activities. It can be used to capture information about gaps that were identified through the TCAT assessment, prioritize strategic areas for strengthening, identify the resources that can be brought to bear on the initiative, develop action strategies, and monitor results.

Organizational change teams are encouraged to conduct these activities through the lens of this capacity strengthening framework. Capacity planning can be conducted before the telehealth technology is adopted, reviewed through implementation, and used to monitor progress in key domains.

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Slide 2.104 Note to Trainer: In advance of the training session, create a replica of the scoring table on a piece of newsprint paper. As the Case Study activity evolves, this table will be used to tablulate an Overall Score for the mock agency in the case study.

Instruct participants to take out the Case Study for Organizational Telehealth Readiness.

Break the full group of participants into five (5) small groups using your preferred method for dividing into groups. These five groups will use the TCAT to score the mock agency across all six domains. Since there are fewer questions in Domains 5 and 6, these two domains are to be scored by the same subgroup.

Give participants 5 minutes to read the Case Study. Allow another 10 minutes for the groups to discuss and score the TCAT. Ask each group to report their findings and score to the larger group. As each score is reported, record it on the newsprint pad. When all scores are reported, follow the final scoring procedures outlined in the TCAT to arrive at the Overall Readiness Score. Solicit discussion of issues from the participants.

Slide 2.105 This last segment will summarize what has been taught today, and will share the major lessons learned by organizations that have implemented telehealth technologies for both general healthcare and behavioral health care. Overall, the deployment of telehealth solutions is a time-consuming process from start to finish, as healthcare leaders must develop a strategy, coordinate adoption of solutions, train staff and implement measurement tools to track progress.

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Slide 2.106 Telehealth-enabled programs disrupt the status quo. Telehealth requires a different mind-set to achieve desired changes in practice and targeted outcomes. An organization’s ability to promote a culture of openness, preparedness, and adaptiveness to technology-led change will increase the likelihood that the implementation will succeed. It is important to be prepared to address barriers.

Program development involves a multidisciplinary, team-based approach.

Telehealth requires the integration of technical, clinical, and business processes into a standard program at initiation and at points within the treatment lifecycle. Some telehealth team members tend to specialize in providing the technology expertise, wraparound support and training, and equipment installation, while other team members provide the clinical expertise for successfully designing and implementing the technology for use in care.

Technology implementation is a social process. Technology-enabled solutions in health care are very much social in nature. Establishing leadership support and identifying program champions. Patient/client activation (having the knowledge, skills, and confidence to manage one’s health) and engagement have also been key to successful program outcomes.

Source Broderick, A. & Lindeman, D. (2013, January). Scaling telehealth programs: Lessons from early adopters. Commonwealth Fund Publication, Vol.1, 1-10.

Slide 2.107 Align telehealth strategy with organizational vision and mission. The ability of the organization to connect vision, strategy, and technology for the delivery of the desired services helps to anchor the new philosophy of care and service protocols in the culture. Effective mechanisms - such as strong leadership support, articulation of a strategic vision and compelling business case, coupled with a strong commitment to standardized work processes, policies, and training – facilitate the change process.

Dedicate resources to staff training and devel­opment. Workforce development solutions can help leaders introduce new concepts of the strategies in a piecemeal fashion, allowing employees to slowly integrate what they have learned into daily practices for high levels of mastery. Training and development activities (such as supervision) should occur: 1) Just prior to initial program adoption and implementation, and 2) Ongoing for new staff working in the telehealth program and refresher training for existing staff. Each person on the telehealth team will need general telehealth training and then more specialized training pertinent consistent with their respective responsibilities. The breadth and depth of the training depends on the role of the staff within the telehealth program. As part of a program’s development process, specific telehealth responsibilities should be identified and assigned to new and/or existing positions.

Successful programs can take time to scale suc­cessfully. It takes time to integrate technology into care delivery and to allow staff to adapt. Structure, coordination, planning, and setting goals and expectations are critical.

Source Broderick, A. & Lindeman, D. (2013, January). Scaling telehealth programs: Lessons from early adopters. Commonwealth Fund Publication, Vol.1, 1-10.

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Slide 2.108 Telehealth services need to be monitored. Telehealth evaluation can serve several purposes. One purpose is to determine success or failure of telehealth programs in reaching explicit objectives. Another purpose is to determine if the program has undesirable or unintended effects. In addition, evaluation needs to lead to informed policy decisions on continuation/termination or changes to the existing program.

Evaluation of costs are important to decisions about increasing, maintaining, or decreasing funds for telehealth initiatives.

Telehealth data can empower all stakehold足ers. Telehealth data can have a positive impact on client/patient care when placed in the hands of motivated clinicians and clients/patients. The use of real-time personal data can help edu足cate and motivate patients to make necessary life足style changes and realize better clinical outcomes. Additionally, the sharing of outcome data with clinical staff helps to lower resistance to use the innovation and provide motivation for continued use of the innovation (if the data is positive).

Source Broderick, A. & Lindeman, D. (2013, January). Scaling telehealth programs: Lessons from early adopters. Commonwealth Fund Publication, Vol.1, 1-10.

Slide 2.109 Questions

Slide 2.110 Thank You www.nfarattc.org

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Telehealth