TELEMENTAL HEALTH IN VA:TELEMENTAL HEALTH IN VA:

HISTORY AND NEW HISTORY AND NEW OPPORTUNITIESOPPORTUNITIES

Jamie L. Adler, Ph.D.Jamie L. Adler, Ph.D.

VISN 12 Telemental Health CoordinatorVISN 12 Telemental Health Coordinator

With thanks to Linda Godleski, M.D., VHA Lead for Telemental Health for With thanks to Linda Godleski, M.D., VHA Lead for Telemental Health for information on the history of telemental health within VA.information on the history of telemental health within VA.

Historical Perspective - 1968Historical Perspective - 1968

Medical television system connected the Medical television system connected the University of Nebraska Medical CenterUniversity of Nebraska Medical Center Omaha VA HospitalOmaha VA Hospital Lincoln VA HospitalLincoln VA Hospital Grand Island VA HospitalGrand Island VA Hospital

Used for a psychiatric treatment and training Used for a psychiatric treatment and training activitiesactivities

Cost $48,000/yr to connect one site with limited Cost $48,000/yr to connect one site with limited qualityquality

Historical Perspective - 1968Historical Perspective - 1968

Broadening of telemental health to large Broadening of telemental health to large scale operationsscale operations

Massachusetts General Hospital to:Massachusetts General Hospital to: Logan Airport Medical StationLogan Airport Medical Station Bedford VA HospitalBedford VA Hospital

Positive outcomes:Positive outcomes: 2.5 years2.5 years 150 patients150 patients

Historical Perspective – Historical Perspective – 1970’s and 1980’s1970’s and 1980’s

15 federally funded telemedicine projects 15 federally funded telemedicine projects in the 1970sin the 1970s

Cumbersome and expensive technologies Cumbersome and expensive technologies

Resurgence in the 1980s with widespread Resurgence in the 1980s with widespread entry into computer ageentry into computer age

VHA Telemental Health – 1990’sVHA Telemental Health – 1990’s

VHA becomes a world leader VHA becomes a world leader in telemental health delivery in telemental health delivery starting in 1997starting in 1997

Historical PerspectiveHistorical Perspective

Fiscal YearFiscal Year Veterans ServedVeterans Served EncountersEncounters

20032003 8,0008,000 13,00013,000

20042004 9,7899,789 20,77320,773

20052005 15,05115,051 26,67326,673

20062006(through August)(through August)

18,41818,418 26,40526,405

New Technical RealitiesNew Technical Realities

Moore’s LawMoore’s Law: Computer processing : Computer processing power and speed per unit of cost doubles power and speed per unit of cost doubles every 18-24 months.every 18-24 months.

Has held true since Moore first stated this Has held true since Moore first stated this in the 1960’s.in the 1960’s.

The impact on TMH is that the capability of The impact on TMH is that the capability of the equipment and the network is vastly the equipment and the network is vastly better and considerably less expensive better and considerably less expensive than it was only a short time ago.than it was only a short time ago.

Old Beliefs Die HardOld Beliefs Die Hard

““The human element is missing.”The human element is missing.”

““Telemental health is less safe.”Telemental health is less safe.”

““It’s less effective than ‘real’ (i.e. face-to-It’s less effective than ‘real’ (i.e. face-to-face) therapy.”face) therapy.”

““Patients won’t like it.”Patients won’t like it.”

Recent ResearchRecent Research

Several recent studies have shown that, when Several recent studies have shown that, when comparing mental health services delivered by comparing mental health services delivered by telemental health (TMH) vs. face-to-face (F2F):telemental health (TMH) vs. face-to-face (F2F): TMH & F2F have equal patient satisfaction.TMH & F2F have equal patient satisfaction. No difference in attrition.No difference in attrition. No difference in symptom and functional outcome No difference in symptom and functional outcome

reports.reports. No interaction of modality with Axis II diagnosis.No interaction of modality with Axis II diagnosis. No increase in safety issues.No increase in safety issues.

Limitations to Recent ResearchLimitations to Recent Research

Most of the studies have been on Most of the studies have been on telepsychiatry.telepsychiatry.

A couple of small N studies on A couple of small N studies on telepsychology and tele-addiction (same telepsychology and tele-addiction (same outcomes).outcomes).

Much room for investigation in this area.Much room for investigation in this area. Despite these limitations, currently no data Despite these limitations, currently no data

to suggest worse outcomes or lower to suggest worse outcomes or lower satisfaction for TMH.satisfaction for TMH.

Traditional “Scarcity” ModelTraditional “Scarcity” Model

Historically, telemental health (TMH) initiatives in Historically, telemental health (TMH) initiatives in throughout the VA have followed a “Traditional” throughout the VA have followed a “Traditional” or “Narrow” deployment strategy.or “Narrow” deployment strategy.

Equipment was expensive and hard to come by, Equipment was expensive and hard to come by, often costing over $8000 for each end point.often costing over $8000 for each end point.

Less expensive equipment, when available, Less expensive equipment, when available, would not provide useable video resolution or would not provide useable video resolution or motion for clinical work.motion for clinical work.

Traditional “Scarcity” ModelTraditional “Scarcity” Model Facilities had a single originating room used by Facilities had a single originating room used by

one dedicated TMH clinician or shared by one dedicated TMH clinician or shared by several clinicians who each had scheduled time several clinicians who each had scheduled time blocks.blocks.

Services to remote sites were rationed and Services to remote sites were rationed and typically were limited to tele-psychiatry.typically were limited to tele-psychiatry.

The traditional model was also labor intensive, The traditional model was also labor intensive, requiring associated mental health staff to be in requiring associated mental health staff to be in the room with the veteran or nearby.the room with the veteran or nearby.

TM HS PEC IA LIS T(S )

C BOC 1

C BOC 3

C BOC 2

C BOC 4

C BOC 5

NARROW (TRADITIONAL) TELEMENTAL HEALTHDEPLOYM ENT STRATEGY

Transition to a New ApproachTransition to a New Approach

GOALS:GOALS:

100% coverage of CBOCs.100% coverage of CBOCs.

Access to a wide variety of clinical services at Access to a wide variety of clinical services at all remote sites.all remote sites.

Mental Health clinician access throughout the Mental Health clinician access throughout the CBOC clinic day.CBOC clinic day.

Transition to a New ApproachTransition to a New Approach

GOALS:GOALS:

Access to same-day assessment & treatment Access to same-day assessment & treatment planning.planning.

Meet the mental health treatment needs of rural Meet the mental health treatment needs of rural veterans who live far from the hospital or CBOCs.veterans who live far from the hospital or CBOCs.

Use existing clinician capacity whenever possible.Use existing clinician capacity whenever possible.

““Broad” Telemental Health Broad” Telemental Health Deployment StrategyDeployment Strategy

Many or most outpatient clinicians receive Many or most outpatient clinicians receive inexpensive, computer based or desktop inexpensive, computer based or desktop videoconferencing units.videoconferencing units.

Inexpensive “individual” sized video equipment Inexpensive “individual” sized video equipment at all remote sites. Attempt to equip multiple at all remote sites. Attempt to equip multiple rooms at larger remote sites.rooms at larger remote sites.

Mental Health & CBOC conference rooms Mental Health & CBOC conference rooms equipped with more sophisticated group equipped with more sophisticated group videoconferencing.videoconferencing.

““Broad” Telemental Health Broad” Telemental Health Deployment StrategyDeployment Strategy

Utilize data compression capacity of new Utilize data compression capacity of new equipment to reduce bandwidth needs.equipment to reduce bandwidth needs.

New Paradigm: TMH is seen as widely available, New Paradigm: TMH is seen as widely available, rather than as a scarce resource to be rationed. rather than as a scarce resource to be rationed.

Partner with remote non-VA sites to host video Partner with remote non-VA sites to host video endpoints.endpoints.

Non-VA PartnershipsNon-VA Partnerships

Reach rural veterans far from VA clinics.Reach rural veterans far from VA clinics. Partner site provides room, reception, and Partner site provides room, reception, and

possibly network connection.possibly network connection. VA assumes responsibility for MH care of VA assumes responsibility for MH care of

veteran.veteran. VA can also provide some specialty VA can also provide some specialty

consultation via video.consultation via video.

M H/ PTS D/ S UDGROUP

C BOC 1(LA RGE)

C BOC 3

C BOC 2

C BOC 4

C BOC 5

BROAD (DISTRIBUTED) TELEMENTAL HEALTH DEPLOYMENT STRATEGY (EXAMPLE 1)

PA RTNER S ITE 1

PA RTNER S ITE 2

S M IC LINIC IA N(S )

S UDC LINIC IA NS

PTS DC LINIC IA NS

M HC LINIC IA NS

M H/PCINTEGRA TION

TEA M

M H/ PTS D/ S UDGROUP

C BOC 1(LA RGE)

C BOC 3

C BOC 2

C BOC 4

C BOC 5

BROAD (DISTRIBUTED) TELEMENTAL HEALTH DEPLOYMENT STRATEGY (EXAMPLE 2)

PA RTNER S ITE 1

PA RTNER S ITE 2

S M IC LINIC IA N(S )

S UDC LINIC IA NS

PTS DC LINIC IA NS

M HC LINIC IA NS

M H/PCINTEGRA TION

TEA M

M H/ PTS D/ S UDGROUP

C BOC 1(LA RGE)

C BOC 3

C BOC 2

C BOC 4

C BOC 5

BROAD (DISTRIBUTED) TELEMENTAL HEALTH DEPLOYMENT STRATEGY (EXAMPLE 3)

PA RTNER S ITE 1

PA RTNER S ITE 2

S M IC LINIC IA N(S )

S UDC LINIC IA NS

PTS DC LINIC IA NS

M HC LINIC IA NS

M H/PCINTEGRA TION

TEA M

Telemental HealthTelemental HealthEquipment OptionsEquipment Options

New InitiativesNew Initiatives

$9 Million in FY 2006 to expand general $9 Million in FY 2006 to expand general and specialty telemental health care to and specialty telemental health care to CBOCs.CBOCs.

Further expansion funds available in FY Further expansion funds available in FY 2007 for CBOC equipment and for VISN-2007 for CBOC equipment and for VISN-wide PTSD and Addiction TMH care.wide PTSD and Addiction TMH care.

Opportunities for PsychologyOpportunities for Psychology

Substance Abuse Continuity of Care Substance Abuse Continuity of Care Performance Measure.Performance Measure.

Evidence Based Psychotherapy for PTSD, Evidence Based Psychotherapy for PTSD, Depression, Anxiety, Addiction, Health Depression, Anxiety, Addiction, Health Psychology.Psychology.

Assessment and Treatment Planning.Assessment and Treatment Planning. Limited psychological / cognitive Limited psychological / cognitive

assessment.assessment. Primary Care Integration with CBOCs.Primary Care Integration with CBOCs.

For More information:For More information:

Jamie L. Adler, Ph.D.Jamie L. Adler, Ph.D.

Mental Health Service Line (116)Mental Health Service Line (116)

William S. Middleton Mem. Veterans HospitalWilliam S. Middleton Mem. Veterans Hospital

2500 Overlook Terrace, Madison, WI 537052500 Overlook Terrace, Madison, WI 53705

608-280-7015 / Fax: 608-280-7203608-280-7015 / Fax: 608-280-7203

jamie.adler@va.govjamie.adler@va.gov