# Presentation: 379872

## VIRTUALLY THERE: IMPROVING ACCESS TO BEHAVIORAL HEALTH SUPPORT THROUGH TELEHEALTH

**Peter Stuart, MD**
**IHS National Psychiatry Consultant**
**July 2008**

- Peter Stuart, MD peter.stuart@ihs.gov

## IHS AND THE INDIAN COUNTRY BEHAVIORAL HEALTH CRISIS

- Peter Stuart, MD peter.stuart@ihs.gov

## IHS AND THE INDIAN COUNTRY BEHAVIORAL HEALTH CRISIS

- Peter Stuart, MD peter.stuart@ihs.gov

## IHS AND THE INDIAN COUNTRY BEHAVIORAL HEALTH CRISIS

**From ppt: C. M. Ryan et al**** Tracking American Indians and Alaska Natives: ****IHS Data Issues Associated with Measuring  HP2010 Objectives,  IHS**

- Peter Stuart, MD peter.stuart@ihs.gov

## AI/AN CAUSES OF MORTALITY

| Rank Order | Cause | Number |
| --- | --- | --- |
| 1 | *Diseases of Heart | 2467 |
| 2 | *Malignant Neoplasms | 2175 |
| 3 | Accidents | 1488 |
| 4 | *Diabetes | 744 |
| 5 | *Cerebrovascular | 567 |
| 6 | Chronic Liver Disease and Cirrhosis | 547 |
| 7 | *Chronic Lower Respiratory | 452 |
| 8 | Suicide | 324 |
| 9 | Influenza/Pneumonia | 293 |
| 10 | Homicide | 267 |

- Deaths: Leading Causes for 2002; National Vital Statistics Report 2002; Vol 53:17.

- Primary BH Contributors

- *Secondary BH Contributors

- Peter Stuart, MD peter.stuart@ihs.gov

## AMERICAN INDIAN SUICIDE RATE BY SEX US 1999-2002

- Peter Stuart, MD peter.stuart@ihs.gov

## WHO IS THAT ELEPHANT IN THE CLOSET?

- Behavioral Health as traditionally defined remains one of the highest acuity and need areas in IHS
- Behavioral Health concerns undergird almost all chronic illness management and pose serious challenges to providers
- Growth has been restricted by line item status
- Coordination and Collaborative Efforts with medical services have been hampered by long-standing bureaucratic and philosophical barriers
- Providers are increasingly under pressure to do more in less time

- Peter Stuart, MD peter.stuart@ihs.gov

## BEHAVIORAL HEALTH PRACTICE

- Appt based access
- Episodes of care last month to years
- Office-based
- Privacy-concerned
- Illness oriented
- Individual focus
- Altering self

- 15-20 minute sessions
- Immediate access
- Episodes of care last weeks to months
- Clinic based
- Health-concerned
- Distress oriented
- Population focus
- Function and balance

**Current**

**New**

- Peter Stuart, MD peter.stuart@ihs.gov

## OUR CHALLENGE

- Making Behavioral Health care as available as . . . .
- Getting penicillin for strep throat
- Getting diet support for identified pregnancy-induced hyperglycemia
- Getting an uncomplicated fracture splinted and casted
- Getting RAD/asthma medication adjustments during a high pollen period
- Getting an STD treated

- Peter Stuart, MD peter.stuart@ihs.gov

## HOW DO WE GET FROM THE OLD PRACTICE . . .

- Limited providers
- Limited access
- Circumscribed area of concern
- Entrenched practice patterns
- High volume of need
- Stigmatized interventions

- Peter Stuart, MD peter.stuart@ihs.gov

## TO THE MEDICAL HOME AND INTEGRATED CARE?

- Access when you need it
- 24/7 availability
- Access where you need it
- Small clinic/large clinic/hospital/urban setting/home
- Access to effective services that last just long enough to do what is needed
- Evidence based care that rests on practice and outcomes not theory
- Access that is cost-effective and scale appropriate
- Pay only for the services your population requires
- Access that is flexible and adaptable
- Adjust to changing population and clinic needs

- Peter Stuart, MD peter.stuart@ihs.gov

## WHY NOW? USING TELEMEDICINE TO HELP BRIDGE THE ACCESS GAP

- Technology infrastructure for broadband access is now affordable
- Technology applications have become more user friendly
- EHRs are becoming broadly available
- Service is sufficiently reliable
- Hardware (monitors/televideoconferencing units) is approaching the cost of a PC
- Use experience is broadening rapidly and defining best applications – in IHS as well as elsewhere

- Peter Stuart, MD peter.stuart@ihs.gov

## Telebehavioral Health Visits 03-07 IHS

- Peter Stuart, MD peter.stuart@ihs.gov

## WHAT IT IS NOT . . .

- Telebehavioral Health technology is not the same as “Primary Care Behavioral Health” or “Integrated Care”
- It facilitates such care if deployed and used appropriately
- “Integrated Care” is a systemic understanding and response to the contribution of BH factors to disease establishment and maintenance

- Peter Stuart, MD peter.stuart@ihs.gov

## AUGMENTING ACCESS THROUGH TELEBEHAVIORAL HEALTH

- Regional Networks of Care
- Scale of care allows smaller units to bundle needs together to create system that can support FT (PT) psychiatrists/psychologists/therapists or other specialists
- Central site provides technical support, troubleshooting, setup advice, scheduling and integration services
- 24/7 access
- With sufficient aggregation of units and deployment of telebehavioral health technology access becomes as simple as setting up a call schedule and making the call (think tele-radiology though less complex)
- Care Flexibility
- With broader access to shared specialists, care can be delivered as needed – not when it’s on the specialist’s schedule
- Care can even be delivered in home if needed

- Peter Stuart, MD peter.stuart@ihs.gov

## AUGMENTING ACCESS THROUGH TELEBEHAVIORAL HEALTH

- Provider Support
- Primary Care
- Providers both receive more direct support for complex cases and repeated exposure to BH concerns increases capacity for managing routine concerns
- Provider/clinic efficiency is improved
- Behavioral Health
- Isolation for on-site providers is reduced
- Clinical Supervision  and case consultation for complex presentations readily available
- Supervision is available for ongoing education, internships, and other program capacity building activities
- Educational Support
- Integrates well with expanding web-based continuing education opportunities

- Peter Stuart, MD peter.stuart@ihs.gov

## OUTCOMES

- Better distribution and availability of scarce resources
- Improved economies of scale
- More comprehensive programming
- Significantly expanded access
- Improved ability to provide patient-centric/tailored services
- Improved retention of existing providers

- Peter Stuart, MD peter.stuart@ihs.gov

## CHALLENGES

- Bringing programs together across tribal/federal bureaucratic boundaries to establish regional networks of care
- Promoting understanding of TeleBH technology as a tool for improving access, not a program in and of itself
- Building a more user-friendly infrastructure
- Establishing a supportive funding/billing environment
- Improving acceptance of services delivered by TeleBH among providers and program managers

- Peter Stuart, MD peter.stuart@ihs.gov

## OUR GOAL

- Best Practice based Behavioral Health Services available when patients and providers need them, where they need them, how they need them and for a reasonable price.

- Peter Stuart, MD peter.stuart@ihs.gov

## HI – I’M YOUR DOCTOR AND I’M READY TO HELP . . .

- Peter Stuart, MD peter.stuart@ihs.gov