Telebehavioral elebehavioral Pain

Management: Bringin

Specialty Pain Services To 

Veteran

Linda Godleski, M.D.

John Sellinger, Ph.D.

Purvi Vanderploeg Vanderploeg, Ph.D.

VA National Telemental T elemen al Health Cente
Telementallemental Health inHealth in VHA

Brief Overview verview

Linda Godleski, MD, 

Director National Telemental Health Cen

US Department of Veterans Affairs;

Associate Professor of Psychiatry, Yale Sc

Medicine.
Where We Started Where We Started
Telemental elemental Health To

Health To
Current Current TMH Use

• Is used to treat virtually every DSM (Diagnostic and Statistic

diagnosis, including affective disorders, anxiety disorders/ P

disorders, disorders, and substance substance use disorders. disorders.

• Is employed to deliver virtually every treatment modality inc

individual therapies, group therapies, medication manageme

therapy, couples therapy, cognitive b he avior therapies, psych 

testing, etc

• Takes place at multiple sites of care including VA medical cen

Community Based Outpatient Clinics, non‐VA healthcare faci

health centers, homeless shelters, supervised housing sites, a

• Is delivered delivered by clinicians clinicians from multiple multiple mental health profes

profes

specialties including psychiatrists, psychologists, advanced pnurse specialists, physician assistants, social workers, RNs, ad

specialists specialists, vocational vocational rehabilitation rehabilitation specialists specialists, and trainees trainees
TMH CVT Growth Summary Summary in V

• Total Telemental Health encounters from 200

= over 800,000.

• From 2003‐2012, Telemental Health annual

encounters have increased over 15‐fold from

14,000/yr to over 212,000/yr.

• From 2003‐2012, Telemental Health annual u

patients have increased approximately 10‐ fo

8,000/yr to nearly 80,000/yr.

• In 2012, Telemental Health was delivered bet

approximately approximately 50 Medical Medical Centers Centers and 530 cl

cl
WHERE WE ARE NOW:

VA TMH Services FY 2003‐2012

250000150000200000100000150000

50000

0

2003 2004 2005 2006 2007 2008 2009 2010 2011 20
Outcomes of 98,609 U.S. Department of Veteran

patients patients enrolled enrolled in telemental telemental health services services, 20

Abstract

• Psychiatr Serv. 2012 Apr 1;63( ) 4 :383‐5. Godleski L, Darkins A, Peters J.OBJECTIVE:• The study assessed clinical outcomes of 98,609 mental health patients befo

enrollment in telemental health services of the U.S. Department of Veteran

2006 and 2010.

METHODS:• The study compared number of inpatient psychiatric admissions and days o

hospitalization among patients who participated in remote clinical videocon

an average period of six months before and after their enrollment in the tel

services.

RESULTS:

• Between 2006 and 2010, psychiatric admissions of telemental health patien

an average of 24.2% (annual range 16.3%‐38.7%), and the patients' days of 

decreased decreased by an average average of 26.6% (annual (annual range 16.5%‐43.5%). 43.5%). The numbe

and the days of hospitalization decreased for both men and women and in 8

groups.

CONCLUSIONS:• This four‐year study, the first large‐scale assessment of telemental health se

after initiation of such services, patients' hospitalization utilization decrease

of approximately 25%. 
–

VA National National Telemental Telemental Health C

• To unify the use of telemental health technol

– To assure access to uniform uniform mental health

services nationwide

To increase increase access to specialty specialty care in all

geographic areas

• To est bli a sh panels of national clinical ex

• To provide highly specialized services• To develop resource bank opportunities
– ‐

National Telemental Healt

Center Progress

• Over 2000 clinical encounters completed• 5 clinical clinical programs programs

– Tele‐Behavioral Pain– Tele‐Bipolar– Tele Compensation and Pension– Tele Insomnia

– Tele Psychogenic Non‐Epileptic Seizures

• Delivering care across 15 states and 29 site

• Successfully conducted international evalua

from Connecticut Connecticut to Okinawa Okinawa
Stepped Care Approach

to Pain Management

Stepped care is instituted as a strategy to provide a continuum of effective treatmena population of patients from acute pain caused by injuries or diseases to longitudmanagement of chronic pain diseases andisorders that may be expected to persismore than 90 days, and in some instancethe patient’s lifetime. 

VHA Pain Management Directive 200VHA Pain Management Directive 200
VA Stepped Pain Care

Ad RISK RISK vanced dianced diagnostics 

nostics 

interventions

CARF accredited pain re

Integrated chronic pain an

onic pain an

treatment Comorbidities

TreatmentRefractory

Complexity

Pain MM edicine

Rehabilitation Medicine

Behavioral Pain Mana in Management 

Multidisciplinary Pain Clinicsin Clinics

SUD Programs 

Mental Health Pr Mental Health Programs

Routine screening for presence & intensity of p

Comprehensive pain assessment

Management of common pain conditions

Support from MH-PC Integration, OEF/OIF, & 

Post-Deployment Teams

Expanded care management 

Opioid Renewal Clinics
Need for Greater Greater Outrea

Outrea

• Approximately 3 million Veterans live 

settings1

• Approximately 44% of active duty serv

members come from rural settings members 1 come from rural settings1

• Veterans in rural communities have lo

health‐related quality of life compared 

counterparts in urban and suburban acounterparts in urban and suburban a

– Both physical and emotional functioning

1 Nordeoff, C. Field Hearing before United States Senate Committee on Vetera2 Weeks, et al. (2006). Differences in health-related quality of life within disease 

Veterans. J. Rural Health. 2006; 22:204-11. 
Telemental Telemental Health Pain Ser

Ser

Picture from Dept. of Vetera
Social Biological

Psychological
Biopsychosocial Biopsychosocial Model of Pain Manag

Manag

Bi l i l Biological 

PAIN 

Psychological Social 

Behaviors 

Thinking Emotions 

GOALS: Improve function, increase degree of sGOALS: Improve function, increase degree of s

minimize experience of pain and enhance qua
Cognitive Cognitive Behavioral Behavioral Ther

Ther

• Patient‐centered treatment approach• Addresses Addresses links between between Affect, Behav

ehav

Cognitions and the pain experience

• C t en ered around personalized b he avi

goals

• Motivational interviewing is a key com

of this treatment treatment approach approach

• Should be an integrated component o

treatment
–

Empirical Empirical support support for CBT

• Strong empirical empirical support support for the effec

effec

of CBT compared to control groups an

active treatments

– Pain Intensity

Cognitive appraisal

– Pain interference– Depression– Cognitive coping– Quality Quality of life

( l l Mor ey et al., 1999; Hoffman et al ) ., 2007)
NTMHC – Telebehavioral P

Management Program

• Psychosocial pain assessment

– Affective and Behavioral components of – Substance use and abuse– Pain self‐management management and coping

• Behavioral and psychosocial intervent

– Cognitive‐Behavioral Therapy (CBT)

• Consultation Consultation to providers providers
NTMHC – Telebehavioral P

Management Program

• 2.5 FTE psych l o ogists

• 230 consults from 16 remote sites sin

2010

• 1,009 clinical clinical encounters encounters

• Quality manager monitors program m

– Receipt and disposition of consults

– Consult response time

– Duration of services (number of visits)

– Documentation
NTMHC Telebehavioral Pa

Management Program

• Tap into existing telemental h l ea th

infrastructure at remote sites

– Facility telemental health leads– Clerk support (TCT’s)– Establishment of clinics on both ends

• Educate Educate providers providers at remote sites abo

telepain services

• Consults placed to NTMHC from P ir ma

Pain Clinics, and Mental Health
NTMHC Telebehavioral Pa

Management Program

• Inii l t a vi is t is a comprehensive psychosoc

evaluation (60‐75 minutes)

• If appropriate and interested, Veteran is 

f/u for pain‐focused cognitive‐behaviora

(60 min. appts)

• Assessment and treatment materials are

transmitted by fax or e‐mail

• Follow‐up consultation is provided to pro

remote site (medical and mental health 

members)
NTMHC ‐ Nuts and Bolt

• Appointments made on both ends

– Remote site gets workload credit– Clinical encounter codes entered on prov

• MOU b t e ween NTMHC and remote sit

centralizes credentialing and privilegin

• Clinician granted access to CPRS system 

remote site – documentation documentation entered entered ends
Telepain Service Deliver

Logistics Logistics and Considerations Considerations
Logistics Logistics & Consideration

Consideration

• Logistics Logistics of setting setting up individual individual clinics clinics for each l

l

(e.g., equipment)

• Coordinated Coordinated schedule schedule among all sites

– Available times for service site and remote sit– Availability of space at small CBOC locations

• Defined roles of the remote site Telehealth techn

clerical staff

• Clear assignment of responsibility:

– scheduling and contacting patients

– checking patients in and completing patient e

– placing patients in front of the video units at 

sites (Telehealth (Telehealth techs or remote clerical clerical staff

staff
t t e o se ces 

Logistics Logistics & Consideration

Consideration

• Promoting the service to remote pr

getting their “buy‐in” on services p 

• Procedures established for

– Having technical support available wh

problems occur during appointment

– Transferring materials across sites (fax

mail)
Clinical Considerations

• Established plans and procedures fo

handling handling in‐session session psychiatric psychiatric and 

emergencies

–Who to contact, how to activate l

emergency plans

• Ensuring confidentiality

• Encrypted emails

• Volume of machine
Clinical Considerations

• Patient positioning in front of mach

– Too far/close far/close, patient patient wants to mov–Volume

• Non‐verbal communication

– What does patient patient see?– Eye contact

• Verbal communication

– Sli hg t d l e ays in transmi i ss on
Do your Veterans Veterans need Te

Behavioral Pain Services

Becoming Becoming a Remote Site
Appropriate Patients

• Veterans who have experienced a sign

decrease in their quality of life as a re

their chronic pain

• Interested Interested in learning learning skills to assist in 

self management of pain

• Veteran is not at active risk for self ha

psychiatrically unstable

• Veteran not actively abusing substanc
ease e a e u . a de oe 

Initial Steps in Administrat

Process

• The collaborative relationship between rem

and the NTMHC must be supported by serv

chief(s), chief of staff, and facility telehealth

coordinator (FTC)

• Please email me @ Purvi.Vanderploeg@v

– If you would like materials that summari

program program to discuss discuss this service service with you

line chiefs or other interested parties
Initial Steps in Administrat

Process

• Patient side sites will have:

• Telehealth Clinical Technician (TCT) su

• Scheduling appointments• Securing rooms for appointments

• Equipment and Office Space• Clinical Referral Support

• Program sustained with consistent referral strea
Initial Steps in Administrat

Process

• NTMHC will help facilitate the proced

becoming a remote site

– Will help build the agreement between NTMHC and rem

• Key contact sheet• Memo of understanding/ Service agreement

– Will complete the Credentialing and Privileging of provid

– Will coordinate coordinate with the Information Information Technology Technology (IT) staf

remote site to set up the clinic

• Determining schedule for the clinic• Setting up Inter‐Facility Consult

• Setting up clinic in VISTA• Creating progress note ti lt es
Do your Veterans Veterans need Te

Behavioral Pain Services
Contact Information

• Purvi Vanderploeg, Ph.D. ‐ Purvi.Vande• John Sellinger, Ph.D. ‐ John.Sellinger1@v• Linda Godleski, M.D. ‐ Linda.Godleski2@
Thank you!