**Transcript of Cyberseminar**

**Spotlight on Pain Management**

**Telebehavioral Pain Management: Bringing Specialty Pain Services To the Veteran**

**Presenters: Linda Godleski, M.D.; John Sellinger, Ph.D.; Purvi Vanderploeg, Ph.D.**

**December 4, 2012**

**Telebehavioral Pain Management: Bringing Specialty Pain Services To the Veteran**

**December 4, 2012**

Bob Kerns: Good morning everybody. Welcome to this month’s spotlight on pain management. I’m Bob Kerns. I’m the national program director for pain management. I’m delighted to have you join us today for this special presentation on the National Telebehavioral Pain Management Initiative.

Just by way of introduction, this is an important initiative for our pain management program office in collaboration with the Office of Telehealth services and also importantly with mental health services – who sponsors the National Telemental Health Center, which is the base for this initiative. I want to thank very much the support of Dr. Adam Darkins in particular – who is the Chief Consultant for Telehealth Services and a person who has great interest and support for our several pain management initiatives to promote the use of Telehealth services to advance access for veterans who are in need of pain management services. 

I also want to specifically thank Linda Godleski who is going to coordinate this session today. I’ll introduce her in a minute. Dr. Godleski is the director of the National Telemental Health Center. She is the director of this center as well as being an associate professor in the Department of Psychiatry here at the Yale University School of Medicine in New Haven, Connecticut. Since 2003 with Dr. Godleski was first appointed the national lead for Telemental Health, over 800,000 mental health encounters have been delivered using Telehealth technologies. 

Dr. Godleski is clearly a pioneer in the use of Telehealth services for mental health services and has published several important papers that document the effectiveness of this kind of service. Dr. Godleski also serves as the associate chief of staff for education at our facility here at VA Connecticut Healthcare System. And, quite importantly, in 2012 she was the recipient of the David M. Warfin award from the Office of the Academic Affiliations for her career achievement in educational excellence – VA’s highest recognition for academic accomplishments. 

Dr. Godleski received her Bachelor of Science degree from Yale University and her MD degree from the University of Virginia where she also completed her psychiatry residency training. Dr. Godleski and I are good friends and colleagues. It’s my great pleasure to turn things over to her to introduce our primary speakers for today.

Linda Godleski:Hi Bob. Thank you so much for the generous introduction. I’m Linda Godleski. I’m the director for the National Telemental Health Center and it’s been really delightful to work with Bob who has advocated for Tele-mental health particularly in dealing with pain and veterans in pain at VA Connecticut for a number of years. As we opened the National Telemental Health Center it was a natural evolution to begin with the Telepain Initiative. We will hear from Dr. John Sellinger who was the pioneer, clinical lead – taking the National Telemental Health Center Telepain Program forward. And now, Purvi Vanderploeg who is taking over in the role as of January. 

My job on this presentation is to give you a really quick, brief overview of Telemental Health in VA just to put in context the Telepain Program. The focus of this presentation is really on Telepain, but I wanted you to have some perspective of where we were. 

I always like to start with this slide, which is where we started. It’s a picture from 50 years ago and the first publication on Telemental Health. It is a simulated session in Nebraska where the VA in Nebraska began with the University of Nebraska, delivering telesessions – group therapy sessions. You can see in this picture that the televisions were small and clunky and pretty blurry. I do point out that we still – within the VA – have some of those chairs available even though it’s 50 years later. But, the technology has changed dramatically in terms of the Telemental Health equipment.

So, what we have now is – that’s Dr. Sellinger and Stephanie Purcel – our Quality Manager at the National Telemental Health Center. Now you can see Telemental Health today is really clinicians sitting at their desktop and their computer is right beside them with medical records and then they can see the patient virtually with one of these very clear, very easy to use desktop units. So, just putting it in context – this is a very busy slide, but the bottom line is that currently Telemental Health is used now for virtually every diagnosis, every treatment modality, individual group therapy, cognitive behavioral therapy, medication management, psychological testing. 

It’s used at multiple sites of care. Originally it was just used at VA medical centers. Now it’s expanded to CBOCs, to other non-VA settings and into the home. And, it’s delivered for multiple mental health professions. So, originally Telemental Health was just psychiatrists doing med checks as adjunctive therapy to a patient sitting in a room with a non-prescribing mental health clinician. Now, all mental health clinicians deliver Telemental Health treatment across the board. There have been a number of publications demonstrating the effectiveness for Telemental Health in terms of diagnosis as well as different types and levels of treatment and clinicians. 

So, where are we now? In the last ten years the VA has delivered over 800,000 Telemental Health encounters. So, this is not in any way a pilot project. Last year alone there were over 212 Telemental Health encounters – a 15 fold increase over the last ten years. And, over 80,000 veterans received Telemental Health services. Again, this is just Telemental Health. There are many more veterans who are receiving Telehealth services in areas beyond mental health. And, you can see medical centers and in over 600 sites were delivering care. 

Just a quick slide to give you the visual: continued and steady expansion in both patients and number of visits. One of the important pieces that we just published this year was looking at outcomes of nearly 100,000 veterans who were enrolled in Telehealth services and within six months of being enrolled their hospitalization rates – pre and post – decreased by on the average, close to 25%, both in days of hospitalization and numbers of admissions. I cite this really briefly, but it’s important because not only has Telemental Health been found to be as good as or as effective as traditional face-to-face services, but also the improved access has the potential to really improve outcomes above and beyond what the usual care would be. 

And so, the National Telemental Health Center was instituted to basically bring a national perspective to Tele-mental health services. The traditional model was just hub and spoke going from a VA facility to its CBOCs. And, once the National Telemental Health Center opened – now two years ago – the idea was to unify the use of Tele-mental health technologies and to increase access to specialty care in all geographic areas. 

So, panels of national experts – like John Sellinger and Purvi Vanderploeg – were established to be able to deliver expert care to patients anywhere within the VA who were not able to receive them. In addition, highly specialized services are part of our mission at the National Telemental Health Center - for example – transgender evaluation. There are not a large number of veterans for whom this applies, but having national experts to be able to deliver the most optimal evaluation is really something we can now do with the technologies and logistical resources of the National Telemental Health Center. Also, we can develop resource bank opportunities – so things like comp and pen exams. If there are areas of the country that don’t have the resources we can deliver them from any site to any site. 

So – this is the last of my slides – the National Telemental Health Center has now delivered over 2,000 clinical encounters with specialized clinicians delivering care to a number of different sites. Again, moving beyond just the hub and spoke model of a facility delivering care to the CBOCs. We have five main clinical programs: Tele-Behavioral Pain was the first and premier program. We have Tele-Bipolar, Tele Compensation and Pension, Tele Insomnia, and Tele Psychogenic Non-Epileptic Seizure programs. We’re now delivering care across 15 states and 29 sites, including international evaluations from Connecticut to Okinawa.

With this as a backdrop, I want to turn the presentation over to Dr. Sellinger who has been the lead clinician and really started and opened the Tele-Behavioral Pain national program. Dr. Sellinger...

John Sellinger:Thank you Dr. Godleski. What I’d like to do now is given that backdrop for Telemental Health Services, I’d like to transition the talk a little bit into the domain of pain – which fortunately being able to pair up with Dr. Godleski and the National Telemental Health Center, we really had a nice opportunity to deliver evidence-based care for veterans at a behavioral and cognitive behavioral level who are dealing with pain but who simply don’t have access to psychologists in their remote sites. I think where we can base this or where we can ground this is really in the VA stepped care approach to pain management where in all steps of the stepped care approach we look at a call for behavioral intervention. The stepped care approach is really designed to deliver the right level of care to the right patient at the right time in the right place. 

Graphical representation of the stepped care model really shows us that if we look at all three levels starting in our patient-aligned care teams in primary care up through secondary consultation and tertiary, interdisciplinary pain centers there’s really a call for behavioral intervention at all levels. When we look at how we have implemented the Tele Pain Program here within VA we see most of our care delivered to a primary care setting and that we are receiving consults directly from primary care. We’re able to provide what’s called for at the primary care level, including a comprehensive pain assessment and support for behavioral interventions. But, in some sites, we are also delivering to secondary settings such as pain clinics and mental health clinics as well.

Just to emphasize the need for greater outreach, when we look at the stepped care model they’re obviously challenges embedded in it for our sites across the country who are limited in resources. A lot of times these limitations are imposed by geographics and patients’ unwillingness to travel great distances because it is a long way to travel for a lot of our veterans to receive this care. So, when we think about approximately 3 million of our veterans living in what are classified as rural settings and we look at our active duty service members and we know that about 44% of them come from rural settings, we know this is a problem that persists today and one that if we don’t address it will continue to grow as these active duty service members return and start to seek care from our system.

There’s also some research to suggest that veterans in rural communities tend to have lower health related quality of life – perhaps due to access issues. This is compared to counterparts in urban and suburban areas. Interestingly, these findings really cut across both physical and emotional functioning. So, this really sets the stage for, at least in the domain of chronic pain, the implementation of a behavioral and cognitive behavioral treatment approach to help address both physical and emotional functioning issues.

I like this slide, which is why I include it. I stole this from the Department of VA’s website. This really just serves to demonstrate how rural some parts of our country are. I put this up here just to demonstrate how in the area that encompasses Washington D.C., Pittsburgh, New York City, and Boston, we can fit the entire state of Montana. I think that really goes to demonstrate for some of the veterans in our country how rural their settings are and how the limitations to their access to healthcare can be.

So, to bring this back to the stepped care model, we really – in shaping the intervention that we deliver – take a look at pain from the biopsychosocial perspective and understanding that for patients who have pain that transitions from the acute phase into the chronic phase, it’s no longer about the biological pathology. It’s no longer about what’s physically going on. We have to start to take a look at how pain starts to impact on psychological and emotional wellbeing as well as social functioning in terms of relationships, employment, etc. 

We really believe that if we are to continue to treat patients with chronic pain and just take that biomedical approach and ignore the psychosocial elements of functioning that we truly will be missing an opportunity to help that patient progress. Really, if you look back at the stepped care model you can see the elements of the biopsychosocial model are wrapped into every one of the steps calling for, again, comprehensive assessment and engagement of mental health providers at the level of primary care all the way up through steps two and certainly in our interdisciplinary tertiary pain centers - our CARF programs. 

To take another look at this from the biopsychosocial perspective, this really starts to set up what the role of a psychologist can be. When we think about the biopsychosocial model and focusing primarily on a patient’s psychosocial functioning we really break psychosocial functioning down into its three core elements – a patient’s behaviors, a person’s way of thinking and making sense of their condition - of themselves and the world in which they live, and their emotional functioning. And, for those – presumably everybody on this call has worked at some point with patients who suffer from chronic pain. We know that these three elements can become greatly disrupted in the context of pain that is unrelenting.

The treatment that we deliver – again using a behavioral and cognitive behavioral perspective – really targets these three core elements of the patient’s experience – their behaviors, their way of thinking and making sense of themselves and their capabilities in the world in which they live and their emotional wellbeing. The goals here obviously are to help a patient improve their functioning, increase their degree of self-reliance, and minimize their experience of pain while enhancing their quality of life. 

This brings us to cognitive behavioral therapy. I just wanted to give a very brief overview about what cognitive behavioral therapy is, knowing that most people have heard about it in the world of chronic pain, but some don’t know the essential elements of cognitive behavioral therapy. 

So, what CBT is it’s really a patient centered treatment approach in that what we really do is we have a set of skills that we seek to teach patients to help them improve their functioning, to improve their quality of life, but more importantly to wrap those skills around goals, around things that the patient is interested in. We’re not here to tell a patient what their goals should be. We’re simply trying to help them explore their goals to the extent that they have stopped doing so because of their pain. Then, to teach them some skills that they can wrap around, trying to move themselves closer to those goals. 

Again, the way we do that is we target specific skills around affective or emotional functioning, around behavioral approaches to pain, helping patients to shape the way they approach activities in the context of pain - for example – helping them to find ways to engage in an activity that they’ve been avoiding, but to do so in a way that isn’t going to enhance their pain or make it so that they’re having to pay the price for days afterwards. Then, as I mentioned earlier, the cognitive components – helping patients with simply making sense of who they are now with this pain and how they can remain functional despite the fact that pain may be something that will persist for the remainder of their life. 

Motivational interviewing is a key component of this treatment in that oftentimes when patients enter treatment they’ve been dealing with pain for so long that there’s either not a sense of how they could do things differently or when they hear about how they can do things differently and they hear the education about the biopsychosocial model, there’s a sense of that’s not for me or that doesn’t... there’s no way I could do that. So, we use motivational interviewing to help patients explore their capabilities and try to enhance their motivation for becoming an active member of their treatment team.

That last point really is to highlight that this treatment is not designed to be delivered in isolation by any stretch. Usually what a psychologist is doing in helping a patient address things like emotions and behaviors and thoughts is the best thing we can do is really be pairing up with other members of the patient’s treatment team – whether it’s a rehab medicine specialist, a primary care provider, another mental health provider. The treatments that we deliver here through the tele program involve not just direct contact with the patient by video but oftentimes subsequent phone contact with providers who are also engaged in that patient’s care.

In terms of the evidence base, I know Dr. Godleski had talked about the extensive evidence there is for the delivery of Telemental Health services. What I really see this as is a nice opportunity for us to take what we know is an empirically based treatment modality and pair it with a delivery mechanism that also has support. So, we know that cognitive behavioral therapy has a strong evidence base for helping with a variety of treatment outcomes including things like pain intensity- the extent to which pain interferes in a patient’s life, depression, cognitive coping, and overall quality of life. So, here again we’re using an empirically validated mechanism to deliver treatment and we’re delivering a treatment with a solid evidence base. 

Talking specifically about the National Telemental Health Center’s Telebehavioral Pain Program, as we see it we really have three core services that we provide. The first is the psychosocial pain assessment. If you recall the slide with the stepped care model, this is one of the things that’s really called for at the level of primary care is to make sure that a comprehensive pain assessment is done. While that’s in part a physical workup of the patient’s pain, once that pain transitions into chronic it’s really important that we also get a sense of what does the psychosocial context look like in which this pain is occurring. 

So, here we really help to explore areas that primary care providers are usually too busy to spend a lot of time on. So, helping to explore the affective and behavioral components of the pain experience, looking at things like substance use and abuse, adherence to medications, etc., and looking at a patient’s overall sense of coping – what are they already doing? A lot of our patients come in and they have very effective strategies that they use. But, more importantly where are the areas where they could continue to use some support or some new skill building?

We then deliver a behavioral and psychosocial intervention. We are delivering, through our program, a cognitive behavioral therapy, as I’ve mentioned. There are also other models across the country for growing evidence base for things like acceptance and commitment therapy, which there are some research trials funded through VA that have actually demonstrated the effectiveness of act interventions using a tele modality. 

The third component that we deliver is consultation to providers. Again, that’s usually following that initial assessment, or if we have a patient for whom we’re providing treatment and issues come up in the treatment that involve the need for greater coordination of care, or simply sharing of information that we’re gathering that other members of the team may not be aware of, we provide an ongoing consultation.

In terms of who we are, at this point the National Telemental Health Center has two and a half full time psychologists based out of VA Connecticut. We’ve been in existence since July 1, 2010 and since that time we’ve grown to deliver care to 16 remote sites, including within VA Connecticut and across the country. We’ve conducted 230 consults to date for a total of just over 1,000 clinical encounters. This data is through September of this year. As part of the National Telemental Health Center, we have a quality manager who helps us to really gather this data, to keep an eye on things like the receipt and the disposition of our consults, helping us calculate our response time to consults, how long we’ve been working with patients, making sure that things with a patient are closed out as they’re supposed to be, and making sure that our documentation is in order.

Through the National Center, in essence, what we are is we’re a resource at one site seeking to connect to sites across the country. The way that we do that is we tap into what really is a growing infrastructure at sites across the country which  includes tapping into resources like the facilities Telemental Health Leads, as well as the Telehealth Clerks etc. that are now being brought on board at most sites. What we seek to do is we establish clinics that connect from our site to sites usually at remote settings – community based outpatient clinics.

The way we jump in is once we get these technical issues set up and we get our clinical issues in order in terms of getting clinic times and availability of equipment worked out, we then really unleash an educational campaign. So, if we’re delivering to a primary care setting we will connect usually to team meetings and make sure that all of the potential referral sources for our program are aware that we’re on board and that they’re aware of what we can do and what we can do to help their patients who are suffering with chronic pain. I think that’s the most essential part of what we do in the early stages because if providers don’t understand what it is we can do to help, we can very quickly fall off their radar.  So, it’s very important for us to maintain close contact – specifically in the early stages of our program.

What happens then is consults are placed from these remote sites. As I said earlier in the presentation, we currently – at some of our sites – receive consults directly from primary care settings, at a couple of our sites our consults come also from pain clinics, and at other sites from mental health clinics as well. The consult is placed at the remote site. We have a consult package that we drop into whatever remote system it is that we’re working with, and that consult then transitions over here into VA Connecticut’s system at the National Telemental Health Center. Then, upon receipt of that consult we then seek to engage the patient in those three levels of care I described earlier – initial consultation, evaluation, and then - if the patient is interested – engaging them in treatment.

The initial visit we conduct is really a comprehensive psychosocial pain assessment. We allot up to 75 minutes for these evaluations because we do cover a lot of ground. Really, what our objective here is to not just understand the physical pain and to understand kind of the biomedical perspective of that patient’s pain, but also to understand the psychosocial context in which that pain is occurring because that’s ultimately where we’re going to be able to deliver intervention.

If the patient is deemed appropriate and interested in participating in a cognitive behavioral protocol we then will engage that patient usually for an average of up to 8 to 10 sessions. Those are delivered via individual 60 minute follow-up appointments. What we do is we transmit all of our material. We started by fax, although we are now starting to scan a lot of these things electronically. We – the clinicians here in the National Center – are in direct contact with the Telehealth clerks at the remote sites and we just send these materials directly to them. Then they’re responsible for setting the patient up in front of the machine and making sure that we’re ready to go.

Then, the follow-up consultations that I mentioned earlier are usually done offline, phone calls outside of our sessions with patients. Again, sometimes that’s with one provider and sometimes it’s with a team depending on what the issues are or what the patient’s healthcare team looks like on the other end. We really seek to see ourselves as a member of that team and not somebody who is here to operate in isolation.

The other point I will make before passing this along to Dr. Vanderploeg is that we do not see ourselves as a patient’s primary mental health provider. Although, I can say anecdotally that most of the patients who are referred to us have an active mental health provider – either somebody who they see for regular psychiatric care or perhaps engage in another type of therapy, not pain specific. We don’t see ourselves as becoming or taking over a patient’s primary mental health care. We’re simply seen as consultants who are here to provide an additional, highly focused therapy – which again, is often delivered in consultation with that patient’s ongoing mental healthcare at the remote site.

One last slide for me is just to talk a little bit about the logistics here. So, what happens is these are usually the questions we get about the program. When we set up care with a patient, the appointments and the management of appointments are really handled at the local site. They put the appointments in their local system. We also have appointments put in our system. What this allows us to do is it allows us to document at both sites, but more importantly to ensure that both sites are receiving clinical workload so that the remote site - who’s actually checking the patient in and sitting them in front of the machine – are getting credit for that work. The clinical encounter is actually entered on our end here at the National Center.

We, in advance, put a memorandum of understanding in place that exists between the National Telemental Health Center and the remote sites that we’re connected with. What that MOU really does is it spells out the roles and  responsibilities so it’s clear to everybody involved what components of the interactions we will take care of and what things we expect from the remote site in terms of...it could be very simple things like who is going to check the patient in and who is going to handle clinical emergencies on the remote end if they’re to come up.

Then finally, the clinician here at the National Center is granted access to the local CPRS system. So, this has been a huge step for us. In our early days we really did all of our interacting through Vista Imaging, which became very clunky and archaic, but now we're able to get into remote systems. We’re able to document directly into the remote site so that any provider working with that patient will see our notes as part of the CPRS system and they don’t have to go digging for them. That’s been a really nice way of closing the loop in terms of developing a team approach.

To talk a little bit more about the logistics of the program and to also put in a plug for further expansion, I’m going to pass it over to Dr. Vanderploeg who is our new acting lead for the Tele Pain Program.

Purvi Vanderploeg:Thanks John. Just as Dr. Sellinger mentioned, we’re going to move on to some of the logistical considerations with the Tele work. The main logistical factor that probably comes to most people’s mind is scheduling. With the help of some of the key players in the remote site the Telehealth Clinical Technicians - the TCT’s - as well as the FTC are some of our administrative staff at the National Center. They really play an incredible role to insure that the patient, the provider, the equipment, and the space are all available at the same time. And, they work to coordinate all these different pieces so that the process really can feel seamless. It also really helps to make our scheduling very efficient.

One of the primary reasons the coordination works well is because everyone has a clear understanding of their defined roles and responsibilities in this process. For example, our Telehealth Technicians – our TCT’s – they really take the lead with scheduling and contacting patients, checking patients in, completing their encounters, putting them in front of the video unit. That really helps us move this process very seamlessly.

Similarly, we need to consider how to promote our program since our colleagues are not in the same facility that we are. We’re not going to run into you in the hall or at meetings. So, we really make a concentrated effort to contact our remote providers – whether that’s individually, via email or phone, whether that’s us calling into staff meetings or providing brief presentations at these meetings, etc. - so that they can have a really good understanding of what we do, the value this program can bring to their service, and then consequently think about it as an integrated part of the services that they offer.

We also have established procedures for technical support. If and when technical support is needed it is readily available through the local TCT facility Telehealth coordinator that is at each facility as well as you have the National Center helpline, which is always available to assist anyone. Technical support can sometimes be things as simple as recently I was seeing a veteran for an initial intake. Shortly into the visit there was a lot of sunlight coming in from the window that was creating a significant glare. When that happened I was very easily able to contact my TCT via instant communicator and she was able to come in, manage the situation, and go out where it didn’t really create any sort of blip that the patient responded to. They work very effectively – our TCT’s – as our hands in these sessions.

The same thing applies to transferring materials across sites. We are a CBT based intervention as John mentioned. That involves a lot of worksheets and handouts and homework and things of that nature. They really work to make sure we work together so that our veterans receive all the same materials they would as if they were in in person care. It works quite well.

Moving onto some of the clinical considerations, one of the primary factors that probably comes to mind is how do you handle a psychiatric or medical emergency in session? Who are you going to contact? This is something that we address when we first make contact with the remote site and we start to establish that relationship. There are procedures that are put into place where we have the people we would contact, their numbers, the procedures of what needs to be done, and then if you happen to not be able to contact that person it goes a couple of people deep so that we’re really protecting our veteran in case something were to happen. 

In one of my first cases when I started here I got to personally test out this system and really saw how well it worked. One of my first veterans, his first therapy session, he was actively suicidal. Again, using the instant communicator I was able to contact my TCT who came into the room. Once my TCT was in the room, I was able to call our National Center helpline where they were able to really go into the background and make calls that needed to be made to the remote site and we were able to provide the care that veteran needed in a very time efficient way without any additional chaos. You could really see just how well this procedure works and everybody following the roles that they have.

Similarly, for insuring confidentiality – as every provider in our system takes – we take that very seriously. With scheduling and things we might have more emails going back and forth between TCT and provider and we make a great deal use of our encrypted email system. We are also very thoughtful about things like when a veteran is sitting in session and if they need to raise the volume for their machine or something like that, that we use things like white noise makers and things like that to drown out sound. And, thoughtful about you know if a TCT is coming in to pick up a veteran that’s just completed an appointment, of not talking about any veteran specific information in case the next appointment is standing behind the TCT and things of that nature.

Our equipment and technology, as Dr. Godleski and Dr. Sellinger mentioned, are really very good. The picture and the sound are incredible. I’ve found that I’m able to build rapport and experience the session with the veteran without really any sense of distance. It feels very similar to in person care, which is a testament to how good the technology and the equipment are. So, because this is based on just how far we’ve come with the equipment and the technology you want to be aware of how those factors play so that you can use them to provide a session that feels like an in person session by making sure your patient is positioned well - they’re not too far or too close to the equipment. You want to make sure the volume is set at an optimal level. 

With the use of this technology, it is a factor that you want to be aware of in terms of nonverbal communication. So, something like eye contact. If you're not able to make eye contact with your patient or you're not sure if your patient is making eye contact with you, with this type of work you want to be able to remind yourself and assess if there is a technical reason that could be affecting this. And, you put that in part of your assessment so you can make the appropriate judgment. It can impact verbal communication at times if there’s slight delays in the transmission of  the signal, but that rarely happens. I mention these things to remind us that when we’re doing tele work, that we want to help keep the technical factors in mind when we’re making clinical judgments or assessments.

You've heard a great deal about our program and how valuable we believe it is. If you're thinking what do we do if we have veterans that need Telebehavioral pain services? These next two slides are for you. 

Our inclusion criteria are really pretty simple. We accept veterans who are living with chronic pain where it has impacted their quality of life and where they’re interested in learning some self-management skills to improve their quality of life. Our exclusionary criteria are: veterans who are at active risk for self-harm or actively abusing substances. As Dr. Sellinger mentioned, once veterans are psychiatrically stable we will gladly work with those veterans and coordinate care with their primary mental health providers.

The relationship between our remote sites and us, this collaborative relationship, is really based on the support that we have from our colleagues who would referred to us, to service line chiefs, to the facility Telehealth coordinator, to the chief of staff – all of these people really need to ... we all need to be on the same page to provide enough support for the program. If you are interested and you're a provider listening to this call, we really encourage you - as a first step - that you start having a conversation with fellow colleagues or your service line chief to talk about your interest in this program and see if that is going to move into something more substantial. If you'd like any materials that would assist you in having that conversation – summarize our program – I’ve included my email address on this slide so that you could email me directly and I would be glad to provide that for you.

Some of the things that the patient side sites need or our remote sites need are things that you probably already have. You would require a Telehealth technician, a TCT, for the administrative support, equipment, and office space as well as a need for the chronic pain intervention and veterans that would benefit from this intervention where it’s not currently readily available. 

It may seem overwhelming to think of what is required in terms of the steps of becoming a remote site with the paperwork and procedures and things of that nature. But, I really want to encourage you and remind you that our National Telemental Health Center will really facilitate the procedure of becoming a remote site. Our administrative staff is wonderful and they have done this many, many times and would really facilitate your process going through this in a very organized fashion. It will typically begin with something that John had mentioned, the memo of understanding or service agreement between our site and the National Center and your remote site.

But then, the National Center will take care of things like credentialing and privileging of the providers. They’ll work with the remote site’s IT staff to help set up the clinic. They are really wonderful at what they do and do it very, very well. I mention these things to sort of give you an idea in the broad strokes of what is required and the resources that are available that make this a very organized process. 

Do your veterans need Telebehavioral pain services? Hopefully at this point, you have an understanding of what our program can do and some first steps you can take if you are interested. We’ve really appreciated the time and attention that you've provided as we’ve given you this information and the opportunity to talk to you about our program. We are now going to move to the question and answer portion of this presentation. On this next slide you can note our contact information as we wait to kind of move the slide forward, which has our email addresses on it. If we don’t get to your question during the question and answer portion of the remaining time in this presentation, you can send us an email directly and we will follow-up with your responses. Thank you.

Moderator:Great. Thank you all for presenting. For our audience, as we mentioned, we do have a limited amount of time for Q&A today. We will try to get to as many questions as we can, but feel free to submit questions through the Q&A pane in go to webinar. It’s located on the dashboard on the right hand side of your screen. Just click on that orange arrow to open it up and type your questions in there. 

For our presenters, the first question that we received: As a Tele pain psychologist for VISN 19, I have run Tele pain motivational interviewing groups connecting veterans in pain from Montana to Colorado. Sometimes we have limited bandwidth. Have you had success with groups with multiple sites via Telehealth technology?

John Sellinger:I would say that we have not done groups as part of the National Telemental Health Center. In the very early days of our program we had a couple of sites that had some bandwidth issues, but those were quickly resolved. It was really – as we understood it – a VA contracting issue where they were working with outside venders to get a better bandwidth lines put into the remote clinics. I can say that really we’ve had a lot of success with the technology. Very rarely do we have issues where the equipment goes down or provides even things like pixilation. We’ve really been quite successful despite the fact that we’ve had a couple of significant winters here in the Northeast while we’ve been active. Really the only barrier to engaging patients during those storms has been patients not wanting to come out for the appointment.

Dr. Godleski has some additional information on bandwidth. I’ll pass the phone to her.

Linda Godleski:Actually, I was going to comment on groups. As you saw on the 50-year-old photograph, Telemental Health started with groups. So, that concept is viable. Within the VA, having patients at one site and the clinician at the other site has been demonstrated extensively – particularly in the Hawaiian Islands, going from one island to another, and to Guam and Samoa. The concept, as I understand the question, of having patients potentially at two separate sites and the clinician at a third site – has not been well established within the VA. There’s nothing to say that it’s prohibited, but the technology to do that is at a slightly higher level and it has not become state of the art yet.

So, what you're doing is pioneering if you are doing more than one site per patient and the clinician at a third site. We encourage you to do that. If there are issues with the bandwidth now, there is a National Telehealth Technical Assistance Hotline. Whenever there are issues, we ask that you call that number so that they can at least record what the problems were. And then, there is a lot of work being done now, which wasn’t available even a year or two ago, whereby the IT will then get the report and try to troubleshoot to see if there are any ways to improve the bandwidth if you're having issues specific to any site. 

To sum it up, group therapy has been done a lot with Tele mental health – generally with the patients at one site and the clinician at another. If you have patients at two separate sites, it’s still not well established. If you're having technology problems, report them the National Help Desk so that they can follow-up with them.

Moderator:Great, thank you. The next question that we received in: A number of our rural veterans inquire about home cameras for Tele Pain Behavioral appointments. Has your program had access to and success with in home cameras?

Linda Godleski:As many of you may be aware imminently, this month the Office of Telehealth Services, which is now just VA Telehealth Services, is rolling out an extensive clinical video into the home program, not limited to mental health, but to include all disciplines – including neurology, spinal cord injury patients, multiple sclerosis patients, etc. The technology is there. The platform is called Jabber. The patients can download the software so that at the time of their appointment they will get an alert on their computer. They will then be connected to the clinician at the clinical site.

The infrastructure within VA, not just the technical equipment infrastructure, but the administrative infrastructure is in place. There’s been extensive training of the facility Telehealth leads who will walk clinicians through that entire process as well as walking the patients through that process. So, if you have patients who have computers at home and are pretty savvy and if you have clinicians who are willing to pilot this, you should contact your facility Telehealth coordinator and alert them now that you would be interested in participating – this is a pilot. 

In terms of success, it’s been piloted to over 80 patients in the last six months with unquestionable success. There has been a few sites that had issues with different specific internet providers or equipment. Most of those issues have been resolved. Again, if you have any problems, contact the helpdesk. This is something that I think we will see, over the next year, expand dramatically. So, if you have interest in it, contact your facility Telehealth coordinator very timely. Telehealth Services is rolling that out now.

Moderator:Great. Thank you. The next question we have here: Are you implying that you are accepting referrals to your pain management program or are you demonstrating how this could be implemented in other locations?

Purvi Vanderploeg:We are definitely taking referrals into our program. If you are interested, we definitely encourage you to follow-up with your colleagues and service line chiefs to see if that’s something your facility is interested with and then contact me directly and we can certainly move this process forward.

Moderator:Great. Thank you. I have two questions I’m going to combine into one. They’re very similar or along the same line here. Do you ever allow veterans to engage in Telehealth from home if they have the technology to do so? Are there any limitations in place because of security of data? Could smart phones or IPads be used?

Linda Godleski:The answer to the first question is what I had explained with the previous question that there is a mechanism now in place for video into the home. If you're interested in doing that, connect with the facility Telehealth coordinator because that is rolling out as a national initiative now. In terms of what we have done, there have been – within the National Telemental Health Center – a few pilots of delivery of care into the home using the Telehealth Services process of downloading the software and the procedures that are in place. We haven’t done that specifically with Tele Pain, but we have with Tele Bipolar so far. 

In terms of the security issues with the smartphones and the IPads, right now the focus is to try to demonstrate that there are security issues if you're using the commercial products like Skype or Face Time. So, you cannot use those to deliver patient care. There are products technically available that are encrypted for those devices. However, the VA – in a step wise fashion – is moving to do the delivery of care into the home using PC’s. Ultimately, future steps will then likely address the smartphones and tablets and those kinds of devices. But, right now the issue is moving it into the home using PC’s. 

Moderator:Great. Thank you. The next question that we have here: Are there any logistical issues to providing Tele Psych services to patients in one state while being licensed to practice psychology in a different state?

Linda Godleski:Let me answer that as well. Generally speaking, there are not. However, there are psychology boards state by state that have different regulations. So, if there are any questions, the guidance is to have your local legal counsel investigate and provide a legal opinion on that. The VA itself... if you're delivering care from one site to another site and within the VA and they’re both VA sites, generally speaking there are no issues involved. As you know, we don’t have to have a license in any particular state. As long as we have a license in one state we can practice within the VA, which is exactly why telemedicine works so easily within the VA as opposed to if we were not within a Federal system. 

With that said, if there are any questions, we ask you to take them to your local legal counsel because there are so many nuances that are state specific. We have not found any prohibitions to date. To date, there is nothing that we’re aware of that prevents you from delivering care within one VA to another using Tele with the state license. But again, if there are any questions... there have been some questions. They have gone to the local and regional council and there has not been any guidance prohibiting it. That said, I am not the representative for legal counsel, so if you have any questions, err in the direction of getting your local legal opinion.

Moderator:Great. Thank you. The next question we have here: When you say that you receive access to CPRS at the remote site, is the documentation loaded to both sites at the same time or is one copied into the other system?

John Sellinger:I’ll take this one. What we do is we do our documentation in our local system and then what we do is we cut and paste the note into the remote system as well. What happens is the two appointments get closed out with the same encounter information. The only difference is that at the patient site we use a Q code, which is a Telehealth facility fee – that’s the procedure code used at the site where the patient is. Then, at our end here in Connecticut, we put the clinical encounter information – if it was an assessment code or a treatment code. 

We found – as I had said in the presentation – in the early days of the program we were not able to do that. We were simply putting the note into our system and then trusting that providers at the remote site would go into Vista Imaging and see the notes. They weren’t showing up in their list when they’d sign into a patient’s record. But, this has really helped to close the circle in terms of helping us to see what’s happening with a patient at the remote site without having to go through the clunky Vista Imaging. But, it also allows the providers at the remote site who are working with the patient to see our notes and to see what it is that we’re talking about in the hopes that they can reinforce some of the behavioral principles that we’re working with the patient around.

Moderator:Great. Thank you. The next question that we have here: Would a veteran be required to be actively involved in mental healthcare at the parent facility in order to participate?

John Sellinger:I would say that it’s not mandatory. But, as I had said earlier, a lot of our patients who come to us are currently engaged in treatment. But, if there’s not a need for broader mental health services, we’re not going to require that they have a primary mental health clinician just as a way of getting into our program. But certainly, on our initial assessment if we uncovered something that seems wow, this really needs to be treated or this is an obvious barrier to a patient being able to effectively engage in our treatment, we might defer our engagement with the patient further until they are connected and stabilized psychiatrically if that happens to be the issue. But, it’s not required that they have mental health services at their remote site.

Moderator:Great. Thank you. The next question: Is this a similar concept to scan echo?

Linda Godleski:The big difference between scan echo is that the patient is not directly involved in the scan echo encounter. So, the scan echo involves a video consult from clinician to clinician. What this involves is actually clinician to patient video contact. In addition, scan echo tends to be more consultation. A patient is presented, there’s a consultation. Where, this is ongoing, time limited treatment modules that are being delivered.

Moderator:Great. Thank you. The next question: The presenters have given a very nice administrative and provider-centered overview of the program. What have you heard from veteran users of this intervention?

John Sellinger:I’ll go first and I’m sure Purvi will have something to add. I can tell you clinically that the patients have shown great response to this program in terms of frequency of attendance. I’ve made this point to several of my colleagues locally here. One of the things that we do in cognitive behavioral therapy is we spend an hour with the patient and we really do skill building. But, most of the treatment really takes place between the session as the patient goes home and they practice and then come back and report to us how the use of that skill went. A lot of that is – as Purvi had mentioned earlier – requires things like keeping logs and filling out worksheets. 

I have found the patients I’ve engaged through the Tele program compared to the patients I see face-to-face show a higher level of completing of the homework. They come back. They’ve got their materials. They’re anxious to fax them to us or send them to us. In my head, I’ve been trying to figure out what is that related to. I can only think that it’s just due to this appreciation for having this service available to them at their site. And, many of them will comment on it. They’ll say I really could have used this years ago or this has never been offered in my area. But, there’s just a high level of engagement once a patient gets in the door. Sometimes there’s that initial awkwardness of wow, I’m looking at you on a television screen. But, usually within the first 5 or 10 minutes of interview you see that kind of fall away and people really start to engage in a very intimate way through the video.

In terms of ... I get anecdotal information from patients all the time about how much they appreciate it. And, also from the staff. Usually the comments that come to us will be via the TCT’s. The patient will make a comment to the TCT on the way out the door saying this is really great. I wish I would have had exposure to this before. I’ll get offline emails from the TCT saying Mr. Smith really loves this or something like that. 

Granted, for some of our patients at some of the sites we’re connected with, they still do travel a great distance – even to their local CBOC. We will occasionally get comments that they would like to put some more time between their sessions because coming weekly, even to their local CBOC, is an hour and a half drive. So, you'll see some verbalization of wanting to space out their appointments for that reason. But, overall my sense is that patients are really enjoying and appreciating the service.

Purvi Vanderploeg:I would echo those comments. Most of everyone I’ve worked with since I’ve started has been really appreciative, engaged, and really a joy to work with.

Moderator:Great. Thank you. We do have a couple other questions. They are duplicates of a lot of other things. One just came in here: Are you aware of any upcoming rollout of a VA program to train local psychologists in CBT for pain patients to increase capacity across the system?

John Sellinger:I am aware of this. I don't know if Bob Kerns is still on the line. Bob would know more about this.

Bob Kerns:Yes. I can speak to that. Thanks for the question. Yes, our program office is partnering with mental health services in the dissemination of a large in scope initiative to build capacity for mental health providers to deliver cognitive behavior therapy for chronic pain. This is not specifically connected with this initiative that we’re talking about today. But, nevertheless, is ultimately about making evidence-based psychotherapy and cognitive behavioral therapy available to a larger proportion of veterans who would not otherwise receive it. 

This is a national initiative that is in the context of a broader evidence-based psychotherapy initiative. Every facility has a funded evidence-based psychotherapy coordinator. That would be likely the person at your facilities with whom you would speak to learn more about this initiative. The bottom line is that mental health providers are being solicited to participate in an intensive in person training program to learn about delivering cognitive behavioral therapy for chronic pain and then are provided with ongoing support, mentoring, supervision for a significant period of time subsequent to that training in order to build that person’s capacity to deliver that service at the facility.

Maybe that’s enough for now. If you have additional questions, I do again encourage you to talk to your facility, evidence-based psychotherapy coordinator. Thanks a lot.

Moderator:Great.

Bob Kerns:I should say I actually have to get off the call. I have another call coming in. I want to thank Linda, John, and Purvi for their presentations today. I want to thank Heidi and CIDER for their support of this initiative. I wish everybody a wonderful holiday season and happy New Year and will join you again in the New Year.

Moderator:Thank you Bob. And, that actually is it for the questions that we will be getting to today. Do any of you have any final remarks you'd like to add before we close out today?

Purvi Vanderploeg:I just want to say thank you for the opportunity.

John Sellinger:I would echo that and encourage any offline questions could be emailed to us. We’d be happy to follow-up with the people who are interested.

Moderator:Great. Thank you so much. Purvi, John, Linda, we really appreciate the time you've put into putting this together and presenting for us today. Thank you very much for that. For our audience, thank you for joining us today. We will be sending you the archive information on this shortly. If you do have a question we didn’t get to today our email address is on your screen right now. Feel free to send those in to one of our presenters and they will get back to you on that. Thank you everyone for joining us today and we hope to see you at a future spotlight on pain management cyber seminar. Thank you.

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