Redesigning Care 3

GuideREDESIGNING to ImplementingCARE TelebehavioralA How-To Guide for Hospitals and Health Systems Seeking to Implement, HealthStrengthen and Sustain Telebehavioral Health ii

ABOUT NATIONAL QUALITY FORUM ABOUT AHA CENTER FOR HEALTH RUNNING SECTION HEAD Founded in 1999 and based in Washington, D.C., INNOVATION the National Quality Forum (NQF) is the nation’s The AHA Center for Health Innovation, created by resource for health care quality measurement and the American Hospital Association (AHA), enhances improvement. NQF is an independent, not-for-profit, hospital and health system transformation and membership-based organization that brings health accelerates innovation at scale. The Center was care stakeholders together to recommend quality formed in September 2018 from the merger of the measures and improvement strategies that reduce AHA’s Health Forum, Health Research & Educational costs and help patients get better care. Through its Trust, Data Center and The Value Initiative. The multistakeholder membership of more than 400 Center serves as a key partner to AHA members, organizations, NQF facilitates dialogue on health supporting their innovation and transformation care measurement and improvement and strives to journey with new tools, data products and analytics, lead national collaboration to improve health and learning collaboratives, conferences and virtual health care quality for all Americans. expeditions, market intelligence and advisory services.

A PARTNERSHIP TO ADVANCE TELEBEHAVIORAL HEALTH NQF and AHA share a common goal to advance health in America, in part through guidance, resources and tools that improve health care quality and outcomes with smarter spending. This Guide builds on historic work by both organizations to improve telehealth and behavioral health care services, including AHA’s market intelligence on behavioral health and telehealth trends, and NQF’s work in telehealth and serious mental illness that highlights how to use quality measurement and best practices to enhance access to care and improve outcomes. Leveraging NQF’s uniquely trusted ability to bring together all stakeholders to advance quality, and AHA’s vast network of hospitals, health systems, providers of care, and their patients and communities, along with expertise in field engagement, public policy and innovation, this Guide provides a practical tool built on a foundation of multistakeholder expertise. It will support efforts to deliver innovative, high-quality telebehavioral health services to patients and communities across the nation.

ACKNOWLEDGMENTS National Quality Forum and AHA Center for Health Innovation gratefully acknowledge the multistakeholder experts who participated in the Telebehavioral Health Project through key informant interviews, an in-person forum on November 27, 2018, in Washington, D.C., virtual forums in October 2018 and January 2019, and peer review to help inform the development of this Guide. These individuals are listed in Appendix A.

The conclusions, findings and opinions expressed by project participants who contributed to this publication do not necessarily reflect the official position of any contributor’s affiliated organization.

THIS GUIDE IS FOR INTERNAL NONCOMMERCIAL USE ONLY. REPRODUCTION, TRANSMISSION, DISTRIBUTION, PUBLIC DISPLAY OF, PUBLIC PERFORMANCE OR CREATION OF DERIVATE WORKS, IN WHOLE OR IN PART, IS STRICTLY PROHIBITED WITHOUT PRIOR WRITTEN PERMISSION OF NATIONAL QUALITY FORUM, INC. (“NQF”) AND AMERICAN HOSPITAL ASSOCIATION (“AHA”).

This Guide contains hyperlinks to websites and other downloadable applications. NQF and AHA do not control or own such websites or applications, and are not responsible for generating, developing or monitoring their contents. NQF and AHA are not responsible for the protection and privacy of any information you provide while visiting such websites and applications, and you do so at your own risk.

TRANSFORMING CARE DELIVERY WITH TELEBEHAVIORAL HEALTH 2

USING THIS HOW-TO GUIDE 4

ELEMENTS OF SUCCESS FOR TELEBEHAVIORAL HEALTH IMPLEMENTATION 5

SUCCESS FACTOR 1: LEADERSHIP COMMITMENT 7

SUCCESS FACTOR 2: ORGANIZATIONAL POLICIES AND CLINICAL WORKFLOWS 13

SUCCESS FACTOR 3: STAFF EDUCATION AND TRAINING 19

SUCCESS FACTOR 4: PATIENT, FAMILY AND CAREGIVER ENGAGEMENT 25

SUCCESS FACTOR 5: MEASUREMENT 29

SUCCESS FACTOR 6: COMMUNITY PARTNERSHIPS 33

DRIVERS OF CHANGE 36

A PATH FORWARD 38

APPENDIX A: Participating Experts 41

APPENDIX B: Tools and Resources by Success Factor 4

TRANSFORMING CARE DELIVERY WITH TELEBEHAVIORAL HEALTH

Each year, behavioral health disorders affect millions of Americans. Yet fewer than half of the 44 million adults who have a mental illness receive the treatment they need.1

Behavioral health disorders include mental illness and substance use disorders. Mental illnesses are specific, diagnosable disorders characterized by intense alterations in thinking, mood and/or behavior over time. Substance use disorders are conditions resulting from the inappropriate use of alcohol or drugs, including medications. Persons with behavioral health care needs may suffer from either or both types of conditions, as well as physical comorbidities.2

There are myriad reasons that behavioral health Telebehavioral health can encompass: needs go unmet. The stigma of mental illness, the lack of coverage and inadequate reimbursement, and a • Patient-to-provider interactions significant shortage of behavioral health professionals • Direct-to-consumer interactions initiated by prevent those with behavioral health needs from the patient seeking and receiving care. With a national shortage • Provider-to-provider interactions of psychiatrists, many of those who are practicing psychiatrists nearing retirement, and a general lack It can involve: of mental health professionals across the United • Synchronous (real-time) video communication States, health systems and hospitals face challenges through computers and mobile devices providing behavioral health care to those in need. • Asynchronous transmission of video and Overcoming these barriers to access and delivering images high-quality behavioral health care is essential for improving patient outcomes and reducing the cost –– Through a secure electronic system, of untreated behavioral health disorders, currently commonly referred to as store and forward estimated in the range of $200 billion3 to more than • Remote patient monitoring (RPM) $444 billion per year.4 –– Personal health data is transmitted from an Telebehavioral health offers tremendous potential individual in one location to a clinician in a to improve patient outcomes and experience by different location transforming care delivery, overcoming geographic • Mobile health (mhealth) applications distances, and enhancing access to care, particularly –– Designed to foster health and well-being for those in underserved and/or rural areas. Telebehavioral health involves the use of technology • Any combination of these modalities to provide behavioral health care services at a distance for individuals who are at risk for or suffer from mental illness, or behavioral or addictive Behavioral health care is well-suited to telehealth 5 disorders, ranging from mood and anxiety disorders, as talk therapy is a primary method of care. In this to substance use disorders, to post-traumatic stress way, telebehavioral health can be used to deliver disorder, and suicidality. services such as depression screening, follow-up care after hospitalization, behavioral counseling for

substance use disorders, and/or psychotherapy Improved Outcomes with Telebehavioral Health for mood disorders. Health systems and hospitals can leverage telebehavioral health care to engage in upstream prevention strategies for chronic OVER conditions.6 Telehealth can be applied to support medication management and monitoring for patients % with behavioral health needs, including text-based or mobile app reminders to take medications; 70 OF RURAL AND URBAN continuing care group chat and social media support PATIENTS reported moderate groups to prevent relapse; and collaboration and to extreme satisfaction with professional development for clinicians through using telebehavioral health. emergency department (ED) consultations and virtual rounds.7 Early adoption of telebehavioral health in hospitals and health systems can help position organizations to capitalize on advancements PATIENTS WITH SCHIZOPHRENIA in data and technology with respect to artificial using telemonitoring for medical intelligence and machine learning. adherence had fewer emergency visits, fewer medical appointments Benefits of telebehavioral health are and improved symptoms. well-documented: For patients and families: • Timelier, more convenient access to care and treatment • Improved outcomes and experience

• Remain in care continuum, avoiding high-cost WEB-BASED COGNITIVE setting BEHAVIORAL THERAPY improved symptoms, quality of For hospitals, health systems, providers and payers: life and happiness among • More timely care students at risk for depression. • Enhanced capacity to deliver initial and follow-up care • Reduced utilization of higher-cost services.8,9

The quality of clinical interactions, Having a telepsychiatry the reliability of clinical assessment, consult in the ED led to a and the treatment outcomes REDUCTION OF DAYS associated with telebehavioral health .86 in inpatient length of stay. services are generally equivalent to, if not better than, the quality of Bashshur R.L., Shannon G.W., Bashshur N., Yellowlees P.M. (2016) those associated with in-person care. The Empirical Evidence for Telemedicine Interventions in Mental Disorders. Telemed J E Health. 22(2),87-113. Research has also demonstrated the clinical efficacy and cost-effectiveness of telebehavioral health care across populations and settings.10,11,12

Studies have shown a correlation between the use Challenges hospitals and health systems face of telebehavioral health and decreased hospital implementing telebehavioral health: admissions and costs, thus demonstrating that • Not knowing where to begin telebehavioral health can contribute to a hospital or health system’s overall cost-savings.13,14 • Cost of initiating and implementing telebehavioral health services Despite the evidence base demonstrating the quality and value of telebehavioral health care, • How to design clear processes for implementation and consumerism driving demand for virtual care, • How to overcome resistance to change telebehavioral health care utilization by patients and • How to engage leadership, staff, patients and adoption in health systems and hospitals remain caregivers to ensure adoption and sustained use of relatively low.15,16 telebehavioral health services FROM 2010-2017 • How to navigate the regulatory and payment landscape; it can be complex as new legislation is introduced and regulations vary across states BEHAVIORAL HEALTH visits accounted for % Legislation and regulations within your state will 34.5% telemedicine visits. 34.5 shape the program decisions you may need to make to start, strengthen and sustain your telebehavioral health program. Online tools provided by the National Consortium of Telehealth Resource Centers SUBSTANCE USE and the Center for Connected Health Policy (CCHP) % DISORDER visits accounted can help organizations determine telehealth-related for 1.4% telemedicine visits. legislation and regulations in each state and the 1.4 District of Columbia. These resources can help your

Shigekawa E., Fix M., Corbett G., Roby, D.H., Coffman, J. (2018) hospital or health system increase awareness and The Current State of Telehealth Evidence: A Rapid Review. understanding of applicable laws, regulations and Health Affairs. 37(12), 1975-1982. reimbursement policies.

USING THIS HOW-TO GUIDE

This Guide provides concrete strategies and The Guide is organized by six elements for successful actions for hospitals and health systems seeking to telebehavioral health implementation. Each implement, strengthen and sustain telebehavioral element of success includes a brief description, health programs. The Guide is not a list of “must- implementation examples, potential barriers and do’s,” but rather offers options from which to choose, suggested solutions, and curated tools and resources depending on organizational context, resources and that provide more in-depth information and needs. While intended primarily for hospitals and guidance on relevant topics. Appendix B includes health systems, a broad set of stakeholders, including hyperlinks to all tools and resources by each element payers, community-based provider organizations, of success. The Guide also includes information, and policy and regulatory bodies may find it valuable strategies and resources on key drivers of change, in helping to encourage increased adoption of specifically payment, policy and workforce issues. telebehavioral health.

Your organization can use the implementation developed resources and toolkits to guide examples to design, launch, refine and extend your telebehavioral health service delivery, telebehavioral organization’s approach to telebehavioral health health implementation and telehealth program and increase the potential for success. Many of development. This Guide does not replace the the strategies build on those used to successfully guidance that professional societies, associations and implement telehealth within hospitals and health other agencies have produced. Rather, it builds on systems, while considering specific issues that arise work the American Telemedicine Association (ATA), in applying telehealth to service lines that would American Psychiatric Association (APA), Substance benefit from greater access to behavioral health care. Abuse and Mental Health Services Administration (SAMHSA), National Council for Behavioral Health The implementation examples detail strategies for (NCBH) and others have done to move the field and hospitals and health systems that are starting new practice of telebehavioral health forward. You’ll find programs, and for those that are strengthening links to guidance and tools from these organizations or sustaining their progress. These categories are throughout the body of this Guide. approximate based on likely resource-intensiveness and organizational effort. A hospital or health This Guide uses multistakeholder input from experts system that is just starting out need not limit itself representing patient and caregiver advocates, family to strategies in this category before moving to caregivers, health care administrators, behavioral strategies for strengthening or sustaining progress. health directors, front-line clinicians, payers and Rather, determine which approaches are best for telemedicine vendors to provide practical strategies your organization based on context and available to use across your organization to start, strengthen resources. The implementation examples include and sustain telebehavioral health programs. From a broad range of options to use and increase the this Guide, hospitals and health systems can gain likelihood of success. insights on lessons learned, leading practices and solutions to common implementation barriers in With growing recognition of the opportunity order to provide patients with the right care, in the for telebehavioral health, many groups have right place, at the right time.

ELEMENTS OF SUCCESS FOR TELEBEHAVIORAL HEALTH IMPLEMENTATION National Quality Forum and the AHA Center for Health Innovation identified six elements for successful telebehavioral health implementation by hospitals and health systems:

Leadership commitment Organizational policies and clinical workflows Staff education and training Patient, family and caregiver engagement Measurement Community partnerships

Success Factor 1: LEADERSH Leadership Commitment I

Strong and committed leadership that champions the use of telebehavioral health P COMM is essential to successfully implementing and sustaining telebehavioral programs. I Key Takeaways: • Help drive and sustain implementation efforts TMENT • Build an organizational culture that welcomes by recognizing the potential for telebehavioral innovation and technology to support health to: implementation efforts. –– increase timely access to appropriate • Get buy-in from leaders at all levels, including behavioral health care, the board of directors, health system executives, –– improve outcomes, service line directors, and clinical and operational team leaders. –– decrease costs, • Ask that leaders demonstrate a commitment to –– create a new revenue stream, and improving access to and quality of behavioral –– ensure hospital and health system health care through integration of telehealth sustainability. solutions across the system of care by: • Invest time and resources into planning, –– supporting telebehavioral health as a implementing and integrating telebehavioral supplement and an alternative to in-person health throughout the system. care, and • Consider not only the business model but also –– offering the right types of support and the financial and operational staffing model for incentives to clinicians and patients for using telebehavioral health within their own context. telebehavioral health services.

Implementation Strategies

STARTING OUT

• Identify what optimal care and patient experience • Demonstrate return on investment (ROI) through are, regardless of setting or modality proof of concepts and small tests of change • Determine the purpose and goals of • Engage multistakeholders, including a clinical and implementing telebehavioral health and align the administrative champion, in building the business value proposition for telebehavioral health with case for telebehavioral health integration across the organizational mission and strategic plan the system of care • Identify the organization’s and patients’ biggest • Promote grassroots initiatives and early pain points in behavioral health (e.g., ED staff adopters within the health system to implement burnout, patient lack of transportation) and use telebehavioral health these as potential areas to explore where to start • Understand the potential business models the telebehavioral health service (see Table 1) for telebehavioral health, and • Emphasize how telebehavioral health services identify which model best fits the needs of the address quality, cost, and patient and clinician organization experience • Develop the business case for implementing • Identify and define the target population(s) that telebehavioral health for a single service line, will benefit from telebehavioral health detailing need and demand, infrastructure and workforce, levels and hours required for training,

billing procedures and rates, and funding develop and implement the startup telebehavioral

LEADERSH mechanisms health plan • Dedicate a multidisciplinary team, including a • Set priorities and targets for telebehavioral health project manager, quality improvement leaders, IT adoption and use across service lines and sites I

P COMM leaders, clinical leads and an executive sponsor, to

STRENGTHENING AND SUSTAINING I TMENT • Hire leaders at the C-suite who have expertise in • Establish recognition and/or financial incentives behavioral health and telehealth implementation for staff, clinical leaders and service lines to promote the use of telebehavioral health • Ensure adequate staffing resources are dedicated to sustaining the program • Test approaches to use telebehavioral health as an alternative to in-person care to meet patient • Centralize operations for the telebehavioral health needs (e.g., close clinic to in-person visits for a set program to realize efficiencies in administrative time each week to focus on telebehavioral health and operational functions services) • Scale up from pilots or single service lines to • Share stories of successes, failures and lessons other service lines (e.g., general medicine) and learned across service lines and settings and with sites (e.g., ED) to design a system of care in which other health systems and hospitals, to encourage telebehavioral health is embedded and support continuous quality improvement • Invest in centralized infrastructure and • Create mechanisms such as organizational resources, such as schedulers, trainers and other reporting to hold service lines and sites administrative and operational-focused staff, to accountable for meeting priorities and targets for enhance capabilities and streamline adoption of telebehavioral health use telebehavioral health systemwide • Set performance expectations for the percentage • Dedicate resources for IT infrastructure, of time devoted to virtual care monitoring, continuous quality improvement and patient satisfaction with telebehavioral health • Explore integration of direct-to-consumer mobile services applications as a next step in the evolution of the telebehavioral health program

Potential Barriers and Suggested Solutions

Lack of resources or limited budgets and still meets security guidelines, rather than Suggested Solutions investing in new hardware • Integrate telebehavioral health into service lines • Highlight the potential to address workforce that generate revenue, or seek ways to implement shortages through access to an array of mental in value-based care or shared savings programs health professionals since behavioral health practitioners can work under many different • Emphasize how telebehavioral health can help types of licenses, such as licensed clinical social differentiate the organization from competitors, worker (LCSW), doctor of psychology (PsyD), lead to new consumer acquisition, and retain top peer counselor, psychiatric and mental health talent through flexible work arrangements nurse practitioner • Identify and apply for grants to support startup • Identify potential partners that can share already costs, including co-investment with payers to established resources or invest jointly in new support telebehavioral health implementation structures for delivering telebehavioral health • Use a small-scale pilot or proof of concept to services demonstrate ROI • Emphasize cost savings achieved through • Explore lower-cost software-based technology reducing clinician travel and brick-and-mortar that works within the existing IT infrastructure overhead costs

Leadership lacks the appetite for change without telebehavioral health LEADERSH Suggested Solutions • Describe lost opportunity costs of not offering • Create a burning platform for change by telebehavioral health to patients who are emphasizing that the status quo is unacceptable increasingly demanding easy and convenient I

and communicating an inspiring vision for the access to services P COMM future that aligns with the existing strategic plan Lack of leadership and clinician understanding • Educate hospital and health system trustees on

or discomfort with federal and state policies I TMENT the importance of behavioral health and engage and regulations (e.g., 42 Code of Federal them in the shift to telebehavioral health services Regulations [CFR] Part 2) • Review organizational actuarial malpractice Suggested Solutions data to understand differences, if any, between • Understand the actual policy and regulatory risks of using virtual versus in-person behavioral requirements specific to providing virtual care and health services telebehavioral health services by the organization • Share qualitative data on exceptional clinician and and within the state (see Resources on Legislation, patient experiences, such as patient testimonials Regulations and Policies next page) about the benefits of using telebehavioral health • Partner with other organizations and tap into services consumer demand to advocate for changes to • Provide leaders with data on value of telebehavioral policy on a national or state level health such as decreased costs of care, • Consult regional and/or national telehealth particularly for chronic illness management, resource centers to increase understanding of reduced ED utilization, enhanced market share applicable state and federal policies and improved patient and clinician experience • Develop a Part 2 consent registry to manage • Communicate the alternative: consumers and consent and provider access patients may not receive the care they need

Suggested Tools and Resources

Tools to Support Business Case Development • California Telehealth Resource Center, Telehealth • American Medical Association Digital Health Program Developer Kit Implementation Playbook Step 5: Making • California Telehealth Resource Center, the Case Best Practices • California Telehealth Resource Center, • Conducting a Telehealth Needs Assessment Sustainability Worksheet to Assist Business Development (Excel) • Indian Health Service Telebehavioral Health Center of Excellence Step-By-Step Guide for • Proforma Tool to Build a Sample Business Setting Up Telebehavioral Health Services Case for Behavioral Health Integration • SAMHSA-HRSA Center Telebehavioral Health • Telebehavioral Health Care: A Solution to Improve Training and Technical Assistance Series Cost, Access, and Quality of Care • Telehealth Needs and Organizational Telebehavioral Health and Telehealth Readiness Guide Startup Toolkits • Telligen and gpTRAC Telehealth Start-Up • American Medical Association Digital Health and Resource Guide Implementation Playbook Literature Supporting the Business Case • APA and ATA Best Practices in for Telebehavioral Health Videoconferencing-Based Telemental Health April 2018 • Exploring the Business Case for Children’s Telebehavioral Health

• Milliman American Psychiatric Association into the Care Continuum

LEADERSH Report, Economic Impact of Integrated Medical- Behavioral Health Care Resources on Legislation, Regulations and Policies • Telebehavioral Health: The ROI for • AHA TrendWatch: Realizing the Promise of

I Long-Term Care P COMM Telehealth – Understanding the Legal and • Telemental Health Care, an Effective Alternative Regulatory Challenges to Conventional Mental Care:

I • Center for Connected Health Policy Tools TMENT a Systematic Review • CMS Rules for Telehealth Services Resources on the Value of Behavioral Health Care and Telehealth • Improving Behavioral Health Access & Integration Using Telehealth & Teleconsultation: A Health • AHA Fact Sheet: Telehealth Care System for the 21st Century • AHA Issue Brief on Telehealth: Helping Hospitals • Health Resources and Services Administration Deliver Cost-Effective Care (HRSA) Telehealth Compendium • AHA TrendWatch: Bringing Behavioral Health • Regional Telehealth Resource Centers Taking Action

What would be/is the purpose of our program? What are our biggest pain points that telebehavioral health could help us solve? What business models might work in our context? Whom do we need to involve in business planning?

Table 1: Potential Business Models for Telebehavioral Health LEADERSH The National Council for Behavioral Health and the Substance Abuse and Mental Health Services Administration have previously described three potential business models for telebehavioral health services, outlined below.17 Hospitals and health systems may employ a combination of these models when I implementing their telebehavioral health programs. P COMM

Model Type Hub & Spoke Site-to-Site Within a Direct Remote Specialist I Health System Hiring TMENT

Description Hospital or health system Hospital or health system Hospital or health system partners with remote uses their own specialists recruits behavioral health specialists at a different to provide services specialists from any hospital or health system. virtually. location, either directly or through a third-party recruiting or staffing company. Patient location Originating site or Site where the patient Remote specialist spoke site (e.g., rural is located schedules the evaluates or treats the hospital) schedules the telebehavioral health visit patient via technology. telebehavioral health visit and hosts the patient Patient need not be and hosts the patient on-site. Remote specialist present at the hospital or on-site. Remote specialist evaluates or treats the health system. at hub site evaluates or patient via technology. treats the patient via technology. Payment Standard professional Facility fees are potentially “Undefined” under Considerations fee payment goes to the excluded. Medicare and some specialist at the remote Medicaid programs, site, and originating site meaning it complies with where patient is seen applicable regulations but receives a facility fee. may not be what the law intended. Challenges Potential payer-mix Requires an existing Need to ensure remote challenges and patient workforce with capacity specialists are licensed no-shows. to evaluate and treat in the state where the additional patients. patient is located. Benefits Able to treat more patients Reduces clinicians’ travel Retains clinicians if and provide greater access time across sites, leading they move, so supports to more timely care. to increased capacity continuity of care and and efficiency within the relationship building with system. patients and care teams.

Success Factor 2: ORGAN Organizational Policies and Clinical Workflows I ZAT

Engaging all stakeholders in developing organizational policies and clinical I ONAL POL workflows will support the implementation, uptake and continued use of telebehavioral health and encourage innovative use of technology. I C

To support telebehavioral health implementation and sustainability, at a minimum, I ES AND CL organizational policies should address: 1) information technology (IT), 2) staffing (e.g., credentialing) and multidisciplinary care, and 3) patient care protocols. I N

Key Takeaways: • Make sure policies address interpretations of I CAL WORKFLOWS • Ensure that new and existing policies do not external regulations and coverage requirements exclude telebehavioral health services by to clarify organizational expectations and provide implying that patients only receive care in a clear direction to staff. brick-and-mortar setting. However, policies will • When multistakeholder groups with broad need to address considerations for the physical representation design clinical workflows, tailor environment where clinicians provide and patients workflows to the local context and take into receive care. account available community resources; they can • In organizational policies, do not hold help embed telebehavioral health into the system telebehavioral health to a different standard of care. than in-person care, and ensure policies support • Integrate workflows into the electronic health clinicians to work at the top of their licenses. record (EHR) to help to ensure telebehavioral health is scalable across the organization.

Implementation Strategies

STARTING OUT

• Engage front-line clinician and staff champions, target populations (e.g., sitters, volume and noise patients and caregivers in the initial development adjustments for psychiatric patient populations) of policies and workflows to increase buy- • Understand how telebehavioral health scales up in and understand barriers and unintended and scales down, and what type of technology consequences of policies solution is right for the organization • Engage in-house experts and external consultants • Begin the credentialing and privileging process for areas where specific expertise is needed to early to ensure clinicians can legally practice develop policies (e.g., clinical software, security, within your facility documentation, privacy) • Use “proxy credentialing” to rely on information • Integrate and codevelop policies with IT and from another hospital or health system in making related departments, recognizing that policies do credentialing decisions and thus reduce the not need to start in the IT department and can be administrative burden of this process developed simultaneously • Convene representatives from across the • Ensure there are policies in place to address organization—including legal, finance, clinical issues that would have traditionally been departments—and an executive sponsor with a addressed through physical location of behavioral can-do attitude, to develop and implement policies health care (e.g., potential violence, crisis care) • Talk to as many people as possible within • Lay out physical space considerations for specific the hospital/health system and field prior to

developing a request for proposal (RFP) or delivery objectives ORGAN having discussions with vendors • Ensure workflows are designed in-house; only • Design workflows to achieve programmatic consult with vendors in an advisory role on how I

ZAT objectives that align with the hospital’s or they have seen others incorporate technology health system’s overall business and service into workflows I ONAL POL STRENGTHENING AND SUSTAINING

• Dedicate a team of clinical staff and operational • Challenge current processes and workflows by I C stakeholders (e.g., legal, compliance) to review thinking about how technology can enhance or I ES AND CL and refine policies and workflows improve them, rather than simply embedding technology into current workflows • Engage patients and families in ongoing policy review and evaluation to protect against negative • Integrate workflows into EHRs to support data I N unintended consequences collection, increase productivity and reduce I CAL WORKFLOWS burden • Develop policies on compensation and payment for synchronous and asynchronous modalities • Ensure policies and workflows emphasize multidisciplinary care teams to support clinicians • Implement a policy to require proxy credentialing practicing at the top of their licenses and achieve as the default for telebehavioral health potential cost-savings through using lower cost • Standardize use of telehealth follow-up actions care when individuals drop out of care or are at risk • Address cybersecurity issues within the of lost to follow-up (e.g., text messages, peer organization and work with external partners to support social networks, instant messaging) ensure they have robust cybersecurity policies in • Align clinician compensation with strategic goals place to ensure that clinicians are not penalized for • Proactively identify process and outcome data providing virtual rather than in-person behavioral to collect in piloting the workflow to inform care health services delivery and demonstrate workflow effectiveness • Ensure clinical policies and/or protocols address • Explore the use of artificial intelligence and appropriate handoffs between telebehavioral machine learning to help identify how best to health and other care settings move patients through the system of care

Potential Barriers and Suggested Solutions

Lack of support for organizational change Inconsistent policies and practices across the Suggested Solutions organization • Build telebehavioral health into the organization’s Suggested Solutions health care access strategy and align workflow to • Convene leaders and champions from across the organizational strategy and vision organization to agree on policy and workflow requirements • Engage board of directors and/or trustees to obtain top-down support for the program • Obtain buy-in from necessary stakeholders and create governance structures for policy • Emphasize ROI and that patients lost to follow-up development and review will go elsewhere for services or not get the care they need • Clarify organizational goals and desired outcomes, and review policies to ensure • Obtain buy-in from front-line clinicians and work alignment, relevance and currency upward to administrators and executives • Conduct a readiness assessment to identify areas • Share stories of how telebehavioral health was where policies need to be strengthened used to care for patients and maximize clinician or aligned time and expertise •

• Develop protocols for policy and workflow review patient stories, and communicating improved

and revisions patient and system outcomes associated with ORGAN both behavioral and telebehavioral health • Standardize processes for using telebehavioral I

health across the organization, care settings, • Educate staff on the intersection of behavioral ZAT services lines and sites; share standard processes health and chronic conditions I with external partners as appropriate ONAL POL • Engage in an organizational and/or community Historic lack of understanding of behavioral campaign to reduce the stigma of mental illness health by leadership, clinicians and staff within • Incentivize clinicians to work with patients with I C the hospital or health system I behavioral health needs through recruitment and ES AND CL Suggested Solutions professional development opportunities • Raise awareness of the value of behavioral health • Use existing standard lexicons18 for telebehavioral by disseminating white papers, sharing compelling

health and behavioral health care I N I CAL WORKFLOWS Suggested Tools and Resources

Information Technology (IT), Legal and Interstate Licensing Compacts Regulatory Resources • Interstate Medical Licensure Compact • American Health Information Management (Physicians) Association Telemedicine Toolkit • Nurse Licensure Compact • California Telehealth Resource Center Webinar: • Physical Therapy Compact Mapping and Designing Telehealth Clinic Workflows • Psychology Interjurisdictional Compact (PSYPACT) • Center for Connected Health Policy HIPAA and Telehealth • Recognition of EMS Personnel Licensure Interstate CompAct (REPLICA) • Health Resources & Services Administration Medicare Telehealth Payment Eligibility Analyzer Sample Policies and Protocols • Sample Crisis Protocol for Telebehavioral Health • Legal, Regulatory, and Risk Management Issues Services in the Use of Technology to Deliver Mental Health Care • Sample Privileging and Credentialing Agreement • Preparing for the Telehealth World: Navigating • Telemental Health Toolkit, Chapter 2: Legal, Regulatory, Reimbursement, and Ethical Policy and Protocol Issues in an Electronic Age Selecting Vendors • SAMHSA Consent2Share Application • California Telehealth Resource Center Telehealth • Telebehavioral Health Institute HIPAA Risk Technology Toolkit (see PDF page 125) Assessment Template • A Guide for Telemedicine Service Vendor • Telehealth Resource Centers HIPAA & Telehealth, Contracting: Applying Traditional Contracting A Stepwise Guide to Compliance Considerations in a New Arena • Telemental Health Comparisons Proxy Credentialing Information • CMS Memorandum on Streamlined Credentialing Tools and Resources to Combat Stigma & Privileging for Telemedicine Physicians & • AHA Behavioral Health - Combating Stigma Practitioners • CEOs Against Stigma • Joint Commission, Final Telemedicine Revisions • National Alliance on Mental Illness (NAMI) In Our Own Voice Program • NAMI StigmaFree Program

Taking Action ORGAN What policies do we need to create? What policies do we need to revise? I ZAT I ONAL POL I C I ES AND CL I N I CAL WORKFLOWS

Taking Action ORGAN What workflows do we need to create? What workflows do we need to revise? I ZAT I ONAL POL I C I ES AND CL I N I CAL WORKFLOWS

Success Factor 3: STAFF EDUCAT Staff Education and Training Hospitals and health systems should dedicate resources to train and educate staff I across the organization on the benefits, availability and use of telebehavioral health. ON AND TRA Given the links between mental disorders and chronic disease19, clinicians in physical medicine service lines can benefit from using telebehavioral health to check on I

patients’ compliance and progress on physical conditions and comorbidities such as N I managing diabetes or congestive heart failure. NG

Key Takeaways: including how to work with a multidisciplinary • Use organizational training to address the stigma virtual care team with a mix of skills. of mental illness, emphasizing the importance of • Base training on the most up-to-date evidence- behavioral health care. based practice guidelines, while remaining flexible • For service lines where staff will use telebehavioral to account for emerging guidance and innovative health with their patients, train every team practices. member on how to integrate telebehavioral health • Using effective education and training, stimulate into usual care. the uptake of telebehavioral health by increasing • Each team member must know the process for provider and patient comfort with the technology, initiating and completing a telebehavioral health and securing stakeholder buy-in. encounter, including how to use and troubleshoot • Leverage telebehavioral health for supervising issues with the technology. and mentoring staff at originating and remote • Tailor training to address each profession and role, locations to support continuing education and professional development efforts.

Implementation Strategies

STARTING OUT

• Set expectations for using telebehavioral health as equivalent to in-person behavioral health care during orientation and onboarding of staff across • Integrate telebehavioral health into physical the organization, including physical medicine medicine service lines to address and treat service lines comorbidities and other physical health conditions • Ensure staff have access to training on • Monitor and track patient outcomes and troubleshooting, addressing common issues and experience to identify opportunities where training responding to behavioral health crises and educating providers could improve care or • Incorporate telebehavioral health training into pre- experience with telebehavioral health services and post-licensure training requirements • Celebrate exemplars who successfully use • Ensure adequate infrastructure and resources to telebehavioral health services to improve patient train staff on standard operating procedures access and outcomes • Provide in-depth training “just-in-time” only to • Freely disseminate metrics on telebehavioral those who will have an immediate opportunity to health utilization and quality dashboards to front- use the technology line staff and clinical leaders on a consistent and frequent basis • Standardize training across service lines utilizing telebehavioral health to ensure the service is seen

STRENGTHENING AND SUSTAINING STAFF EDUCAT • Create processes for staff to stay current on • Use regular communication channels (e.g., technology, evidenced-based care and best newsletters, monthly videos) to feature clinical practices overall champions showcasing innovative uses of telebehavioral health • Designate an individual or group of individuals I ON AND TRA who are responsible for assisting staff with using • Share protocols across the organization and the technology, managing challenging cases and broader system, and educate staff across each staying current on technology and best practices service line within the organization on how to use telebehavioral health • Clarify roles and responsibilities through a I

N job protocol redesign and ensure work is • Incorporate coordinating clinical, technical and I NG appropriately distributed across care teams administrative components into training • Ensure training incorporates evidence to • Ensure focus on interprofessional care delivery demonstrate when telebehavioral health care is rather than on independent “silos,” supporting superior and/or preferred to in-person care providers to work at the top of their license • Incorporate peer-to-peer training on using • Evaluate competencies through performance telebehavioral health and addressing common assessments and interprofessional peer review challenges into professional development

Potential Barriers and Suggested Solutions

Limited resources to train and educate staff • Share stories from clinician champions, on telebehavioral health highlighting their use and successes with Suggested Solutions telebehavioral health • Use existing training and learning resources to • Incorporate the patient voice to make the case incorporate telebehavioral health into annual for why this matters training for clinicians • Offer incentives to clinicians, such as continuing • Leverage existing educational tools and medical education credits, to encourage uptake resources, particularly web-based and virtual and usage training (e.g., online training modules, learning • Provide flexible training options, including remote management system) training, multiple time offerings and peer-to-peer • Support staff to operate at the top of their learning licenses by tailoring training for various care team • Demonstrate connections between behavioral members based on their profession, roles and health and physical health, including chronic responsibilities disease management • Integrate telehealth training into other educational offerings (e.g., orientation, virtual Challenges engaging remote staff brown bag lunches) Suggested Solutions • Explore train-the-trainer models, training a few • Ensure equipment across locations is similar to key clinical champions to subsequently train what’s used during training their staff and colleagues • Engage clinical champions to communicate and train across care teams Lack of clinician buy-in Suggested Solutions • Host virtual team huddles and focus on sharing challenges and lessons learned to create a • Expose clinicians to telebehavioral health support network through virtual rounds and videos

• Implement a user engagement team to follow up, of change (e.g., pilot testing, Plan-Do-Study-

troubleshoot issues and share testimonials Act cycles) to increase comfort with the new STAFF EDUCAT technology and processes • Require completion of training by all staff, regardless of physical location, and align training • Encourage clinicians to use telebehavioral health goals and incentives across sites with established patients who could benefit from and are interested in the service I

• Educate staff in a synchronous and asynchronous ON AND TRA curriculum and ensure curriculum is consistent • Ensure staff are engaged in redesigning new with on-site care workflows • Use virtual brown bag lunch and learns to build • Support and celebrate early adopters of I

team relationships and encourage team learning telebehavioral health N I NG Discomfort with the technology or • Compare to something new that was successfully something “new” introduced and made work and life better for staff Suggested Solutions • Introduce telebehavioral health in small tests • Engage clinical champions to generate excitement and build trust in the new technology

Suggested Tools and Resources

Competencies and Practice Guidelines • Best Practices for Remote Psychological • American Academy of Child and Adolescent Assessment via Telehealth Technologies Psychiatry Practice Parameter for Telepsychiatry • SAMHSA Treatment Improvement Protocol: with Children and Adolescents Using Technology-Based Therapeutic Tools in • American Telemedicine Association (ATA) Behavioral Health Services Practice Guidelines for Telemental Health with • Transcultural Psychiatry Made Simple: Children and Adolescents Asynchronous Telepsychiatry as an Approach • ATA Practice Guidelines For Video-Based Online to Providing Culturally Relevant Care Mental Health Services Training Programs • A Framework of Interprofessional Telebehavioral • American Hospital Association’s Team Training Health Competencies: Implementation and Program: Team Strategies and Tools to Enhance Challenges Moving Forward Performance and Patient Safety (TeamSTEPPS®) • The Need to Implement and Evaluate Telehealth • ATA Accredited Telemedicine Training Programs Competency Frameworks to Ensure Quality Care across Behavioral Health Professions Common Terminology for Training • A Comparison of Telemental Health Practice Tools Terminology used Across Mental Health State • American Psychiatric Association (APA) Licensure Boards Clinical Practice Guidelines • Telebehavioral Health Institute Informed • APA and ATA Best Practices in Consent Library Videoconferencing-Based Telemental Health April 2018

Taking Action STAFF EDUCAT TYPES OF TRAINING WHO? WHEN? HOW?

Importance of addressing behavioral I ON AND TRA health needs and overcoming stigma I N I NG

Availability of telebehavioral health services and who could benefit

Using the technology with clinicians and patients, including initiating and completing a telebehavioral health encounter

Integrating telebehavioral health I into usual care ON AND TRA I N I NG

Working with a multidisciplinary virtual care team with a mix of skills

Staying up to date on relevant evidence-based practice guidelines

Other topics?

Success Factor 4: PAT I Patient, Family and Caregiver Engagement ENT, FAM Telebehavioral health provides patients with private, timely and convenient access I to needed behavioral health services and care. It also provides an opportunity to LY AND CAREG reach patients who may not otherwise access health care resources due to social isolation or lack of transportation to in-person care.

Your hospital or health system can use telebehavioral health to follow up with I VER ENGAGEMENT individuals who miss appointments and can support keeping patients in care by eliminating many existing barriers to accessing high-quality behavioral health services. Patients and caregivers who use telebehavioral health are generally satisfied with the service and report positive experiences.20,21

Key Takeaways: their confidence in the reliability, confidentiality • Engage all patients who could benefit—regardless and user-friendliness of the technology. of their age, socioeconomic status or other • Provide opportunities for ongoing engagement demographic factors—in discussions about their between care teams and patients to share preferences to receive care through telebehavioral progress, comfort level and any issues with using health. telebehavioral health, to ensure care remains –– Many patients and caregivers may wish to use appropriate. the technology, but may not know it is available • Engage patients who support and those who are as an option for how to receive care. skeptical of telebehavioral health to help design • Use shared decision-making with patients, family telebehavioral health programs and ensure they and caregivers to discuss their goals, values and are truly patient centered. preferences, and also the benefits, risks, costs –– By engaging patients and caregivers up and alternatives to telebehavioral health as a front in service planning and design, treatment option. the services are more likely to be accepted • Work with patients and caregivers to increase and to work in real life.

Implementation Strategies

STARTING OUT

• Engage patients and caregivers in early compliant mechanisms to share patient records discussions about telebehavioral health program and information gathered through telebehavioral design health visits with appropriate providers, to support coordination and continuity of care • Use existing communications and educational materials to support conversations with patients • Provide evidence-based training, resources and on what to expect from telebehavioral health care tools for all staff to support patient and caregiver engagement in telebehavioral health care • Equip clinicians offering telebehavioral health to patients and caregivers with answers to common • Ensure the patient and family advisory council questions about effectiveness, security, privacy (PFAC) is familiar with telebehavioral health and and protocols (e.g., what happens if…) informs implementation • Ensure there are secure, Health Insurance • Create tailored patient and caregiver educational Portability and Accountability Act of 1996 (HIPAA) materials for various patient populations and

common services that use telebehavioral health • Ensure compliance with state-specific informed

PAT consent regulations regarding telehealth • Empower patients and caregivers by providing

I interactions ENT, FAM them with tools to initiate a telebehavioral health visit without first requiring an in-person visit I

LY AND CAREG STRENGTHENING AND SUSTAINING

• Embed engagement in the organizational culture older adults, nonverbal adults) to help ensure all clinicians have ownership over • Conduct patient, family and caregiver surveys and engaging patients, families and caregivers in focus groups to assess perceptions, utilization and patient care I

VER ENGAGEMENT opportunities for improvement • Establish peer support groups for patients, • Collect patient, family and caregiver stories families and caregivers using telebehavioral of positive experiences and outcomes using health to encourage uptake and sustain patient telebehavioral health and share in monthly engagement newsletters and other published materials • Include patients, families and caregivers in • Engage the patient and family advisory designing new organizational and patient-facing council (PFAC) in identifying areas, service lines resources to support use of telebehavioral health and sites that could benefit from the use of • In newsletters and presentations, feature lessons telebehavioral health learned from engaging an array of patient • Create a digital front door that is easy for patients populations in telebehavioral health care to access and provides up-to-date information on (e.g., children and adolescents, guardians, telebehavioral health services and benefits

Potential Barriers and Suggested Solutions

Patient, family and caregiver skepticism telebehavioral health to ensure all patients who about the effectiveness of or hesitance can benefit from accessing care in this way have to use telebehavioral health care the opportunity to use it Suggested Solutions • Encourage clinicians to use telebehavioral • Collect and share patient and caregiver stories services, through financial incentives and patient that demonstrate the value of using telebehavioral success stories health care, including data that demonstrate the • Use case studies to demonstrate the variety equivalency to in-person care of patients that can and have benefited from • Create short resources (e.g., one-pager with telebehavioral health services (e.g., children frequently asked questions) that highlight and adolescents, mothers with postpartum the equivalency of telebehavioral health to depression, older adults) and the variety of ways in-person care patients can access telebehavioral health services (e.g., smartphone, laptop, tablet) • Ensure patients and caregivers understand that this is an option and they can change their mind • Share published evidence supporting the use of and decide later not to receive care virtually telebehavioral health with all patient subgroups (e.g., ATA Practice Guidelines note that no • Build trusting relationships through in-person care studies to date have identified subgroups that then transition to using telebehavioral health do not benefit from, or are harmed by, remote Patients, families and caregivers may not videoconferencing as a telebehavioral health be offered telebehavioral health because of modality.) assumptions about their preferences based on • Use patient navigators and/or discharge demographic and socioeconomic factors coordinators who understand local resources to Suggested Solutions set up initial appointments for all eligible patients • Assess patient needs and understanding of and connect to community supports

• Implement patient engagement metrics within • Have an IT support plan in place that includes

telebehavioral health service lines (e.g., through a 24-hour help desk or contract for support PAT

patient experience surveys) services with vendors I ENT, FAM • Provide technical assistance for providers and • Ensure there is sufficient broadband for the patients to support access to payment and patient volume I

reimbursement to encourage usage LY AND CAREG • Check patient ZIP codes to determine cell Patients, families and caregivers experience service strength technical difficulties (e.g., poor connections), • Establish and use a checklist for initially limiting desire for future use connecting a patient to a clinician that clearly outlines what to do and who should do it Suggested Solutions I VER ENGAGEMENT • Ensure clinicians have guidance for trouble- • Have a documented plan for crisis escalation shooting technical issues during a telebehavioral (e.g., patient expresses suicidality in session), and health encounter, including contingency plans practice the emergency protocol (e.g., telephone call if video is spotty)

Suggested Tools and Resources

Caregiver Resources on Behavioral Health • SAMHSA Shared Decision Making in Mental • NAMI Family-to-Family Program Health • NAMI Homefront Program for Family, Caregivers, • Telehealth and Patient Satisfaction: and Friends of Service Members and Veterans A Systematic Review and Narrative Analysis

Tools to Support Patient, Family and Caregiver Videos on Engaging Patients, Families and Engagement Caregivers in Telebehavioral Health • AHRQ Engaging Patients and Families • Telemental Health Toolkit, Chapter 4: in Their Health Care Engaging the Client on Video • Health Research & Educational Trust (HRET) • Telemental Health Toolkit, Chapter 5: Patient and Family Engagement Resource Cognitive/Interpersonal Approaches Compendium • Telemental Health Toolkit, Chapter 7: • NAMI Provider Education Family and Group Therapy • National Quality Partners Playbook™: Shared Decision Making in Healthcare

Taking Action

How can we build telebehavioral health into our patient and family engagement strategy?

Success Factor 5: MEASUREMENT Measurement It is important to identify measures specific to your organization and use them to determine whether the telebehavioral health program is meeting the system’s and program’s goals and objectives, and where opportunities for improvement exist. Clear and standard definitions for data and quality will support efficient tracking, monitoring and reporting within the organization and to external stakeholders for learning and quality improvement. This can support information sharing to avoid fragmentation in care.

Key Takeaways: the effectiveness of telebehavioral health • Prior to selecting measures, understand what programs. data sources are available and think proactively • Whether working to improve access, improve about what data can be collected. Data and the patient and clinician experience, retain staff, measurement can be powerful tools for reduce the total costs of care or any combination understanding an organization’s current needs, of these goals, select measures that are: strengths and opportunities. –– meaningful to patients, clinicians and • Use measurement to help demonstrate the value administrators; of telebehavioral health to internal and external stakeholders. –– improvable; • Start with structural measures (i.e., assessments –– feasible to deploy; of whether the organization has specific –– broadly usable; and capabilities), and then move to process measures and finally clinical outcome measures to assess –– aligned with the overall system goals for telebehavioral health.22

Implementation Strategies

STARTING OUT

• Define the purpose for data collection and • Obtain agreement from stakeholders across the measurement care continuum on what quality measures will be used to measure progress • Obtain input from front-line staff and patients to identify outcomes of interest prior to • Ensure measure results are used to drive quality implementation improvement and inform decision-making, particularly about where to offer services, to • Implement a measurement framework (i.e., the whom services should be offered and how to NQF Telehealth Measurement Framework) to improve service delivery identify which quality measures should be used to assess progress, selecting measures that are • Design and implement EHRs within the most relevant to your hospital or health system organization with an eye toward real-time data collection and clinical decision-making for • Begin using operational measures such as patients with behavioral health needs adoption of technology, provider training volume, or no-show rates, then assess processes such • Incorporate telehealth as an encounter into as time to first appointment and medication the specifications of existing behavioral health adherence measures

• Use measurement results in newsletters, communication channels to highlight early

MEASUREMENT town halls, virtual brown bags and other adopters and encourage uptake

STRENGTHENING AND SUSTAINING

• Create patient, caregiver and clinician experience • Design workflows to capture routine data within surveys, and use the data to improve service the EHR to guide program improvement delivery and program design • Frequently use data to inform organizational • Employ outcome measures, including patient- decisions about where to expand or reduce reported outcome performance measures, to telebehavioral health services, and what workflow assess outcomes of interest such as improved changes are required symptomatology, recovery, aggregate • Share key performance metrics across the improvement on depression scores, and improved organization and with senior leadership (e.g., quality of life publish data on dashboards) on a consistent and • Centralize ownership of tracking, assessing and frequent basis, and identify strategies to address interpreting quality measures to a department or any metrics that are below target team within your hospital or health system • Publish results and share lessons publicly in • Designate staff to lead organizational quality literature and at conferences to encourage others improvement initiatives based on measure results to adopt telebehavioral health and to eventually benchmark performance against others

Potential Barriers and Suggested Solutions

Measurement burden and mobile applications) to automate data collection, competing measurement priorities measurement and reporting across stakeholder groups • Explore the use of nonclinical staff to collect data Suggested Solutions for measurement purposes • Use the multistakeholder groups involved in program, policy and workflow design to prioritize Limited adoption of telebehavioral health may a subset of telebehavioral health measures within lead to denominator challenges the health system or hospital Suggested Solutions • Communicate the value and evidence for • Use measures to help understand operational measurement across the organization, building delivery of telebehavioral health a culture of data-driven continuous quality • Investigate the reasons why there is limited improvement adoption and employ relevant change • Implement common measures for telebehavioral management strategies to increase uptake health across service lines and sites • Ensure all staff understand how to code • Ensure there is a strong evidence base for telebehavioral health activities to avoid the “if it’s selected measures, selecting those that are not coded, it doesn’t exist” mentality actionable and inform clinical decision-making • Measure appropriateness of the modality of care • Leverage technology (e.g., EHR, patient portals, for clinical conditions where telebehavioral health was used

Suggested Tools and Resources

Behavioral Health Quality Measures and • Measures Required for Certified Community Measurement Information Behavioral Health Clinic (CCBHC) • 2019 Core Set of Behavioral Health Measures Demonstration Program for Medicaid and CHIP

• NQF Behavioral Health and Substance Use Telehealth and Telebehavioral Health Quality Standing Committee Reports Measurement Resources MEASUREMENT • Pragmatic Characteristics of Patient-Reported • Ensuring Clinical Quality in Telemedicine Outcome Measures Are Important for Use in • A Lexicon of Assessment and Outcome Measures Clinical Practice for Telemental Health • Medical Technology in the Value-Based Environment: An Assessment of Quality Measure Gaps • NQF Telehealth Measurement Framework

Taking Action

What measures make the most sense for our organization to assess our telebehavioral health services?

How can we ensure the measures we select are meaningful to stakeholders and do not overly burden patients, caregivers and clinicians?

MEASUREMENT DOMAIN MEASURE DESCRIPTIONS DATA SOURCES

Access to care

Financial impact / cost

Experience

Effectiveness

Success Factor 6: COMMUN Community Partnerships I Communities are key to successfully implementing and sustaining telebehavioral TY PARTNERSH health programs. Community partners can help patients and caregivers access telebehavioral health 23 by providing a trusted point of entry and access to technology. I PS

Key Takeaways: clinicians, community agencies, faith-based • To effectively partner with the community, organizations, law enforcement agencies, first understand: responders, emergency medical technicians and more—all play an important role in connecting –– the behavioral health needs within your patients and caregivers to appropriate services. community; • Ensure that community partners are aware of –– key community stakeholders (e.g., the telebehavioral health services your hospital local government, safety-net providers, or health system offers and the ways in which local community leaders, community-based patients, caregivers and partners can access the organizations); and services. –– the gaps in current community resources • Provide partners and community members with and services. ongoing opportunities to offer feedback on the • Use community health needs assessments and telebehavioral health services available, including collaborate with community organizations to opportunities to improve and strengthen existing build a shared vision and goal for telebehavioral programs and partnerships. health. • Collaborate with community leaders or advocate • Identify the critical partnership(s) needed to to build trust in the community to increase the ensure telebehavioral health programs are likelihood that the community will accept and successful and sustainable. Community-based embrace the telebehavioral health program.

Implementation Strategies

STARTING OUT

• Conduct a community health needs assessment virtually to highlight the ease of the interactions to understand the behavioral health needs and • Identify community points of access (e.g., identify gaps in current and desired levels of churches, barbershops, community centers) services available in the community where patients and caregivers may feel • Educate the community (e.g., first responders, comfortable accessing behavioral health clergy, community agency staff) on telebehavioral resources or support health availability, expectations and use, including • Identify an existing inventory of community treatment for substance use disorder and other resources and make this available to patients, conditions or illness that may be prevalent within caregivers and clinicians the community • Collaborate with community partners to raise • Provide resources to the community on reducing consumer awareness of the availability of the stigma of mental illness telebehavioral health services and connect • Be accessible to community leaders and build patients to care trust with them through community meetings • Explore the use of social media platforms as a and town halls, including holding such meetings community engagement tool

STRENGTHENING AND SUSTAINING COMMUN • Partner with the community’s trusted points of association) to offer telebehavioral health services access to offer telebehavioral health services to • Engage community partners in advocacy efforts

I patients and caregivers TY PARTNERSH for improved benefit parity and telebehavioral • Build partnerships with the judicial system, law health reimbursement enforcement, other hospitals in the area without • Partner with schools to educate them on early existing behavioral health services, and shelters, recognition and identification of behavioral health (among others) to provide support for addressing needs, and create an access point in schools for

I behavioral health disorders in the community PS telebehavioral health prior to ED or hospitalization • Hold community open forums to elicit input and • Dedicate an on-site resource for identifying suggestions on how to improve telebehavioral and connecting with community resources to health care access, cost and quality establish relationships for warm handoffs • Work with community partners to design • Develop coalitions at the local, regional and state marketing campaigns to raise awareness of this levels (e.g., work with your state or metro hospital valuable service

Potential Barriers and Suggested Solutions

Community partners mistrust new approaches • Maintain an up-to-date list of community and/or the hospital or health system resources and contacts, and integrate into referral Suggested Solutions and/or discharge workflows • Establish trust early in the process through • Create a process for anyone involved in community engagement and outreach delivering telebehavioral health services can identify resource gaps and create and • Bring community partners to the table for early implement solutions program design conversations • Create a mechanism for community partners Concern that collaborating with competitors to obtain information and provide ongoing and will negatively impact financial sustainability frequent feedback to the hospital or health Suggested Solutions system • Draft memorandums of understanding (MOUs) • Practice humility, removing any personal agenda with community partners that outline realistic and building relationships with community cost-sharing opportunities and set clear goals partners around their needs and responsibilities for both parties • Begin with one use case to demonstrate success, Fear of overidentification of patients who need e.g., collaboratng with community-based services and lack of capacity to address all of organizations for smooth transitions of care their needs Suggested Solutions • Partner with community organizations and other provider groups to offer services that are not • Set expectations on service capacity and help offered internally within the organization front-line clinicians understand what additional resources may be available in the community and • Build community collaboration into the business where they can go for help case, establishing cost savings to the system through investments in community partnerships • Emphasize how gathering critical information from patients will improve the hospital’s or health • Provide information on how timely access to care system’s ability to address needs upstream will free up physical and financial resources

Suggested Tools and Resources COMMUN Community Health Needs Assessment • A Playbook for Fostering Hospital-Community • Association for Community Health Improvement Partnerships to Build a Culture of Health I Community Health Assessment Toolkit TY PARTNERSH Community and Social Support Resources • Centers for Disease Control and Prevention • Certified Community Behavioral Health Clinics Community Health Improvement Navigator (CCBHCs) • Health Research & Educational Trust Engaging • Community Access resources and services I

Patients and Communities in the Community PS Health Needs Assessment Process • SAMHSA’s Behavioral Health Treatment Services Locator • National Consumer Supporter Technical Assistance Center’s Community Needs Sample Memorandums of Understanding for Assessment Tool Use with Community Partners • SAMHSA How States Can Conduct a Needs • Memorandums of Understanding (MOU) Assessment and Medical Center Memorandums (MCM) for Telemental Health Clinics and Traditional Community Partnerships Toolkits Healers/Healing Services • AHA Ensuring Access to Vulnerable • Sample Memorandum of Understanding for Communities, Community Conversations Toolkit Telemedicine Services and Equipment • Increasing Access to Behavioral Health Care Through Technology

Taking Action

Which community partners do we need to engage?

Community centers

Community clinics

Community health centers

Faith-based organizations

First responders

Law enforcement

Schools

Shelters

Workforce development

Others?

DRIVERS OF CHANGE

Some of the most commonly cited barriers to Medicare beneficiary is physically located at the time the widespread implementation and adoption of service—currently limit hospital and health system of telebehavioral health in hospitals and health abilities to invest in and scale telebehavioral health. systems are: Removing limitations to allow patients’ homes to serve as sites of care for telemedicine reimbursement • Lack of payment and reimbursement models that purposes, and to allow urban and metropolitan support telebehavioral health as a modality of care hospitals and health systems to seek reimbursement • Policy restrictions that limit where and how from Medicare for telebehavioral health services, clinicians deliver care may help increase adoption of telebehavioral 27 • Persistent behavioral health workforce shortages health across the U.S. Medicaid reimbursement for telebehavioral health varies by state, and although In the shift to value-based care, redesigning systems at least 48 state Medicaid programs reimburse for of care to fully integrate and sustain telebehavioral some telebehavioral health services, reimbursement health will require hospitals, health systems, payers, rates differ and may not adequately cover the costs professional societies, state and federal agencies, of services.28 advocacy groups and other stakeholders to work together to take action in these domains. Ideally, payment models should include coverage for the costs of starting a service. Hospitals and Payment Models, Reimbursement health systems may be able to access funding through demonstration projects and grant programs and the Shift to Value to support needs assessments, infrastructure Payment models that include telebehavioral development and pilot testing (e.g., Center for health can facilitate access to the right care, at the Medicare & Medicaid Innovation, Community right time and in the right place. Reimbursement Benefit programs, U.S. Department of Agriculture should support patients to participate in and use grants). Your hospital or health system also may telebehavioral health. However, affordability and lack find success in integrating telebehavioral health into of adequate insurance coverage for telebehavioral covered services rather than using “carve-outs” (i.e., health services prevent patients from accessing separating behavioral health from physical health the care they need in a cost-effective way. Despite care) for payment. federal legislation and state mandates focused on parity for behavioral health services and Value-Based Care Models reimbursement for telehealth, payment and coverage for both behavioral health and telebehavioral health While telebehavioral health is feasible in existing services remain inconsistent across health plans and fee-for-service models, opportunities for greater states.24 impact exist when telebehavioral health is integrated into value-based care models where specialty Several states have mandated reimbursement for care, primary care and behavioral health care are telebehavioral health by commercial payers, but coordinated in a fully integrated service line. In commercial reimbursement remains variable by such models, payers, hospitals, health systems and 25 payer. As of January 2019, Medicare reimburses clinicians agree to meaningful outcomes to which for a number of telehealth services focused on payers can tie payment. Telebehavioral health in behavioral health including screening, behavior value-based care models supports multidisciplinary 26 counseling and psychotherapy. Despite recent care teams to integrate care, share information and legislation to expand Medicare access to telehealth focus on health outcomes rather than volume of services for the treatment of substance use disorders services. Hospitals and health systems implementing or co-occurring mental health disorders, restrictions telebehavioral health have found that it provides on patient originating site—that is, where the sufficient return on investment (ROI) in a variety of

settings, as the costs of virtual services are lower patients across state lines. In areas with a shortage than in-person care.29,30,31 Using tools to calculate of behavioral health professionals or where patients costs and ROI can help with discussions with payers have to travel long distances to access behavioral and support advocacy efforts for reimbursement health services, state licensing limitations may model changes at the state level. contribute to lengthy wait times for services or patients going without the care they need.

Federal and State Policy A critical policy change that could support an The federal and state policy landscape for increased uptake in telebehavioral health and telebehavioral health continues to evolve in improve the ability of the current workforce to the United States. Complex regulations and provide behavioral health services at a distance is inconsistencies across states limit the adoption and national licensure and/or licensure portability across utilization of telebehavioral health services. Federal states. Policymakers are exploring mechanisms such efforts by Medicare and U.S. Department of Veterans as reciprocity across states to facilitate telebehavioral Affairs to expand reimbursement and coverage may health care delivery.34 help hospitals and health systems deliver behavioral health services via telehealth. Prescribing

As new policies and regulations that support the The U.S. Congress passed the Ryan Haight Online use of telehealth are proposed and take effect, Pharmacy Consumer Protection Act in 2008. The your hospital and health system may see greater Ryan Haight Act regulates online prescriptions opportunities and fewer barriers to implementing for controlled substances, including through telebehavioral health programs. For instance, telebehavioral health, requiring a prescriber to have physicians now no longer need to meet with a previously assessed a patient in person prior to patient in person prior to delivering services via prescribing a controlled substance.35 32 telehealth. While the Ryan Haight Act aims to protect patients Changes to policies at the federal and state levels, by restricting access to inappropriate medications, however, should be approached holistically, taking it also has unintentionally served as a barrier to into account a systems view of telebehavioral health. patients gaining access to required medications via Policies should ensure that telebehavioral health is telebehavioral health, particularly patients who may integrated into the broader care delivery system. not have the ability to travel to a prescriber in person. Carving out telebehavioral health and addressing Some states have begun to review and refine their it separately as a care delivery model—rather than remote prescribing laws to improve clinicians’ as a critical component of a high-quality health abilities to treat patients remotely.36 Examples of system—will limit the achievement of optimal revisions include allowing remote prescriptions of health outcomes. In addition to payment and controlled substances for patients with psychiatric reimbursement changes noted above, changes to disorders or substance use disorders, and expanding licensing and prescribing policies would help support state databases to support prescribers’ abilities to implementing and sustaining telebehavioral health in identify patients who may be inappropriately seeking hospitals and health systems. the same prescriptions from multiple clinicians.37

Licensing As your hospital or health system implements and evaluates telebehavioral health, be sure to Most states require clinicians to obtain a license to review state policies to determine whether and to practice in the state where the patient is physically what extent your state legislature allows remote 33 located. For telebehavioral health, this means prescribing. that clinicians may be limited in their ability to treat

Workforce Development to get telebehavioral health services up and running faster and sustain progress. There is a shortage of psychiatrists and other behavioral health clinicians across the United Longer-term efforts are required to promote and States.38 While technology can increase the reach recruit individuals into behavioral health careers. and accessibility of behavioral health services, it is Graduate medical education is an opportunity to not a panacea for workforce and staffing challenges. develop skills in delivering behavioral health services Telebehavioral health still requires a dedicated and through technology and prepare the next generation knowledgeable workforce behind the technology. of behavioral health clinicians to meet the growing demand for telebehavioral health services. From an operational perspective, centralizing the workforce at a systems level and standardizing At your hospital or health system, consider using processes can remove much of the administrative telebehavioral health programs as a recruiting and burden for each hospital or site within a health retention tool for top talent. Telebehavioral health system. For example, a core team dedicated offers behavioral health clinicians flexibility and to licensing and credentialing can build the better work-life balance, as they do not need to be competencies, expertise and relationships required restricted to one setting or geographic area.

A PATH FORWARD

Given the impact of behavioral health disorders in the United States, it is becoming even more critical for hospitals and health systems to focus on expanding access, improving patient outcomes and experience, and redesigning systems of care.

Telebehavioral health care offers hospitals and health equivalent to—if not better than—the quality of those systems a viable solution for overcoming historic associated with in-person care should encourage the barriers to access. Telebehavioral health: uptake and adoption of telebehavioral health on a national scale. • Provides patients with timely and convenient access. Using the strategies and tactics outlined in this Guide, your hospital or health system can begin the • Increases the capacity of hospitals and health journey of implementing a sustainable telebehavioral systems to deliver high-quality behavioral health services. health program or strengthening a program your organization already has in place, moving the field Broad recognition that the quality of clinical and practice of telebehavioral health even further. interactions, the reliability of clinical assessment, Ultimately, this journey will achieve better health, and the treatment outcomes associated with better care, lower cost, and joy at work. telebehavioral health services are generally

ENDNOTES

1 National Institute of Mental Health. (2017, November). 11 Hubley S., Lynch, S.B., Schneck, C., Thomas, M., & Mental Illness. Retrieved from https://www.nimh.nih.gov/ Shore, J. (2016). Review of key telepsychiatry outcomes. health/statistics/mental-illness.shtml World Journal of Psychiatry, 6(2):269-82. http://dx.doi. org/10.5498/wjp.v6.i2.269 2 American Hospital Association. (2012, January). Bringing Behavioral Health into the Care Continuum: 12 Langarizadeh M., Tabatabae, M.S., Tavakol, K., Opportunities to Improve Quality, Costs and Outcomes. Naghipour, M., Rostami, A., & Moghbeli, F. (2017). Washington, DC: Author. Retrieved from https://www. Telemental health care, an effective alternative to aha.org/system/files/research/reports/tw/12jan-tw- conventional mental care: A systematic review. Acta behavhealth.pdf Inform Med, 25(4), 240-246. https://doi.org/10.5455/ aim.2017.25.240-246 3 Insel, T.R. (2008). Assessing the economic costs of serious mental illness. The American Journal of 13 Shigekawa, E., Fix, M., Corbett, G., Roby, D., & Coffman, Psychiatry, 165(6), 663-665. https://doi.org/10.1176/appi. J. (2018). The current state of telehealth evidence: A ajp.2008.08030366 rapid review. Health Affairs, 37(12), 1975-1982. https://doi. org/10.1377/hlthaff.2018.05132 4 Szabo, L. (2014, May 12). Cost of not care: Nowhere to go. USA Today. Retrieved from https:// 14 Narasimhan M., Druss, B.G., Hockenberry, J.M., www.usatoday.com/story/news/nation/2014/05/12/ Royer, J., Weiss, P., Glick, G., Magill, J. (2015). Impact of mental-health-system-crisis/7746535/ a telepsychiatry program at emergency departments statewide on the quality, utilization, and costs of mental 5 Aboujaoude E. (2018). Telemental health: Why the health services. Psychiatric Services, 66(11), 1167-1172. revolution has not arrived. World Psychiatry, 17(3), 277-278. https://doi.org/10.1176/appi.ps.201400122 https://doi.org/10.1002/wps.20551 15 K. Kane, C.K. & Gillis, K. (2018). The use of telemedicine 6 Greenberg, H., Greenberg, P., Huth, T., Klein, R. M., & by physicians: Still the exception rather than the rule. Pande, R. (n.d.). Telebehavioral Health Care: A Solution to Health Affairs, 37(12), 1923-1930. https://doi.org/10.1377/ Improve Cost, Access, and Quality of Care. Washington, hlthaff.2018.05077 DC: Association for Behavioral Health and Wellness. Retrieved from http://www.abhw.org/publications/pdf/ 16 Huskamp, H.A., Busch, A.B., Souza, J., Uscher-Pines, ABHWTelehealthWhitePaper.pdf L., Rose, S., Wilcock, A., Mehrotra, A. (2018). How is telemedicine being used in opioid and other substance use 7 Mace, S., Boccanelli, A., & Dormond, M. (2018, March). disorder treatment? Health Affairs, 37(12), 1940-1947. The Use of Telehealth Within Behavioral Health Settings: Utilization, Opportunities, and Challenges. Retrieved from 17 Lardiere, M. R., Hirsch, P., & Neufeld, J. (2013, June 19). the Behavioral Health Workforce Research Center website: A to Z: Developing Telebehavioral Health Capacity to Serve http://www.behavioralhealthworkforce.org/wp-content/ the Needs of Your Patients [PowerPoint slides]. Retrieved uploads/2018/05/Telehealth-Full-Paper_5.17.18-clean.pdf from https://www.integration.samhsa.gov/operations- administration/Telebehavioral_Health_T_TA_Session_3_ 8 Hilty D.M., Ferrer, D.C., Parish, M.B., Johnston, B., Economics_and_Partnerships_FINAL_6_18_13_Read-Only. Callahan, E.J., & Yellowlees, P.M. (2013). The effectiveness pdf of telemental health: A 2013 review. Telemedicine and eHealth, 19(6), 444-54. https://doi.org/10.1089/ 18 Shore, J.H., Mishkind, M.C., Bernard, J., Doarn, C.R., tmj.2013.0075 Bell Jr., I., Bhatla, R., Vo, A. (2014). A lexicon of assessment and outcome measures for telemental health. Telemedicine 9 Shigekawa, E., Fix, M., Corbett, G., Roby, D., & Coffman, and e-Health, 20(3), 282-292. https://doi.org/10.1089/ J. (2018). The current state of telehealth evidence: A tmj.2013.0357 rapid review. Health Affairs, 37(12), 1975-1982. https://doi. org/10.1377/hlthaff.2018.05132 19 American Medical Association. (2015). Mental disorders linked with chronic diseases. JAMA, 313(2):125. 10 Bashshur R.L., Shannon, G.W., Bashshur, N., doi:10.1001/jama.2014.17382 & Yellowlees, P.M. (2016). The empirical evidence for telemedicine Interventions in mental disorders. 20 Hubley, S., Lynch, S.B., Schneck, C., Thomas, M., & Telemedicine and e-Health, 22(2), 87-113. https://doi. Shore, J. (2016). Review of key telepsychiatry outcomes. org/10.1089/tmj.2015.0206 World Journal of Psychiatry, 6(2):269-82. http://dx.doi. org/10.5498/wjp.v6.i2.269

21 Langarizadeh, M., Tabatabae, M.S., Tavakol, K., 31 Langarizadeh M., Tabatabae, M.S., Tavakol, K., Naghipour, M., Rostami, A., & Moghbeli, F. (2017). Naghipour, M., Rostami, A., & Moghbeli, F. (2017). Telemental health care, an effective alternative to Telemental health care, an effective alternative to conventional mental care: A systematic review. Acta conventional mental care: A systematic review. Acta Inform Med, 25(4), 240-246. https://doi.org/10.5455/ Inform Med, 25(4), 240-246. https://doi.org/10.5455/ aim.2017.25.240-246 aim.2017.25.240-246

22 Bernot, J., Munthali, E., & Jung, M. NQF’s Measure 32 Gallegos, A. (2018, October 5). Telehealth: Prioritization and Feedback Strategic Initiatives States broaden options for locations, providers. The [PowerPoint slides]. Hospitalist. Retrieved from https://www.the-hospitalist. org/hospitalist/article/176599/business-medicine/ 23 Jones, A. M., Shealy, K. M., Reid-Quiñones, K., Moreland, telehealth-states-broaden-options-locations-providers A. D., Davidson, T. M., López, C. M., de Arellano, M. A. (2013). Guidelines for establishing a telemental health 33 Federation of State Medical Boards. (n.d.). program to provide evidence-based therapy for trauma- Telemedicine Policies: Board by Board Overview. Retrieved exposed children and families. Psychological Services, 11(4), from http://www.fsmb.org/siteassets/advocacy/key-issues/ 398-409. https://doi.org/10.1037/a0034963 telemedicine_policies_by_state.pdf

24 National Conference of State Legislatures. (2015). 34 National Conference of State Legislatures. (2015). Telehealth: Policy Trends and Considerations. Washington, Telehealth: Policy Trends and Considerations. Washington, DC: Author. Retrieved from http://www.ncsl.org/ DC: Author. Retrieved from http://www.ncsl.org/ documents/health/telehealth2015.pdf documents/health/telehealth2015.pdf

25 Lardiere, M. R., Hirsch, P., & Neufeld, J. (2013, June 19). 35 Shore, J. (Narrator). (2018). The Ryan Haight A to Z: Developing Telebehavioral Health Capacity to Serve Act [Online video]. Washington, DC: American Psychiatric the Needs of Your Patients [PowerPoint slides]. Retrieved Association. Retrieved from https://www.psychiatry.org/ from https://www.integration.samhsa.gov/operations- psychiatrists/practice/telepsychiatry/ryan-haight-act administration/Telebehavioral_Health_T_TA_Session_3_ Economics_and_Partnerships_FINAL_6_18_13_Read-Only. 36 Lerman, A. F., Kim, D., Ozinal, F. R., & Thompson, T. pdf E. (2018, July 23). Telemental and telebehavioral health considerations: A 50-state analysis on the development of 26 Centers for Medicare & Medicaid Services. (2018, telehealth policy. Telehealth and Medicine Today, 3. https:// November 6). Covered Telehealth Services CY 2018 and doi.org/10.30953/tmt.v3.4 CY 2019. Retrieved from https://www.cms.gov/Medicare/ Medicare-General-Information/Telehealth/Telehealth- 37 Davidsen, B. S. (2018, January 22). New state law Codes.html allows telehealth prescriptions for cntrolled substances; yet, regulatory obstacles still remain. TechHealth Perspectives. 27 Centers for Medicare & Medicaid Services. (2018, Retrieved from https://www.techhealthperspectives. November 15). Information on Medicare Telehealth. com/2018/01/22/new-state-laws-allow-telehealth- Retrieved from https://www.cms.gov/About-CMS/Agency- prescriptions-for-controlled-substances-yet-regulatory- Information/OMH/Downloads/Information-on-Medicare- obstacles-still-remain/ Telehealth-Report.pdf 38 Weiner, S. (2018, February 13). Addressing 28 Von Hafften, A. (Narrator). (2018). Medicaid the escalating psychiatrist shortage. Retrieved Reimbursement in Telepsychiatry [Online video]. from Association of American Medical Colleges Washington, DC: American Psychiatric Association. website: https://news.aamc.org/patient-care/article/ Retrieved from https://www.psychiatry.org/psychiatrists/ addressing-escalating-psychiatrist-shortage/ practice/telepsychiatry/medicaid-reimbursement

29 Townley, C. & Yalowich, R. (2015, November). Improving Behavioral Health Access & Integration Using Telehealth & Teleconsultation: A Health Care System for the 21st Century. Portland, ME: National Academy for State Health Policy. Retrieved from https://nashp.org/ wp-content/uploads/2015/11/Telemedicine1.pdf

30 Rossiter, L., Austin, W., & Gammon, J. (2018, February 1). Telebehavioral health: The ROI for long-term care. Healthcare financial management. Retrieved https://www. hfma.org/Content.aspx?id=59161

APPENDIX A: Participating Experts

Jeffrey Buck Natassja Manzanero Centers for Medicare & Medicaid Services Health Resources and Services Administration Flavio Casoy Cody Mullen JSA California / SOC Telemed Patient & Family Centered Care Partners, Inc David Cohn Peggy O’Brien Regroup Therapy IBM Watson Adam Darkins Jay Ostrowski AristaMD Behavioral Health Innovation and Adaptive Telehealth Christopher Dennis Andy Penn Landmark Health / Teladoc Health Cerner Corporation Seth Feuerstein Todd Peters Magellan Healthcare Sheppard Pratt Health System Matthew Goldman Carlos Reines Substance Abuse and Mental Health Services RubiconMD Administration Bruce Retterath Ann Griepp Pine Rest Christian Mental Health Services Excellus Blue Cross and Blue Shield Sylvia Romm Julie Hall-Barrow American Well Children’s Health System of Texas Jennifer Snow Michael Hasselberg National Alliance on Mental Illness University of Rochester Medical Center Christopher Tavella Kristi Henderson New York Office of Mental Health Ascension Healthcare Ian Tong Phil Hirsch Doctor on Demand Forefront TeleCare Thomas Tsang Judd Hollander Valera Health Thomas Jefferson University Arpan Waghray Theresa Hyer Providence Health and Services Adventist Health and Rideout Shang Wang Joanna G. Katzman RubiconMD Project ECHO Michael R. Lardieri Advanced Health Network

APPENDIX B: Tools and Resources by Success Factor

Success Factor 1: Leadership Commitment

Resource Address American Medical Association Digital Health https://www.ama-assn.org/practice-management/digital/ Implementation Playbook Step 5: Making the Case digital-health-implementation-playbook-step-5-making- case California Telehealth Resource Center, Sustainability http://www.caltrc.org/wp-content/uploads/2018/10/CTRC- Worksheet to Assist Business Development (Excel) sustainability-worksheet-IHC-FQHC-RHC.xlsx Proforma Tool to Build a Sample Business Case http://integration.samhsa.gov/integrated-care-models/ Business_Case_for_Behavioral_Health_Pro_Forma_Model. xlsx Telebehavioral Health Care: A Solution to Improve http://www.abhw.org/publications/pdf/ Cost, Access, and Quality of Care ABHWTelehealthWhitePaper.pdf American Medical Association Digital Health https://www.ama-assn.org/system/files/2018-12/digital- Implementation Playbook health-implementation-playbook.pdf APA and ATA Best Practices in Videoconferencing- https://www.liebertpub.com/doi/full/10.1089/ Based Telemental Health April 2018. tmj.2018.0237 California Telehealth Resource Center, Telehealth https://www.telehealthresourcecenter.org/wp-content/ Program Developer Kit uploads/2018/09/Complete-Program-Developer-Kit-2014. pdf California Telehealth Resource Center, Best Practices http://www.caltrc.org/knowledge-center/best-practices/ Conducting a Telehealth Needs Assessment https://link.springer.com/ chapter/10.1007/978-3-319-08765-8_2 Indian Health Service Telebehavioral Health Center https://www.ihs.gov/telebehavioral/includes/ of Excellence Step-By-Step Guide for Setting Up themes/responsive2017/display_objects/documents/ Telebehavioral Health Services tbhcetoolkit2018.pdf SAMHSA-HRSA Center Telebehavioral Health Training https://www.integration.samhsa.gov/ and Technical Assistance Series operations-administration/telebehavioral-health Telehealth Needs and Organizational http://www.caltrc.org/knowledge-center/ctrc-publications/ Readiness Guide program-guides/organizational-readiness-guide/ Telligen and gpTRAC Telehealth Start-Up and https://www.ruralcenter.org/resource-library/ Resource Guide telehealth-start-up-and-resource-guide Exploring the Business Case for Children’s https://www.scribd.com/document/288520754/Exploring- Telebehavioral Health the-Business-Case-for-Children-s-Telebehavioral-Health Milliman American Psychiatric Association Report, https://www.psychiatry.org/File Library/Psychiatrists/ Economic Impact of Integrated Medical-Behavioral Practice/Professional-Topics/Integrated-Care/Milliman- Health Care Report-Economic-Impact-Integrated-Implications- Psychiatry.pdf Telebehavioral Health: The ROI for Long-Term Care https://www.hfma.org/Content.aspx?id=59161 Telemental Health Care, an Effective Alternative to https://www.ejmanager.com/mnstemps/6/6-1511433290. Conventional Mental Care: a Systematic Review pdf?t=1542376537 AHA Fact Sheet: Telehealth https://www.aha.org/system/files/2018-01/fs-telehealth. pdf

Resource Address AHA Issue Brief on Telehealth: Helping Hospitals https://www.aha.org/system/files/content/16/16telehealth Deliver Cost-Effective Care issuebrief.pdf AHA TrendWatch: Bringing Behavioral Health https://www.aha.org/system/files/research/reports/ into the Care Continuum tw/12jan-tw-behavhealth.pdf AHA TrendWatch: Realizing the Promise of https://www.aha.org/system/files/research/reports/ Telehealth – Understanding the Legal and Regulatory tw/15may-tw-telehealth.pdf Challenges Center for Connected Health Policy Tools https://www.cchpca.org/ CMS Rules for Telehealth Services https://www.integration.samhsa.gov/operations- administration/CMS_New_Rules_Expand_Telehealth_ coverage_July_2013-16547_PI.pdf Improving Behavioral Health Access & Integration https://nashp.org/wp-content/uploads/2015/11/ Using Telehealth & Teleconsultation: A Health Care Telemedicine1.pdf System for the 21st Century Health Resources and Services Administration https://www.telehealthresourcecenter. (HRSA) Telehealth Compendium org/wp-content/uploads/2018/07/ HRSA-Telehealth-Compendium_March2018_v4.pdf Regional Telehealth Resource Centers https://www.telehealthresourcecenter.org/

Success Factor 2: Organizational Policies and Clinical Workflows

Resource Address American Health Information Management https://healthsectorcouncil.org/wp-content/ Association Telemedicine Toolkit uploads/2018/08/AHIMA-Telemedicine-Toolkit.pdf California Telehealth Resource Center Webinar: http://www.caltrc.org/upcoming-webinar-mapping-and- Mapping and Designing Telehealth Clinic Workflows designing-telehealth-clinic-workflows/ Center for Connected Health Policy HIPAA and https://www.cchpca.org/sites/default/files/2018-09/HIPAA Telehealth and Telehealth.pdf Health Resources & Services Administration Medicare https://data.hrsa.gov/tools/medicare/telehealth Telehealth Payment Eligibility Analyzer Legal, Regulatory, and Risk Management Issues in the https://www.sciencedirect.com/science/article/pii/ Use of Technology to Deliver Mental Health Care S1077722914000807 Preparing for the Telehealth World: Navigating Legal, http://psycnet.apa.org/record/2011-28096-001 Regulatory, Reimbursement, and Ethical Issues in an Electronic Age SAMHSA Consent2Share Application https://bhits.github.io/consent2share/ Telebehavioral Health Institute HIPAA Risk https://telehealth.org/blog/ Assessment Template hipaa-risk-assessment-template/ Telehealth Resource Centers HIPAA & Telehealth, A https://cdn.zephyrcms.com/38b774e3-2cb5-4629-84cd- Stepwise Guide to Compliance fced39fd908e/-/inline/yes/hipaa-project-version-1.1 for Printing.pdf CMS Memorandum on Streamlined Credentialing https://www.cms.gov/Medicare/Provider-Enrollment-and- & Privileging for Telemedicine Physicians & Certification/SurveyCertificationGenInfo/downloads/ Practitioners SCLetter11_32.pdf Joint Commission, Final Telemedicine Revisions https://www.jointcommission.org/assets/1/6/Revisions_ telemedicine_standards.pdf Interstate Medical Licensure Compact (Physicians) https://imlcc.org/

Resource Address Nurse Licensure Compact https://www.ncsbn.org/compacts.htm Physical Therapy Compact http://ptcompact.org/ptc-states Psychology Interjurisdictional Compact (PSYPACT) https://www.asppb.net/mpage/micrositehp Recognition of EMS Personnel Licensure Interstate http://www.emsreplica.org/ CompAct (REPLICA) Sample Crisis Protocol for Telebehavioral Health https://www.ncbi.nlm.nih.gov/pmc/articles/ Services PMC4079762/#APP1 Sample Privileging and Credentialing Agreement http://www.caltrc.org/wp-content/uploads/2014/04/ SAMPLE-PRIVILEGING-AND-CREDENTIALING- AGREEMENT.pdf Telemental Health Toolkit, Chapter 2: Policy and https://vimeo.com/115672434 Protocol California Telehealth Resource Center Telehealth https://www.nrtrc.org/content/article-files/Business Technology Toolkit (see PDF page 125) Plans/2012 Program Developer Kit - Part 2.pdf A Guide for Telemedicine Service Vendor https://www.bakerdonelson.com/a-guide-for-telemedicine- Contracting: Applying Traditional Contracting service-vendor-contracting-applying-traditional- Considerations in a New Arena contracting-considerations-in-a-new-arena Telemental Health Comparisons https://telementalhealthcomparisons.com/ AHA Behavioral Health - Combating Stigma https://www.aha. org/2017-12-11-behavioral-health-combating-stigma CEOs Against Stigma http://ceos.namimass.org/ NAMI) In Our Own Voice Program https://www.nami.org/find-support/nami-programs/ nami-in-our-own-voice NAMI StigmaFree Program https://www.nami.org/stigmafree

Success Factor 3: Staff Education and Training

Resource Address American Academy of Child and Adolescent http://www.jaacap.com/article/S0890-8567(08)60154-9/ Psychiatry Practice Parameter for Telepsychiatry with pdf Children and Adolescents American Telemedicine Association (ATA) Practice https://www.liebertpub.com/doi/abs/10.1089/ Guidelines for Telemental Health with Children and tmj.2017.0177?rfr_dat=cr_pub%3Dpubmed&url_ Adolescents ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref. org&journalCode=tmj ATA Practice Guidelines For Video-Based Online https://www.integration.samhsa.gov/operations- Mental Health Services administration/practice-guidelines-for-video-based-online- mental-health-services_ATA_5_29_13.pdf A Framework of Interprofessional Telebehavioral https://www.ncbi.nlm.nih.gov/pubmed/30284147 Health Competencies: Implementation and Challenges Moving Forward The Need to Implement and Evaluate Telehealth https://www.ehidc.org/sites/default/files/resources/files/ Competency Framework to Ensure Quality Care Evaluating Telehealth Competency Frameworks.pdf across Behavioral Health Professions American Psychiatric Association (APA) Clinical https://www.psychiatry.org/psychiatrists/practice/ Practice clinical-practice-guidelines

Resource Address APA and ATA Best Practices in Videoconferencing- https://www.liebertpub.com/doi/full/10.1089/ Based Telemental Health April 2018 tmj.2018.0237 Best Practices for Remote Psychological Assessment http://www.davidluxton.com/publications/Luxton Pruitt via Telehealth Technologies Osenbach 2014 PPRP.pdf SAMHSA Treatment Improvement Protocol: Using https://store.samhsa.gov/system/files/sma15-4924.pdf Technology-Based Therapeutic Tools in Behavioral Health Services Transcultural Psychiatry Made Simple: Asynchronous https://www.ncbi.nlm.nih.gov/pubmed/23451812 Telepsychiatry as an Approach to Providing Culturally Relevant Care American Hospital Association’s Team Training https://www.aha.org/center/performance-improvement/ Program: Team Strategies and Tools to Enhance team-training Performance and Patient Safety (TeamSTEPPS®) ATA Accredited Telemedicine Training Programs http://www.americantelemed.org/main/ata-accreditation/ training-programs A Comparison of Telemental Health Terminology http://tpcjournal.nbcc.org/wp-content/uploads/2016/11/ used Across Mental Health State Licensure Boards Pages387-396-OstrowskiCollins-TelementalHealth.pdf Telebehavioral Health Institute Informed Consent https://www.naadac.org/assets/2416/marlene_maheu_ Library ac17ho2.pdf

Success Factor 4: Patient, Family and Caregiver Engagement

Resource Address NAMI Family-to-Family Program https://www.nami.org/Find-Support/NAMI-Programs/ NAMI-Family-to-Family NAMI Homefront Program for Family, Caregivers, and https://www.nami.org/Find-Support/NAMI-Programs/ Friends of Service Members and Veterans NAMI-Homefront AHRQ Engaging Patients and Families in https://www.ahrq.gov/professionals/quality-patient-safety/ Their Health Care patient-family-engagement/index.html Health Research & Educational Trust (HRET) Patient http://www.hret-hiin.org/Resources/pfe/16/patient-and- and Family Engagement Resource Compendium family-engagement-pfe-resource-compendium.pdf NAMI Provider Education https://www.nami.org/Find-Support/NAMI-Programs/ NAMI-Provider-Education National Quality Partners Playbook™: https://store.qualityforum.org/products/national-quality- Shared Decision Making in Healthcare partners-playbook%E2%84%A2-shared-decision-making SAMHSA Shared Decision Making in Mental Health http://brss-tacs-decision-tool.samhsa.gov/ Telehealth and Patient Satisfaction: https://bmjopen.bmj.com/content/7/8/e016242 A Systematic Review and Narrative Analysis Telemental Health Toolkit, Chapter 4: https://vimeo.com/115713828 Engaging the Client on Video Telemental Health Toolkit, Chapter 5: https://vimeo.com/115717945 Cognitive/Interpersonal Approaches Telemental Health Toolkit, Chapter 7: https://vimeo.com/115726492 Family and Group Therapy

Success Factor 5: Measurement

Resource Address 2019 Core Set of Behavioral Health Measures for https://www.medicaid.gov/medicaid/quality-of-care/ Medicaid and CHIP downloads/performance-measurement/2019-bh-core-set. pdf Measures Required for Certified Community https://www.samhsa.gov/section-223/quality-measures Behavioral Health Clinic (CCBHC) Demonstration Program NQF Behavioral Health and Substance Use Standing https://www.qualityforum.org/Publications/2018/07/ Committee Reports Behavioral_Health_and_Substance_Use_Fall_2017_Final_ Report.aspx Pragmatic Characteristics of Patient-Reported https://www.sciencedirect.com/science/article/pii/ Outcome Measures Are Important for Use in Clinical S0895435615001730 Practice Ensuring Clinical Quality in Telemedicine https://catalyst.nejm.org/ clinical-quality-telemedicine-online-care/ A Lexicon of Assessment and Outcome Measures for https://www.liebertpub.com/doi/abs/10.1089/ Telemental Health tmj.2013.0357 Medical Technology in the Value-Based Environment: https://www.advamed.org/sites/default/files/resource/ An Assessment of Quality Measure Gaps medical_technology_in_the_value_based_environment_-_ assessment_of_quality_measure_gaps.pdf NQF Telehealth Measurement Framework http://www.qualityforum.org/Publications/2017/08/ Creating_a_Framework_to_Support_Measure_ Development_for_Telehealth.aspx

Success Factor 6: Community Partnerships

Resource Address Association for Community Health Improvement http://www.healthycommunities.org/Resources/toolkit. Community Health Assessment Toolkit shtml Centers for Disease Control and Prevention https://www.cdc.gov/chinav/index.html Community Health Improvement Navigator Health Research & Educational Trust Engaging https://www.aha.org/ahahret-guides/2016-06-09- Patients and Communities in the Community Health engaging-patients-and-communities-community-health- Needs Assessment Process needs-assessment National Consumer Supporter Technical Assistance http://www.mha-sc.org/resources/Community-Needs- Center’s Community Community Needs Assessment Assessment.pdf Tool SAMHSA How States Can Conduct a Needs https://www.samhsa.gov/section-223/ Assessment certification-resource-guides/conduct-needs-assessment A Playbook for Fostering Hospital-Community https://www.aha.org/ahahret-guides/2017-07-27- Partnerships to Build a Culture of Health playbook-fostering-hospital-community-partnerships- build-culture-health AHA Ensuring Access to Vulnerable Communities, https://www.aha.org/toolkitsmethodology/2017-07-27- Community Conversation Toolkit community-conversations-toolkit Increasing Access to Behavioral Health Care Through https://www.hrsa.gov/sites/default/files/publichealth/ Technology guidelines/BehavioralHealth/behavioralhealthcareaccess. pdf Certified Community Behavioral Health Clinics https://www.thenationalcouncil.org/topics/ (CCBHCs) certified-community-behavioral-health-clinics/ Community Access resources and services http://www.communityaccess.org/our-story/about Behavioral Health Treatment Services Locator https://findtreatment.samhsa.gov/ Memorandums of Understanding (MOU) and Medical https://www.ruralhealth.va.gov/docs/MOUs-and-MCMs-for- Center Memorandums (MCM) for Telemental Health telemental-clinics.pdf Clinics and Traditional Healers/Healing Services Sample Memorandum of Understanding for https://www.ncbi.nlm.nih.gov/pmc/articles/ Telemedicine Services and Equipment PMC4079762/#APP1

NQF STAFF AHA STAFF

Kathleen Giblin, Senior Vice President Jay Bhatt, Senior Vice President and Chief Medical Officer Kim Ibarra, Senior Director Andy Shin, Chief Operating Officer Shannon Berry, Project Manager Chantal Worzala, Vice President of Health Information Isaac Orea Montero, Project Associate and Policy Operations Danitza Valdivia, Senior Administrative Manager Norma Padrón, Senior Director, Applied Research and Lisa Bolejack, Creative Director Data Analytics

AJ Rolle, Senior Program Manager

Cynthia Hedges Greising, Communications Specialist