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Challenges and Opportunities: Technical innovations in Social Work SWDE April 14, 2016 Marlene M. Maheu, PhD Executive Director TeleMental Health Institute Arizona State University [email protected] 619-255-2788 . Legal Info WHO I AM: I am a licensed psychologist, not an attorney, physician, marketing or information technology (IT) professional. MY GOALS: I hope to inspire you by outlining current and future events in an educational format. My goal is to help you think through the issues. No warranty, guarantee, or representation is made as to the accuracy or sufficiency of the information contained in my presentation for your specific © in connection with your choices. circumstance. I assume no responsibility YOUR PART: Seek documented training for “competence.” Seek written approval from your legal, regulatory, ethical and malpractice bodies before offering any online services or programs to consumers. Have your informed, trusted, local, clinical and legal consultants review all written responses from the authorities for their full significance. There is no conflict of interest with any of the parties mentioned in today’s presentation. . Definitions Behavioral Health: The Affordable Care Act requires more attention to mental health and substance abuse. Behavioral health is the old term being re-defined to describe both mental © health and substance use. Telehealth: The electronic delivery of medical, educational, and health care across distance. Not a specific service, but a way to deliver and improve existing services. Telemental Health and Tele-Behavioral Health . Telehealth vs. Telemedicine vs. Health Care (& Antibiotic Medicine) of the 1930’s Telehealth Regional Health Information Sharing Health Professions Education © Administration Telemedicine Consumer Education Community Health Evaluation Research Homeland Security . Mental Illness & Treatment Serious Mental Illness: Overall Mental Illness Adults: Approximately 13 million (5.8%) Children: Approximately 8 million (10%) Adults: Approximately 55©million (25%) Children : Approximately 16 million (20%) Treatment 1/3 of adults and 2/3 of children with SMI receive no services 2/3 of other people with mental health conditions receive no care . Substance Abuse Substance Use Conditions: Approximately 24 million potential cases/year Substance Use Care: Approximately 2.4 million people receive care/year Treatment © More than 90% of people with substance abuse receive NO care Care that is received comes principally from grants rather than personal insurance More substance abusers are housed in our prison system than are treated in facilities . Why Behavioral Health? Healthcare recognizing that behavioral care is essential to lowering health care “spend” © . Readmission Rates by Frequency Rank Primary Diagnosis Medicare Medicaid Commercial 1 Pneumonia 18.3% 13.3% 9.6% 2 Mood Disorders 20.2% 17.2% 10.2% 3 Osteoarthritis 5.4% 6.0% 3.1% 4 Congestive Heart Failure 25.3% 29.8% 19.7% 5 Cardiac Dysrhythmias 16.6% 18.5% 9.2% 6 Septicemia (except in labor) 22.0% 23.7% 15.7% 7 Coronary Atherosclerosis 15.3% 17.4% 9.0% 8 Childbirth Trauma 0.0% 0.8% 0.6% 9 COPD & Bronchiectasis 21.9% 25.0% 14.4% 10 Nonspecific Chest Pain 12.8% 14.8% 5.0% 15.8% 16.7% Source: hcupnet.ahrq.gov 9.6% All © . Implications of ACA for Behavioral Health Shorter sessions / more clients/patients More specific documentation Documentation will require proof of interventions being tied to the evidence-base (“treat-to-target”) Practitioners will be held accountable for outcomes and paid accordingly © Increased reliance on technology Required use of electronic health records to measure outcomes Decreased reimbursement for free-flowing sessions and non-specific note-taking Apps and other self help tools will proliferate Increased reliance on master’s level practitioners Increased need for vision / graduate education and professional education . Implications of ACA for Behavioral Health Provision of primary care is essential Provision of behavioral health care is essential Facilitation of WELLNESS©and RECOVERY approaches are essential Integrated care is an obvious mechanism to achieve these goals - Ron Manderschied, CIMH, 2014 . Implications of ACA for Behavioral Health Implication for SWDE is that students may want to: Find placements with health plans, primary care offices and/or large/small medical facilities © Focus on: Patient-centered homes Resilience & recovery Technology Electronic Health Records Telehealth Remote patient monitoring . © . Health & Behavioral Care in 10 Years Mobile devices and peripherals will deliver most health and mental health care © Sensor-based information gathering Mirrors, scales, vests, chairs, mattresses, steering wheels, exercise equipment, etc. Self-report Patient portals Social support systems . Health & Behavioral Care in 10 Years Mobile devices will be networked into central database that will correlate all real-time data with your genetic profile: as reported by you, family members, friends and © environment; and neighbors who share your demographics of people who share your habits, lifestyle, and personal preferences for food, drink, exercise; medical conditions and medication; genomic testing for genedrug interactions and drug drug interactions combined with latest empirical evidence about each source in real time . Health & Behavioral Care in 10 Years Data will be complied into recommendations that will deliver medications, foods other ingestible © substances and behavioral prescriptions in ways that will help remedy diseases and problems before they can even be noticed now. . Levels of Security How will such unprecedented change happen in 10 years? © . © . © . Levels of Security What’s the problem (and of course, the solution)? © . © . © . © URL: www.telehealth.org/ethical-statements . Smartphones are the technology of choice for many people Some groups use text messaging significantly more than others: Children Adolescents Young Adults Hispanic Americans African Americans © . Issues of Social Justice and Access © . © Copyright © 2016 All rights reserved. . FitBit, JawBone, Apple Watch, Basis Watch © . Wearables Wearable activity trackers, including the next FitBit or Jawbone is already falling flat Wearable medical trackers is growing to offer remote (home) monitoring © for hospital and population health patients. They will become more compact, less expensive and covered by insurance companies to measure and transmit information to clinical offices about blood pressure, glucose, HRV, EEG, etc. Behavior change professionals at all levels will be needed to understand, implement and interpret information from such devices into treatment . Electronic Health Records 2nd generation EHRs will provide added functionality to extend care Team-based collaboration including caregivers © Patient engagement portals Remote monitoring ICD-10 transition (October 2015) Audits in 2016 Refunds Tying treatment plan to evidence base (Paired with HIPAA Compliance audits in 2016) . Virtual Humans (Avatars) Virtual Intelligent Agents Animated computer characters simulated face-to-face conversation (USC – Skip Rizzo, PhD) Used as virtual coaches, counselors, and for automated health education and basic behavior change interventions © Relationalagents.com Virtual Human Cancer Clinical Trial Assistant (Bickmore, Utami et al. 2013). (Slide made available by David Luxton, PhD) . mHealth Augmented Reality Augmented Reality (AR) overlays computer-generated graphics with live video imagery of the physical world to immerse the patient into a simulated, augmented experience Behavioral health applications: Exposure therapy © change Behavioral activation/Behavior Training applications (Luxton, June, Sano, & Bickmore, 2016) 31 . Integrated Multi-Modal Systems © Conceptual diagram of Mobilyze! app system adapted from Burns et al (2011), in Luxton et al. (2015). . © Copyright © 2016 All rights reserved. . Pharma “Beyond the Pill” initiatives: Drugmakers are teaming up with technology players like Google ($GOOG) and IBM Watson Health--Novartis ($NVS), Sanofi ($SNY) and Novo © Nordisk ($NVO) –to marry Big Data record-sifting with cutting-edge patient-monitoring devices, developing infrastructure. How will that information will be made available to the patient & clinician? Who amongst us will assist these new groups understand the behavioral health population and their needs? (Who will serve as the “Bridges”?) . © . Levels of Security The solution then, is education and training in best practices. © . © All Existing Legal and Ethical Rules Apply . © . BELLWETHER: Georgia Composite Board of Professional Counselors, Social Workers and Marriage and Family Therapists Proposing a new rule for telemental health: 1. Definitions 2. Mandatory 6-hour training 3. Defined competencies to be covered by training © . Telemental Health Best Practices Legal Issues Licensing © (Dynamic) Informed Consent Mandated Reportin Privacy / Confidentiality While thousands of clinicians work online, the vast majority to not understand their legal or ethical mandates.* *Maheu & Gordon, 2000; Maheu, Glueckauf, Drude, Nelson (pending) . Telemental Health Best Practices Ethical Competencies Beyond Legal Issues Intakes © Assessment Equipment Telepresenters Handling Emergencies While thousands of clinicians work online, the vast majority to not understand their legal or ethical mandates.* *Maheu & Gordon, 2000; Maheu, Glueckauf, Drude, Nelson (pending) . Telemental Health Best Practices Liability Insurance Reimbursement (which practice models get reimbursed and related CPT codes) © Risk Management Documentation Case notes Release of Information Forms While thousands of clinicians work online, the vast majority to not understand their legal or ethical mandates.* *Maheu & Gordon, 2000; Maheu, Glueckauf, Drude, Nelson (pending) . © . Informed Consent • Represents a “meeting of the minds” – Information is influenced by many factors, including • Client/Patient’s capacity for absorbing information © • Time limits • Clinician’s schedule – Subject matter is often complex and technical – Clinician thinks she is speaking English – Client/Patient may be under stress (or may assert so later) – Mental illness • Document only serves as important evidence • Active vs. Static informed consent? . HIPAA Privacy Rule Data are “individually identifiable” if they include any of the 18 types of identifiers, listed below, for an individual or for the © individual’s employer or family member, or if the provider or researcher is aware that the information could be used, either alone or in combination with other information, to identify an individual: . HIPAA Privacy Rule (cont.) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Name Address (all geographic subdivisions smaller than state, including street address, city, county, zip code) All elements (except years) of dates related to an individual (including birth date, admission date, discharge date, date of death and exact age if over 89) Telephone numbers Fax number Email address © Social Security number Medical record number Health plan beneficiary number Account number Certificate/license number Any vehicle or other device serial number Device identifiers or serial numbers Web URL Internet Protocol (IP) address numbers Finger or voice prints Photographic images Any other characteristic that could uniquely identify the individual . ⑦HIPAA: Have you chosen a service that provides an “audit trail?” © ⑧ HIPAA: Does the service you have chosen provide “breach notification tools?” . © . ⑨Additional State Regulatory Codes for Privacy/Security also Apply © • Include copy in client/patient record • Other Issues . 11. HIPAA, Business Associates & HITECH • • • All Business Associates in health care must sign an agreement stating their adherence to HIPAA standards • Transactions • Security • Privacy True for any service you hire It is now enforced by the HITECH ACT © Copyright 2012 TeleMental Health Institute, Inc. All rights reserved. TMHI Education & Training Resources . Other Education & Training Available at TMHI: • • • • http://telehealth.org/webinar http://telehealth.org/individual/ © http://telehealth.org/courses http://telehealth.org/graduate Free sample: • http://telehealth.org/intro . Resources Made Available by our Non-Profit, the Telehealth Institute TeleMental Health© Institute Bibliography: www.telehealth./org/bibliography See many other resources at: www.telehealth.org . TMHI’s TeleMental Health News: www.telehealth.o rg/sign-up © . For slides additional resources: www.Telehealth.org/swde © . Questions? © TeleMental Health Institute, Inc. Phone: 619-255-2788 Email: [email protected]