Yale Psychiatry Grand Rounds: October 23, 2020
October 23, 2020Information
Drs. David Moore, Jennifer Doran and Eric Hermes: "Integration of Virtual Care Into An Academic Healthcare System"
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- 00:00Coming. Really excited for
- 00:03this grand rounds today.
- 00:05This is our opportunity at the VA to showcase
- 00:07one of our most exciting initiatives.
- 00:10And so we're really excited to be here.
- 00:13So we're going to be talking
- 00:15about Telemental Health today.
- 00:16the VA has had Telemental Health
- 00:18Center for several years now,
- 00:20and Doctor Linda Godleski,
- 00:21who's one of our faculty members,
- 00:23is the head of that.
- 00:25That is a mental health consultation
- 00:27service and several of our
- 00:29departmental members have worked there,
- 00:31so there's a tell addictions
- 00:32Tele schizophrenia.
- 00:33Tele bipolar.
- 00:34But in 2016,
- 00:35the office of rural health,
- 00:37which is part of BA,
- 00:39nationally decided that they
- 00:40wanted to fund telemental health
- 00:42to actually provide ongoing care,
- 00:43not just consultation to veterans
- 00:45who are in rural areas as a way
- 00:48to increase access and the the
- 00:50idea was that this would happen
- 00:52at each region or each business.
- 00:54So we're visiting One Region 1,
- 00:56which is New England,
- 00:57and we were actually encouraged
- 00:59at the time to apply for this
- 01:01by the then vision director,
- 01:03who is doctor Mike Mayo.
- 01:05Smith is a physician.
- 01:06Because of two reasons.
- 01:08One,
- 01:08he really thought that when we
- 01:10provided excellent clinical care at VA,
- 01:12Connecticut and also he was impressed
- 01:15with our ability to both recruit and
- 01:17retain Hyatt Wrists and psychologists.
- 01:19Other other settings,
- 01:20including just in our region,
- 01:22but nationally, were unable to do so.
- 01:24So in 2016,
- 01:25Loe Travis and Linda Godleski
- 01:27Glen get slick and I applied
- 01:29for funding from the office of
- 01:31rural health and we were funded
- 01:34for a Tele mental Health Center.
- 01:36David Moore was our first employee,
- 01:38and in the spring of 2017 we started
- 01:41the hub with six staff in a computer
- 01:43storage room at the Yale West campus.
- 01:46And because we were in this space,
- 01:48we were well poised to expand.
- 01:50So in the office of rural health,
- 01:53wanted to expand this to develop
- 01:55these clinical resource hubs.
- 01:56We apply Dave more applied and others
- 01:58applied for this and we were funded
- 02:01so in the fall of 2021 we're going to
- 02:03take off with our clinical resource hub,
- 02:06which has been expanded to nearly 100 FT.
- 02:09In mental health.
- 02:09Take care and specialty care and the
- 02:12thing that's interesting about our hub.
- 02:14Our clinical resource hub.
- 02:15We're not the only one in the country,
- 02:17but we're one of the few where
- 02:19psychiatry or mental health is
- 02:21the lead of the entire hub,
- 02:23which includes primary care.
- 02:24A lot of times these are
- 02:25embedded in primary care,
- 02:27so this has been particularly great
- 02:28for us now during this pandemic,
- 02:30where Tele Health has become a necessity,
- 02:32not just an added program,
- 02:34and our clinical resource hub
- 02:35folks and the people that are
- 02:37speaking today have been experts
- 02:39and Telemental Health and have.
- 02:40People to us,
- 02:41so we're really grateful for
- 02:43this opportunity for them to be
- 02:45able to share their work with
- 02:46the entire Department.
- 02:48So First off is doctor David Moore,
- 02:50who's the director of the
- 02:51clinical resource hub.
- 02:52Actually, it's become a service line,
- 02:54so he's the service line manager.
- 02:56Then Jennifer Duran is going to speak.
- 02:58She is the mental health lead,
- 03:00and both are assistant
- 03:01professors in the Department of
- 03:03psychiatry and then Eric Hermes,
- 03:04who is an associate professor in
- 03:06the Department of psychiatry,
- 03:07is going to speak.
- 03:08He's not a directly working for the hub,
- 03:11but he's been in this Tele.
- 03:13Mental health space for several years.
- 03:15Doing a rotation.
- 03:15Leading a rotation for residents.
- 03:17I just want to say that we're
- 03:18going to have all three of
- 03:20these presentations and then at
- 03:21the end we're going to welcome
- 03:23questions from people or comments,
- 03:25so I'll turn it over to Dave.
- 03:27Thank you.
- 03:29Hi everybody thanks is mini and everybody
- 03:33on the call for joining us today.
- 03:37I'm gonna talk. A little bit about
- 03:40developing this new service line
- 03:42really over the last three or
- 03:44four years at VA, Connecticut.
- 03:46It's called a clinical resource hub,
- 03:48and it's an it's built around Tele
- 03:51Medicine and so that's why it seems
- 03:54like an important thing to go over.
- 03:57Kind of given recent events,
- 03:59and so I'm going to go through there.
- 04:02The slides.
- 04:03Some of the work is funded through
- 04:06a research grant from via query an.
- 04:09I've worked as a consultant on
- 04:12some topics related to this for
- 04:15alchemy's in the last year.
- 04:19Up front, I'd like to do acknowledgements
- 04:22I think is Meanie gave kind of a a good
- 04:26idea that this really started and grew out
- 04:29of some pre existing strengths at our in
- 04:33our Department and at VA Connecticut that.
- 04:36It kind of came out of the
- 04:39mental health service line.
- 04:41It's been strongly supported by the primary
- 04:43care service line and now medicine,
- 04:46NBA Connecticut Lou Trevisan is meaning
- 04:48Petrakis and Linda Godlewski and Glenn
- 04:51gets like put together the initial
- 04:53application for the clinical resource
- 04:55hub and it's been able to be a site for
- 04:58research to the conduit implementation
- 05:00team at VA Connecticut, especially.
- 05:02Mark Rosen deserves credit for some of
- 05:05the view pornography work will talk about.
- 05:08And then. A lot of the folks who are
- 05:11in the clinical resource hub,
- 05:14so Jennifer Doran's the mental
- 05:16health lead she'll be talking next.
- 05:18Actually,
- 05:18Paul dross is the primary care lead.
- 05:21We have a great nursing team
- 05:23led by Kathy too.
- 05:24So and then just a larger staff and at the
- 05:28bottom I I put photos of folks who came
- 05:31out of the Yale system one way or another,
- 05:34either as trainees or or already on the
- 05:37staff or faculty at Yale who either.
- 05:40Join the clinical resource hub
- 05:44full-time or volunteer time.
- 05:47Doing clinical work.
- 05:49Lou Travison.
- 05:51Knows northern Maine really well.
- 05:53Now he was providing buprenorphine up
- 05:55there so it's been a great team and it
- 05:58wouldn't have happened without such
- 06:00strong resources of being Connecticut.
- 06:03Just a brief overview,
- 06:04so I'm going to talk about
- 06:06the clinical resource hub.
- 06:08Jennifer is going to talk about
- 06:11developing really training programs.
- 06:14At VA,
- 06:15Connecticut geared towards kind of
- 06:17high quality telemental health care,
- 06:19and then Eric's going to talk
- 06:22not just about Tele health,
- 06:24but kind of digital health care in
- 06:27general and how that's being brought into
- 06:30the Yale Psychiatry resident training
- 06:33program and other training programs.
- 06:36So I'm going to.
- 06:39Hop into the part about the clinical
- 06:41resource hub just for the sake of time
- 06:43'cause they're going to follow up on this.
- 06:45It's based on this.
- 06:47Kinda fact,
- 06:48an observation that there often is
- 06:51a mismatch between where patients
- 06:53live and health care providers live.
- 06:57And that this drives disparities
- 07:00often and drives differences in
- 07:03health care outcomes and.
- 07:05Anne.
- 07:06VA,
- 07:06Connecticut in general has really
- 07:08been a leader in virtual care
- 07:11long before the COVID-19 pandemic,
- 07:13with services like the national
- 07:15telemental health care center,
- 07:17but also even within our own system.
- 07:19And This is why I was selected as a
- 07:22site for the clinical resource up,
- 07:25and so this is now a new service
- 07:28line at VA connect Connecticut and
- 07:30it focuses on underserved facilities,
- 07:33which I'll describe later.
- 07:36It is a great resource for bringing say,
- 07:40experts of VA, Connecticut and
- 07:42Yale to patients nationwide but
- 07:44mostly in New England right now.
- 07:46But really extending the reach.
- 07:50Of our great resources,
- 07:51kind of across the map, and it's also
- 07:54really via Connecticut in general,
- 07:56'cause a lot of Eric's work is a
- 07:59great place for Tele health training,
- 08:02but also for scholarship and research.
- 08:04I want to.
- 08:05Add that key point in,
- 08:07because without that this service line.
- 08:09But also I think everything that
- 08:11we're going to talk about today
- 08:14wouldn't have happened without the
- 08:16environment of VA Connecticut.
- 08:18So VA, Connecticut really has
- 08:20been a leader and virtual care for
- 08:23years on the left side I showed
- 08:26just two examples of virtual care,
- 08:29so related to video Tele health,
- 08:31one is video into a clinic,
- 08:34which I think is what kind of the norm?
- 08:39And the past and then the
- 08:41little iPhone below it indicates
- 08:42really video into the home,
- 08:45which I think people would
- 08:46become more familiar with,
- 08:48either through zoom or or teams
- 08:51or other kind of modalities and.
- 08:54Andy 8 Connecticut's been
- 08:56using these for some time now,
- 08:58but really doing a lot more than that.
- 09:01Our mental health service line has been
- 09:04covering see box so clinics across the state.
- 09:07You know,
- 09:08for probably close to a decade,
- 09:10the National Telemental Health
- 09:11Center Project Echo,
- 09:12which I forgot to mention elenita
- 09:14things in our Department has
- 09:16been using virtual modalities to
- 09:17and a lot of other folks.
- 09:19A VA kinetic at the train.
- 09:21Other staff at other facilities,
- 09:23and kind of more specialized
- 09:24mental health care.
- 09:25And there's been great research,
- 09:27and trainees.
- 09:28Fba, Connecticut been brought into this?
- 09:30On the right is a map of the New
- 09:33England VA clinical resource hub.
- 09:36This is based FDA Connecticut,
- 09:37so this is our service line and
- 09:40some of the locations it covers.
- 09:42You can see it kind of radiates North.
- 09:45Most of this is mental health care,
- 09:48but there's also primary care
- 09:50and some new specialty medical
- 09:51services that we've been building.
- 09:56To take a step back before
- 09:57going into some of the details,
- 09:59I think this is part of the.
- 10:00Philosophy and. And I want to switch
- 10:04gears from health care and talk a
- 10:07little bit about electrical grids.
- 10:09There's I think a lot of folks
- 10:11want to think about how to make
- 10:14our electrical systems greener.
- 10:16But there's an.
- 10:18But there's also this increased,
- 10:20focused on resilience,
- 10:21and this is what the clinical
- 10:23resource hub program,
- 10:25the philosophy that this comes out of,
- 10:28and so that I pulled this from a
- 10:31UCLA site on smart grids talking
- 10:34about battery storage and how it can
- 10:38load balance or smooth out blips in.
- 10:42Peak load and when energy is needed
- 10:44and help re distribute electricity
- 10:46and it's a way of kind of bringing
- 10:50in resources from across the grid.
- 10:53An clinical resource hub.
- 10:54These Tele health hubs that we work
- 10:58in are examples of that because
- 11:00what they can do is they can have
- 11:03pools of experts or providers at
- 11:06different sites that as new need
- 11:08pops up they can fill in those gaps.
- 11:12Likewise, there are also a way that.
- 11:17If sites maybe have excess resources,
- 11:21if workload drops even folks can
- 11:24be redirected to other sites that
- 11:28maybe need care and support and
- 11:32this comes out of one of the PHRO.
- 11:35Principles so you know resilience
- 11:37is trying to build a network
- 11:40that's resilient and so.
- 11:42Looking at on the left,
- 11:44this is the national electric grid.
- 11:48Also including Canada for the United States,
- 11:50you can see it's kind of A.
- 11:54Have a patchwork of interconnected smaller
- 11:56grids and and on the right is a map of
- 12:00all the clinical resource hubs in the VA,
- 12:02and there's 18 of them 'cause the BA is
- 12:05broken up into eight regions called Visions,
- 12:08and we're visiting one in New England.
- 12:11And what you can see is out of each
- 12:14of these hubs is our spokes that are
- 12:17reaching out to other smaller facilities.
- 12:20You can see out West there's
- 12:22a big one in Salt Lake,
- 12:25'cause there's really a huge shortage of
- 12:27providers through the mountain region Ann.
- 12:30Ann and you look up in New England.
- 12:33You can actually see our small hub reaching
- 12:36into the northern parts of New England,
- 12:39and so the philosophy and the idea is
- 12:42that as opposed to an electrical grid,
- 12:45you have these hubs that can smooth
- 12:47out blips in demand for services.
- 12:50Or if a site loses a provider,
- 12:53these hubs can fill in so that
- 12:56there's not a gap in care.
- 12:59An because of this,
- 13:01so you can imagine there's
- 13:03a lot of demand for this.
- 13:05Mini was talking about at the introduction
- 13:08was was that the what was kind of
- 13:11originally the Telemental Health hub,
- 13:13but is now the clinical resource.
- 13:15Hub has rapidly grown in size,
- 13:18so starting with a.
- 13:21Six staff in the beginning of 2017
- 13:24to now for next year and approved
- 13:28staff of nearly 100 providers and and
- 13:32administrative staff on the right.
- 13:35I have a table kind of showing also
- 13:39how the services of diversified.
- 13:42So we started as a mental health hub.
- 13:46We added primary care last year
- 13:48and then this year we're making a
- 13:51large expansion and support staff,
- 13:53scheduling staff, technical staff and
- 13:55then specialty medicine and surgery.
- 13:58At the bottom we mentioned the
- 14:00contact center, so integrating.
- 14:04El IPS, especially APR,
- 14:06ends into the call centers,
- 14:08so if there's urgent questions.
- 14:12And then even human resources
- 14:14staff to help with the hiring.
- 14:16And if you see it's a really
- 14:19diverse group of specialties,
- 14:21and it's because that our
- 14:23health systems really if if.
- 14:25The different specialties
- 14:26are really interconnected.
- 14:28So for example,
- 14:29we're starting to do some work and
- 14:31nephrology out in Oklahoma and one
- 14:34of the things we learned is once
- 14:37they lost their dinner ologist it
- 14:39put their ICU's at risk because.
- 14:42You need to have ability to have
- 14:45renal evaluation to have an ICU,
- 14:48and so these really kind of adding
- 14:50these specialty services actually really
- 14:52important for the health of larger networks.
- 14:55I'm a mental health provider, but.
- 14:59You can see why they're
- 15:01expanding so quickly in Arvier,
- 15:04and So what is driving this
- 15:07one is clinical need.
- 15:09The VM and kind of put a map
- 15:12up soon covers a large area,
- 15:15and many of these are underserved
- 15:17and so that we know there are huge
- 15:20needs to get services out to veterans.
- 15:24Also, I'm going to talk a little
- 15:26bit more about this.
- 15:28Veterans are more likely
- 15:30to live in rural areas,
- 15:32and there are a some practical
- 15:34issues around driving or distance
- 15:36that Tele Health is really valuable.
- 15:38But also these communities
- 15:40often have fewer resources,
- 15:41decreased access, and worse,
- 15:43worse health outcomes in general.
- 15:46And then I'm going to touch on this
- 15:48kind of interesting thing about
- 15:50some of the finances in the A that.
- 15:53When when the VA can't provide a service,
- 15:57we actually have to pay other
- 15:59health systems to provide it,
- 16:01and this is actually a.
- 16:05Actually a big issue in terms of
- 16:07why resource hubs are important.
- 16:10So to talk about that,
- 16:12I'm just going to do this really quickly,
- 16:14so there was something called the
- 16:16Mission Act in 2018 and I made one circle.
- 16:19So the key component of this was that.
- 16:23If a patient needs care and
- 16:26the VA can't provide it.
- 16:30In a timely fashion,
- 16:31which was defined as either a
- 16:3430 years or so 20 or 28 days.
- 16:37So if there's a mental health
- 16:39console and the VA can provide
- 16:42that console in 20 days,
- 16:44then or have a provider see
- 16:46that veteran in 20 days,
- 16:48then they have to be referred
- 16:51to the community.
- 16:53And or if they veteran draw have
- 16:55to drive more than 30 minutes for
- 16:58specialty care, it's a little different.
- 17:0028 days and 60 minutes.
- 17:02And this is this is a, you know,
- 17:05a great law,
- 17:06and this is really well intentioned.
- 17:07But what it does is it.
- 17:10Set up a system where the VA
- 17:12has to pay for health care,
- 17:14but then also it loses the patient
- 17:16and doesn't get reimbursement for it.
- 17:19So in some ways the VA ends up
- 17:21paying twice reviews and so it
- 17:24puts pressure on the VA too.
- 17:28Be able to expand its reach through virtual
- 17:32care so that it can provide services to
- 17:36veterans who live more than 30 minutes
- 17:40away or more than 60 minutes away.
- 17:43An when you look at the Maps,
- 17:46this is a map of all the
- 17:48facilities where the VA is.
- 17:50It has this huge reach,
- 17:52but what we know is that especially in
- 17:54rural areas the distances are really large.
- 17:57The odds of living within 30 minutes
- 18:00of a clinic is almost near 0.
- 18:02This is especially true when nearly 1/3
- 18:05of all veterans live in rural zip codes.
- 18:09So we have these hundreds of facilities,
- 18:11thousands of facilities but
- 18:13but just by probability,
- 18:14there's a good chance that folks don't live
- 18:16within close proximity of their clinic,
- 18:19so it sets up this really
- 18:21tough economic situation,
- 18:22and veterans are more likely
- 18:23to live in rural sites,
- 18:25and so is that some of the financial
- 18:28reason why the resource hubs have grown.
- 18:30I'm going to talk a little bit about
- 18:33the clinical demand and some of
- 18:35the actually the outcomes related,
- 18:37especially to the rural gaps, but geographic.
- 18:40Things in general next.
- 18:42So this slide.
- 18:44Kind of talks about morality and I
- 18:47bring it up because veterans are twice
- 18:50as likely to live in a rural zip.
- 18:54Code is non veterans,
- 18:55so nearly 1/3 of veterans are in rural
- 18:58zip codes an and what were reality?
- 19:01Does?
- 19:01There's a lot of evidence of this now,
- 19:04is it?
- 19:05Kind of exaggerates healthcare
- 19:07disparities and and so this is one
- 19:10side is nice paper that was in the
- 19:13American Journal Public Health.
- 19:15Just looking at all cause
- 19:17mortality for adults.
- 19:18I think it was 25 to 65 year olds an.
- 19:23And if you look at the gap.
- 19:27And so they break counties up by.
- 19:33Poverty level and morality and what
- 19:36you can see, is this widening gap.
- 19:39So rural high poverty
- 19:42counties are the Orange line.
- 19:44The solid Orange Line,
- 19:46an overtime.
- 19:47So since the 1970s there's been this.
- 19:52Separation from other high poverty counties,
- 19:56but especially low poverty counties.
- 20:00Between the rural and the urban high poverty,
- 20:04so the solid blue and the solid orange.
- 20:07You can see this gap widening where they
- 20:10actually had similar health outcomes.
- 20:13Maybe 25 years ago.
- 20:15There's been this separation.
- 20:21Morality also exacerbates.
- 20:25Racial disparities or differences now come
- 20:28in, so this is actually a different paper,
- 20:32but it's also really important this paper
- 20:36came out this year looking at mortality.
- 20:40All cause mortality in older adults,
- 20:43though over the age of 65 an what this
- 20:47is graphing here is the difference
- 20:50between rural and urban mortality rates.
- 20:54And then it stratifies.
- 20:56By race and gender, breaking it up,
- 20:59either white or black,
- 21:01which is obviously an oversimplification,
- 21:03but. This is where they had the greatest
- 21:07data over the longest period of time.
- 21:10And. And what you can see is
- 21:14especially for black men,
- 21:17overtime living in a rural zip code
- 21:21dramatically increased the mortality rate of.
- 21:24Especially men living black men
- 21:27living in the zip codes relative.
- 21:322 White males but also to other groups
- 21:35in that zip code and and it really
- 21:39was was the reality that they found
- 21:42that kind of exacerbated these kind
- 21:45of already differences in outcomes.
- 21:48In these these disparities that
- 21:50are in every zip code.
- 21:52But morality really worsened it.
- 21:58Kind of bringing it back
- 22:00more towards mental health.
- 22:02This is a map of suicide
- 22:05risk or suicide rate.
- 22:06There's a recent paper looking
- 22:10at this in JAMA at mapping out.
- 22:15Kind of a normalized suicide
- 22:18risk kind of accounting for age
- 22:22and some other covariates and.
- 22:25You don't have to really be an
- 22:28expert at geography to look at the
- 22:30map on the left until the really so
- 22:33red is worse that high virality,
- 22:36but also high poverty areas are the
- 22:38areas that have the highest suicide rates.
- 22:42In America and on the right.
- 22:43This is from the same paper.
- 22:47When they they,
- 22:48when they were looking at other covariates,
- 22:51they found, not surprisingly,
- 22:53that poverty or they made a
- 22:55deprivation index that took into
- 22:57other things besides poverty,
- 22:59including education and employment rates.
- 23:01But the what they found is looking
- 23:04at high poverty areas that there
- 23:07is this widening gap.
- 23:09So the top one,
- 23:11the Green Line is rural suicide risk.
- 23:15The rural areas and rural high poverty
- 23:19areas really have been accelerating.
- 23:23This accelerating suicide risk relative to
- 23:26other zip codes that are also high poverty.
- 23:31Kind of either small cities, large cities.
- 23:37And.
- 23:39And then this really kind
- 23:41of is reflected in this map.
- 23:43So this map on the left really look
- 23:45different a decade ago, actually.
- 23:48And finally,
- 23:49kind of again looping it
- 23:51into mental health this.
- 23:53Everyone is very familiar even
- 23:55though it does seem very distant
- 23:57the the opioid over those crisis.
- 24:00That was really most recently
- 24:01driven by synthetic opioids.
- 24:05That
- 24:08Initially really hit rural zip code,
- 24:10but then. Really became much worse
- 24:14and urban zip codes, especially with.
- 24:18Kind of like instead of
- 24:20fentanyl and its derivatives.
- 24:22But one thing to remember in this isn't
- 24:25really just a rural non rural question,
- 24:27but it's an example of how geography
- 24:30can play a role when you map out sites.
- 24:34That have providers or towns or counties
- 24:37that have providers that are X Waivered
- 24:40so they can provide buprenorphine
- 24:42which is really the treatment of
- 24:44choice for opiate use disorder.
- 24:46You can see that nearly half of the
- 24:49map does not have a buprenorphine at
- 24:52least One X waiver provider in it and
- 24:55this is overwhelmingly in rural areas.
- 24:58But even in Non Rural counties and.
- 25:01Even in the counties that do have providers,
- 25:04they often only have a few,
- 25:06and so this is really a big
- 25:08geographic question,
- 25:09and so this kind of is so.
- 25:12This is some of the evidence for why
- 25:14using resource hubs to overcome these
- 25:16geographic barriers is important,
- 25:18and so I'm going to briefly go over.
- 25:22Kind of what we've done looking
- 25:24at one of these problems.
- 25:26So there is a particular interest in.
- 25:30The opioid crisis in New England.
- 25:34In our hub,
- 25:35'cause of the strengths of the
- 25:37addiction programs at Yale and
- 25:39kind of bringing up this idea of a
- 25:42smart grid or an electrical grid?
- 25:44And the need for resilience,
- 25:46really treatments rokkes disorder
- 25:47aren't just outpatient care.
- 25:49They're not just specialized
- 25:50addiction programs or not just
- 25:52residential or opiate otps.
- 25:53They're really a network of facilities
- 25:56and providers that provide care an.
- 25:59And so.
- 25:59When there's a problem in one of these steps,
- 26:04or one of these clinics,
- 26:06or these programs,
- 26:07it can ripple through the network,
- 26:10and because of our strengths at VA,
- 26:13Connecticut,
- 26:13and Yale,
- 26:14when one of our first priorities
- 26:17in the clinical resource hub
- 26:19was to really look at access.
- 26:21Two treatments for opiate use disorder,
- 26:24and so we kind of tapped in to
- 26:28the strengths and VA kinetic
- 26:30at having one of the maybe,
- 26:33I think the largest addictions training
- 26:35program having a lot of experts,
- 26:38an implementation of buprenorphine and
- 26:41treatments for opiate use disorder.
- 26:44And the goal was to really kind
- 26:46of tackle these gaps in access to
- 26:49buprenorphine and rural communities,
- 26:51and so on the right.
- 26:53This is out of a paper.
- 26:58That came out last year.
- 27:00That was really nice and they
- 27:02looked at the stratified counties
- 27:04by access to treatment and also
- 27:07overdose rates and so yellow and red.
- 27:10That means there's high overdose rates in
- 27:13that County and almost all of New England.
- 27:16And we kind of notice already has
- 27:19high overdose rates from opioids,
- 27:22especially synthetic opioids.
- 27:23Ann and then kind of red versus yellow is
- 27:27whether or not there's access so high.
- 27:32So so the Red County the counties that
- 27:35have low access to buprenorphine. Anne.
- 27:38And so kind of what we were looking at is
- 27:41how can we use our clinical resource hub
- 27:44to get buprenorphine to these counties that
- 27:47also they have high overdose rates but
- 27:50they have very low access to buprenorphine.
- 27:53And so this is where I think kind of
- 27:57tapping into the strength that Yale and BA,
- 28:00Connecticut, in general in
- 28:03addictions was was really great.
- 28:06There is this recognition,
- 28:07so Tele Health is just part of the answer.
- 28:11To overcome these,
- 28:12geographic barriers are really
- 28:14complicated questions and and there
- 28:16are a lot of folks in different
- 28:18specialties looking at this and So what
- 28:21ended up happening over the course
- 28:23of about a year too was there was
- 28:25development of something called conduit.
- 28:28The consortium to disseminate and
- 28:32understand the implementation of
- 28:34treatment of opiate use disorder
- 28:37and it's a multi site implementation
- 28:41facilitation effort to get to
- 28:43improve access and also evaluate and
- 28:47study treatments of.
- 28:50For Opies disorder, specifically,
- 28:52trying to get buprenorphine and
- 28:54other medications rope use disorder.
- 28:57Kind of through different types of specialty,
- 29:00so Tele health was one of 'em and
- 29:03our site was the site for Tele health
- 29:07but also hospital inpatient medicine,
- 29:11emergency Department, specialty medical care,
- 29:13primary care, pain care, and so Mark rosin.
- 29:19Who's in our Department is directs
- 29:22addiction program at VA Connecticut.
- 29:24I have reached out and had this idea of
- 29:28doing this project and at put well, Becker,
- 29:31who's in the addiction medicine program here.
- 29:33Via connected,
- 29:34he's actually in the primary care arm of this
- 29:38and is the is the main P for the project.
- 29:41And So what was great is this kind of
- 29:44brought all this academic expertise to.
- 29:47What kind of wedding with
- 29:48something within our own resource?
- 29:50How we wanted to do?
- 29:52And so, So what we did was we use
- 29:56this framework called step care.
- 30:00Air.
- 30:02That via has been trying is in
- 30:05the middle of implementing.
- 30:07The idea is that the bulk of patients
- 30:11getting treatment for opioid use
- 30:13disorder fall under step one that
- 30:16they can happen in primary care
- 30:18or general mental health clinics,
- 30:21and that it doesn't need special
- 30:24subspecialty or specialty care to
- 30:27effectively treat these patients and so we.
- 30:31Our project or our task was to
- 30:33try to develop methodologies for
- 30:35providing buprenorphine.
- 30:36The small rural clinics in northern
- 30:39Maine within the resource hub and then
- 30:42working with Mark and his research
- 30:44team and the research team Zavier,
- 30:46Connecticut.
- 30:47We were going to try to evaluate
- 30:50this and then.
- 30:52Optimize it and working within
- 30:55these small rural clinics.
- 30:57An we used a an implementation
- 31:00facilitation framework to get
- 31:01buprenorphine out to these clinics
- 31:03and we developed a lot of tools,
- 31:06audit and feedback.
- 31:07Staff education community practice.
- 31:08A lot of the things we're not I'd
- 31:11say are not novel in some ways.
- 31:14We found facilitators that really
- 31:16enthusiasm and sense of emission
- 31:18because when this started this
- 31:20was really at the peak
- 31:22of the opioid crisis or what we
- 31:24thought was maybe the the peak even
- 31:27though it looks like it wasn't.
- 31:29And we had really great infrastructure
- 31:31in the VA for Tele Health.
- 31:34And then there were some barriers,
- 31:36questions about regulations and
- 31:38how you work in different teams.
- 31:40So maybe the providers at Connecticut
- 31:43prescribed one way and then there
- 31:46is different on the other side.
- 31:48And so we were really kind of trying to
- 31:51get it out there to these rural clinics
- 31:54and then this was starting in October of.
- 31:572019 and you know the project was starting
- 32:00to take off and we were doing all this
- 32:04work and then something else happened.
- 32:07There was this.
- 32:10Crisis around.
- 32:13Opioid use disorder and
- 32:15synthetic opioids in particular,
- 32:17kind of got overwhelmed and our
- 32:21healthcare systems got overwhelmed by.
- 32:24That COVID-19 Pandemic and so we had
- 32:26put all this work into developing
- 32:30methodologies and getting providers
- 32:32up and running and rural sites.
- 32:35And then what happened this spring
- 32:39and everyone is really familiar with.
- 32:43Non rural sites were particularly
- 32:45hard hit by Covid.
- 32:47This is April and May and so on the
- 32:50right there's a map from the CDC of
- 32:53mortality rates in New England from
- 32:56Kobid 19 this spring and what you can
- 32:59see is it was obviously southern Connecticut,
- 33:02but also Southern New Hampshire,
- 33:04eastern Massachusetts,
- 33:05so these are all the areas we
- 33:09were not focusing on.
- 33:11In our conduit project
- 33:13or in our resource hub,
- 33:15these were areas that had existing addiction
- 33:20programs and what happened was that.
- 33:24This,
- 33:24like pressure on the system actually
- 33:26resulted in staff attrition,
- 33:28and so buprenorphine providers
- 33:30left urban areas.
- 33:31The addiction programs lossed their addiction
- 33:34psychiatrist residential programs that,
- 33:35and so it shifted the focus of
- 33:38our resource hub in our project
- 33:41and so kind of going back to this
- 33:44idea of supporting the grid.
- 33:47The resource hub is shifted actually
- 33:49out of rural areas to supporting.
- 33:52Specialized addiction programs
- 33:54and New Hampshire Ann residential
- 33:58programs in Massachusetts because.
- 34:01Did you know these are integral parts too?
- 34:06Kind of the health of the addiction
- 34:08network in general on the VA and
- 34:10so so I'm going to wrap up now.
- 34:12I think I'll move on as quickly
- 34:14as possible for the sake of time,
- 34:16I think just in summary.
- 34:20Yeah,
- 34:20our resource hub tries to overcome
- 34:23mismatches and.
- 34:24And where people live and where
- 34:26providers live,
- 34:27and I think it's increasingly
- 34:29becoming a great place for scholarship
- 34:32in Tele Health and training.
- 34:34And Jennifer and Erica had talk
- 34:36a bit about that coming up next.
- 34:39And I'm going to stop sharing an
- 34:42give them control at this point.
- 34:48Just so Jennifer, are you.
- 34:52It should pop up and
- 34:54Justice seconds. OK, great.
- 34:59Are you able to see my slides?
- 35:03Yes, I see as many nodding OK perfect,
- 35:05so I'm going to talk a little bit
- 35:08about how we train our mental health
- 35:10workforce to do this work and to
- 35:13provide really high quality clinical
- 35:14care over a Tele health modality.
- 35:20Slides are being OK. Here we go.
- 35:23So at the VA we use sort of a tiered
- 35:25training model in terms of helping get
- 35:29our mental health team up to speed.
- 35:31The first piece of that is didactic training.
- 35:34The second piece is systems
- 35:36in logistics training.
- 35:37Sort of the how to and the third piece
- 35:39is really focused on clinical training
- 35:42and clinical practice issues that
- 35:44occur when you're working in this way.
- 35:48In terms of didactic training,
- 35:50our hospital education system
- 35:51handles most of this.
- 35:53We have a virtual training platform
- 35:55called TMS and these trainings you can do
- 35:58independently and they really focus on
- 36:00sort of an overview of what Tele Health is,
- 36:03how it operates in the VA system,
- 36:05and different roles and responsibilities and
- 36:08terminology that's associated with that.
- 36:09So for example,
- 36:10when we provide clinical video technology
- 36:12into clinics into our seebach clinics,
- 36:15there is a technician on the other side
- 36:18who will sort of do the meet greet.
- 36:21And set up the technology piece so
- 36:23it will teach you things like that.
- 36:26The second piece is systems
- 36:29and logistical training,
- 36:30so the office of connected care at the
- 36:32VA has a number of Lighvan recorded
- 36:36trainings SharePoint resources.
- 36:37They hold office hours for additional
- 36:39help in terms of learning the different
- 36:42platforms and systems that we have
- 36:45at the VA to deliver Tele medicine,
- 36:48separate systems for again clinical
- 36:50video technology,
- 36:51CBT to our clinics and also we use
- 36:53a platform called video connect that
- 36:56allows us to provide services directly into.
- 37:00Veterans homes in the New England
- 37:01region that we work in very important
- 37:04has really helped us increased care.
- 37:06Obviously during Covid That's a given,
- 37:08but also previously we would lose
- 37:10a lot of clinic encounters in the
- 37:12winter months when folks were unable
- 37:15to drive to the clinics.
- 37:16Lots and lots of snow and whether
- 37:19that would prevent people from
- 37:21getting to the sea box.
- 37:22So expanding into the home
- 37:24services has really sort of helped
- 37:26address issues associated with
- 37:27things like whether an again,
- 37:29the current situation that we're in.
- 37:42An in clinically smart ways?
- 37:44How do you adapt your interventions
- 37:47and how do you do what we do over this
- 37:51modality in ways that are ethical,
- 37:53an appropriate so within the hub we
- 37:56developed in in response to COVID-19,
- 37:58actually a clinical resource hub
- 38:00training team consists of three
- 38:02psychologists an we've been offering.
- 38:04Sort of within the VA system to
- 38:07other providers who this was knew
- 38:09too and also sort of out in the
- 38:11community to other healthcare systems
- 38:13when we've been invited to do so,
- 38:16we've offered a 2 hour virtual
- 38:17training on the clinical principles
- 38:19associated with Telemental Health
- 38:21and different considerations and
- 38:23things to think about so that the
- 38:25clinical care pieces is sort of solid.
- 38:29What that consists of and this is a
- 38:31little bit medic 'cause I'm talking
- 38:33about how we how we train in something
- 38:36rather than actually giving the training,
- 38:38but just a few bullet points we go over
- 38:41kind of the history of Tele Health.
- 38:44Recently we've been talking about
- 38:46how kovid has changed the practice
- 38:48landscape in the way that we are sort
- 38:50of approaching our work in general,
- 38:52which is important.
- 38:53We review advantages and disadvantages
- 38:55of using Tele health,
- 38:56kind of big picture and also in
- 38:59individual cases we go over.
- 39:00Assessment considerations and adaptations.
- 39:02So for example,
- 39:03when you need to do a physical exam
- 39:05looking at physical characteristics,
- 39:07things like the aims and the cows,
- 39:09there are actually sort of tips
- 39:11and techniques for how to do these
- 39:14exams in the most comparable way,
- 39:16so that you're still getting the
- 39:18information over Tele health that
- 39:20you would otherwise be able to
- 39:22get in a face to face.
- 39:24Situation we go over clinical
- 39:26considerations and how to adapt your
- 39:29work depending on if you're doing
- 39:31individual or group Tele health.
- 39:33Also services like primary care,
- 39:35mental health integration,
- 39:36and when you're kind of using
- 39:38this for special populations.
- 39:40We also talk about measurement based care,
- 39:43an options for doing that in a virtual way.
- 39:47Risk management is probably one of the
- 39:50most important things that we talk about
- 39:52and in terms of a clinical perspective,
- 39:54it is different over Tele Health.
- 39:56I'll say just a little bit more
- 39:58about that in a few minutes, but.
- 40:00That's sort of a critical piece.
- 40:03Challenges that occur.
- 40:04We go over the evidence base in the
- 40:07research literature also provides
- 40:08sort of a wealth of resources in
- 40:11terms of what adjunctive treatment.
- 40:13So things like AA and na are available
- 40:16in a virtual way at this time.
- 40:19So I saw there was a question in
- 40:21the chat about phone care and that
- 40:24is certainly something that we
- 40:26do thinking Thoughtfully about.
- 40:28The differences between video
- 40:30and phone is important,
- 40:31and having sort of policies and
- 40:33procedures around when one, uh?
- 40:35Action may be more or less appropriate
- 40:37is really important on something
- 40:39that we're constantly sort of.
- 40:41Working on an revising,
- 40:43but talking about the different
- 40:45modalities and what works well,
- 40:47when, where and with who is
- 40:49another really important piece.
- 40:50And finally we use case examples to kind
- 40:53of practice that clinical decision making.
- 40:57So it's a little bit about
- 40:59the training that we do.
- 41:01Some of the clinical considerations that
- 41:03we talk about decision making is really
- 41:06important when is face to face care needed?
- 41:09When is it not?
- 41:10When is Tele health?
- 41:12You know an appropriate or adequate option.
- 41:14Things to think about in terms of
- 41:17patient behavior, logistical challenges,
- 41:19certain diagnosis,
- 41:20or other patient characteristics that may
- 41:23play a role in how well Tele health works?
- 41:25Or doesn't we talk a lot about
- 41:28therapeutic environment?
- 41:29And this goes for us as providers
- 41:31as well As for our patients.
- 41:33How do we create a space that is
- 41:35conducive to mental health appointments,
- 41:37especially when we may be working
- 41:39in a different setting or working
- 41:41from home privacy and security
- 41:43issues around all of this.
- 41:44With virtual care,
- 41:46setting a frame for treatment and
- 41:49kind of having clear expectations and
- 41:52boundaries around the work is arguably
- 41:55even more important than in the clinic.
- 41:59Talk about sort of the different
- 42:01considerations and how to do that.
- 42:03Informed consent for Tele Health
- 42:04is not only a good idea clinically,
- 42:07but is actually required in
- 42:08the state of Connecticut.
- 42:10You have to get it and documented that
- 42:12patient is aware of the benefits and risks
- 42:15of Telemental Health and is OK with that.
- 42:18As an option.
- 42:19We also talk about report and
- 42:20working alliance concerns.
- 42:22Things like eye contact in how
- 42:24to ensure that your patients feel
- 42:26like you're looking at them when.
- 42:28When you may not be in,
- 42:30depending on where this session is framed.
- 42:35So just briefly,
- 42:35I'm not going into any of this in detail,
- 42:38but in terms of decision-making
- 42:40things to think about, you know?
- 42:42How is Tele health helpful or
- 42:43a hindrance for a particular
- 42:45patient that you're working with?
- 42:47What problems does it create?
- 42:48What problems does it solve?
- 42:50What role does it play in your
- 42:52treatment goals and what you and the
- 42:54patient and are hoping to work on?
- 42:56Of course, technology and
- 42:57connectivity is a big part of that,
- 42:59and again, is the environment
- 43:01appropriate for you to do the work?
- 43:03That you need to do.
- 43:06Just I'm not going to
- 43:08talk about this in detail,
- 43:09but there are absolutely considerations
- 43:11relevant to COVID-19 in the situation
- 43:14that we're all in and also sort
- 43:16of important to think through and
- 43:18talk about these just real quickly.
- 43:20Exposure in isolation when you're
- 43:22working with folks you know,
- 43:23Tele Health is great and certainly
- 43:25solves a lot of challenges, but.
- 43:27At times can also be used to
- 43:29sort of collude with things like
- 43:31avoidance and agorophobia not
- 43:33kind of getting out into the world
- 43:36and having appropriate exposures.
- 43:37Something to be mindful of and
- 43:39also self disclosure is different
- 43:41during this time.
- 43:42One quick example,
- 43:43just the fact that you work at home
- 43:46so I like to say if you happen to
- 43:49have a dog or a baby or you know
- 43:51other things in your house despite
- 43:53all of your best efforts to minimize that,
- 43:56you may end up disclosing things
- 43:58to your patients that.
- 44:00You wouldn't otherwise want them
- 44:01to know about. So risk management.
- 44:05Again,
- 44:05I'm going into all of this in
- 44:07sort of very brief overview.
- 44:09We have much more to say about this
- 44:11and other trainings that we do,
- 44:13but it's really important to have
- 44:15an emergency plan anytime that
- 44:17you're doing Tele health,
- 44:18even if that's into the home right?
- 44:20You need to have an emergency plan
- 44:22ahead of time with your patient,
- 44:25and you always want to make sure
- 44:26you have certain information,
- 44:28their location, their address,
- 44:29where they are.
- 44:30If they're not in their home,
- 44:32down to the level of.
- 44:34If patient is,
- 44:35for example,
- 44:36a truck driver and calls you from the
- 44:38side of the road in between work shifts,
- 44:41the closest exit their car,
- 44:42make model and license plate.
- 44:44So were an emergency to happen.
- 44:46You have everything you need to
- 44:48get emergency personnel to them.
- 44:52In our hub we don't require
- 44:54that our providers use this.
- 44:56Most of them do.
- 44:57We actually have an into the home
- 44:59contract that very clearly lays
- 45:01out guidelines and expectations
- 45:03for receiving care into the home.
- 45:05Another benefit of this is it's
- 45:07a place to kind of collect and
- 45:09store emergency information.
- 45:11So for example,
- 45:12I always know the closest Police
- 45:14Department in emergency room
- 45:15to a patients home when I'm
- 45:17working with them into the house.
- 45:22Again, I there was a question
- 45:24about this in the chat earlier.
- 45:26The modality that you used to do
- 45:29Tele health really does matter.
- 45:31The gold standard at the at the
- 45:33VA is clinical video technology.
- 45:35We should be doing video visits with
- 45:38our patients whenever we're able to.
- 45:40It's the closest approximation to
- 45:41what we would do in the clinic.
- 45:44It's not perfect.
- 45:45Depends on Wi-Fi connectivity.
- 45:47There is a higher potential for
- 45:49tech difficulties and frustrations.
- 45:51That can be really distracting.
- 45:52Telephone is great in the sense that
- 45:54it's widely available and accessible.
- 45:56Just about everyone has a telephone.
- 45:58You don't have to worry about
- 46:00some of those tech glitches.
- 46:02However,
- 46:03you lose a lot of clinical information
- 46:05on verbal cues can be harder to kind of,
- 46:08develop a rapport with someone,
- 46:09and there are absolutely
- 46:11important arguments for eyes on
- 46:13assessment in the work that we do.
- 46:15Important to be flexible,
- 46:16but also important to be clinically
- 46:18thoughtful about when different
- 46:19approaches may be appropriate or not.
- 46:21With the folks that you were working with,
- 46:23and this is something that we really
- 46:26kind of go into in detail as well.
- 46:29Another point I wanted to make and
- 46:31I'm just about ready to pass to Eric,
- 46:34But.
- 46:34A lot of the conversation around
- 46:36Tele Health has been well,
- 46:38is it face to face or is it virtual care?
- 46:41And that's not it doesn't have
- 46:43to be the approach.
- 46:45We're sort of advocating for blended care
- 46:47models in the healthcare systems as well.
- 46:49You know,
- 46:50it doesn't have to be all or nothing.
- 46:52Tele health is a really valuable tool
- 46:54that lets us be flexible an we can
- 46:57blend our treatments in different ways.
- 46:59You can, you know,
- 47:00require a face to face assessment,
- 47:02for example an.
- 47:03Then have follow up care that is a mix of.
- 47:06Phone or video with occasional clinic visits,
- 47:09right?
- 47:09There's a lot of options and
- 47:11opportunities to be clinically
- 47:12thoughtful and use these things
- 47:14sort of interchangeably to better
- 47:16to best meet the needs of the
- 47:18healthcare system and the people
- 47:20that we're working with.
- 47:22The VA really does Tele health well.
- 47:27All providers have access to the
- 47:29technology and trainings they need.
- 47:31We have a pretty reliable HIPAA
- 47:33compliant video conferencing
- 47:34platform you can easily do groups
- 47:36you can do live supervision.
- 47:38You can just add a family member
- 47:40or significant other into a
- 47:42session with about two clicks.
- 47:44We have an encrypted email system,
- 47:46so you can transfer files and documents
- 47:48to your patients back and forth.
- 48:02Did she freeze?
- 48:06I think we may have. I mean,
- 48:09see if I can get ahold of Jennifer.
- 48:12Are you guys able to hear me?
- 48:14did I freeze bruise
- 48:15but your back? OK,
- 48:16that's OK, I was just wrapping up.
- 48:19I was just sort of saying the VA does
- 48:21Tele health really well including having
- 48:23a 24/7 24/7 Tech support for our.
- 48:26Patients and providers and just a
- 48:28summary to do this work really well,
- 48:30it's important to have very
- 48:32clear policies and procedures,
- 48:33clear guidelines and expectations,
- 48:35infrastructure and support things like
- 48:38tech support that will allow you to do
- 48:40this work and focus on the clinical issues.
- 48:43And we use this sort of tiered trading
- 48:46model to help our providers get
- 48:48up to speed on all of this stuff.
- 48:51My last slide is just to say
- 48:53keep calm about Tele health.
- 48:54The core of what we do is talking to people,
- 48:57it's listening and it's talking and we can
- 48:59do that over many different modalities.
- 49:00So Tele health helps us be really
- 49:02flexible and doing the kind of work
- 49:04that we do an I will pass to Eric.
- 49:06Who's going to talk about training
- 49:08the next generation, our trainees,
- 49:09and how to do this work.
- 49:19Great thank you everyone,
- 49:21hope everyone can see my slides.
- 49:23So my name is Eric Hermes and I am
- 49:25a psychiatrist and health services
- 49:28researcher out of Villa Connecticut
- 49:30and I'm going to try to compress
- 49:33what I'm talking about here,
- 49:35which is really the training of.
- 49:40Trainees at at Yale in these areas.
- 49:43In what you can see here is this
- 49:45digital health landscape and this
- 49:48is just to say that telepsychiatry
- 49:50or Tele health is just part of
- 49:53this digital health landscape,
- 49:55and we are actually training people
- 49:58at Yale in several areas here.
- 50:00And so let me. Against my slide.
- 50:04And so you may have seen this.
- 50:08Story that came out on Sofia as the
- 50:11first resident trainee in digital
- 50:13health at Yale came out last month.
- 50:16I also want to highlight the work
- 50:19of the Yale Technology Group and so
- 50:21these this is a group of like minded
- 50:25trainees that are interested in kind
- 50:27of in this technology spectrum.
- 50:30And so we're training residents kind of
- 50:32all over this digital health spectrum.
- 50:37Right, and just to kind of highlight the
- 50:40work that Dave and Jennifer are doing at the
- 50:43Tele hub that Ella hub actually serves as
- 50:46a platform for training trainees as well.
- 50:49Clinical psychologists there there are,
- 50:51I think, 3 clinical health psychologist
- 50:54training at the hub right now.
- 50:56And so it really is.
- 50:58Is working as a good training
- 51:00platform and exciting news.
- 51:02This year, they're being able to hire
- 51:05one of their past trainees to actually
- 51:07work at staff, so it's kind of A.
- 51:11A self licking ice cream cone.
- 51:12You might think of it.
- 51:14Great and so just want to focus here
- 51:17for just a few minutes on telepsychiatry
- 51:19training program we have for
- 51:21psychiatry residents via Connecticut.
- 51:24This is a clinic where Yale residents provide
- 51:27general mental health care to VA patients,
- 51:30and this picture here is due to weather's
- 51:33he participated in the program in
- 51:352017 and then subsequently graduated.
- 51:37He works in Manchester,
- 51:39Manchester,
- 51:39NH right now in a lot of his work
- 51:43is intelligent psychiatry.
- 51:46Right, and so these are our current
- 51:48and past PG Y three residents
- 51:49who have worked in the clinic.
- 51:51The program started as an elective and
- 51:54now it's a rotation for a portion of
- 51:57the P GY3 residents that work at the VA.
- 52:00Course I need to comment.
- 52:01These pictures are taken kind of
- 52:03at the beginning of training,
- 52:04so everyone is bright and shiny and
- 52:06has a lot of smiles and our hope
- 52:09is after this training experience
- 52:11they continue to look like this.
- 52:13Great, so our objective.
- 52:14Our objectives really are three.
- 52:16First obviously to get training
- 52:17and telepsychiatry.
- 52:18The second is that this clinic is meant
- 52:20to be an integrated care treatment setting,
- 52:23so it's mental health
- 52:25integrated into primary care.
- 52:26And I'll talk about that real quickly.
- 52:29And then.
- 52:29Third,
- 52:30it's a clinic that reaches out to
- 52:32rural in under resourced settings,
- 52:34and I'll talk about that as well.
- 52:37So first this telepsychiatry.
- 52:38We've already learned a lot
- 52:40about this from Jennifer,
- 52:41and there's certainly a lot of nuance
- 52:44lossed when you move from face to face
- 52:47treatment to treatment over a 2D image,
- 52:49and we do a lot of training up front.
- 52:53The residents here do do the training that
- 52:55that Jennifer was referring to in her talk,
- 52:58but I think this training
- 53:00is really isn't the biggest.
- 53:02It's not the biggest fish in the sea
- 53:04for for our training objectives.
- 53:06Certainly the. Residents know how to do this.
- 53:10Kind of innately now in the
- 53:12patients are learning as well,
- 53:14so it's not the the bulk of the learning.
- 53:17Obviously I think it's important for
- 53:19trainees to be engaged in face to face care,
- 53:22as while they're engaged in telepsychiatry
- 53:24so they can compare the two modalities.
- 53:27And certainly that's the case
- 53:29for our residents in this clinic.
- 53:31Great,
- 53:32so our second objectives is getting
- 53:34the residents training and experience
- 53:36in integrated care operations and I
- 53:38want to start by saying that there
- 53:40are specific criteria to define
- 53:42integrated care and I don't think this
- 53:44clinic meets all of those criteria.
- 53:46For instance, we don't offer warm
- 53:48handoffs or safety assessments,
- 53:50but we do work closely with primary care
- 53:53and specifically we try to make most
- 53:55of the care we do time limited and so
- 53:58that most of our patients go back to.
- 54:01Primary care, so there is a lot of
- 54:04learning on the resident side about how
- 54:06to set expectations for that in how,
- 54:09especially how to understand how we
- 54:11figure out who and when patients are
- 54:13ready to go back to primary care.
- 54:16A second major issue is how you lead
- 54:18a treatment team around these issues.
- 54:21You can see one of the treatment
- 54:23team members here.
- 54:24This is Loretta,
- 54:25who is pictured in the screen here.
- 54:28She's a Tele health technician and
- 54:30we know from Jennifer's talk that.
- 54:32They do a lot of patient contact and
- 54:34management of technology on the patient side.
- 54:37We also have a social work psychotherapist
- 54:39where the residents work and certainly
- 54:42they work with the two primary
- 54:44care providers in the primary care
- 54:45nurses at the clinic as well.
- 54:49And so Lastly,
- 54:50a bit about the uniqueness
- 54:51of the patient population.
- 54:53We see this is where the residency patients
- 54:55at the Winsted community based outpatient
- 54:57clinic and so before covid happened.
- 54:59Patients in this area would go into
- 55:02the clinic and the residents would
- 55:04see them when they're in the clinic,
- 55:06but the residents would be in
- 55:08their offices in West Haven,
- 55:10VA has designated this as
- 55:11a rural facing clinic,
- 55:13meaning that most of the patients
- 55:16who use care in this area.
- 55:18Are in a rural zip code.
- 55:21And as you may know,
- 55:23this area of northwestern
- 55:24Connecticut is very world,
- 55:26as is the surrounding area
- 55:28of New York in western mass.
- 55:30So much different than the
- 55:32patient population.
- 55:32Here in an urban New Haven.
- 55:35And I think for the most part we in our
- 55:38patients we have a bimodal distribution.
- 55:41Many are younger and relatively high,
- 55:43functioning employed patients and
- 55:45then we have a second distribution
- 55:47of older veterans who may be
- 55:49retired or on disability.
- 55:50But what I think sort of draws this
- 55:53patient population together is it
- 55:54has a more tenuous contact to mental
- 55:57health treatment in general compared
- 55:58to patients who might use our larger
- 56:01centers such as Newington or West Dayton.
- 56:05Great.
- 56:06So I want to also highlight real quick.
- 56:09We spend a lot of time discussing the
- 56:12larger context of care within the VA.
- 56:14Care has.
- 56:15V8 has a lot of programs in
- 56:17a lot of treatment.
- 56:18There's a lot of bureaucracy and I
- 56:20think we we try to spend some time
- 56:23explaining the bureaucracy and explaining
- 56:25the services and Tele Health in the
- 56:27Villa is a prime example of that.
- 56:29So we spent some time with
- 56:31residents discussing the most
- 56:32multiple different ways that Tele
- 56:34health programs at the national,
- 56:36regional and local level happen.
- 56:38But of course you know covid
- 56:40really has exploded.
- 56:41All of what we've done and drastically
- 56:43changed the care that we do in
- 56:45this space of about three months,
- 56:47the resident clinic went from
- 56:48something that was sort of novel
- 56:50in really new now to something that
- 56:52all residents at the VA are doing.
- 56:54For instance, we don't see any
- 56:56patients in the Winsted clinic anymore.
- 56:58All the care that we do is exclusively
- 57:00Tele health into the home.
- 57:02And we made this transition in
- 57:03the space of a couple months,
- 57:05and I really want to spend the last minute.
- 57:08Talking about kind of the way forward,
- 57:11I would say our current educational
- 57:13challenge is how do we functionally
- 57:15teach this blended care model?
- 57:17And so someone someone chatted in here?
- 57:20This idea of blended care model
- 57:23and So what that is,
- 57:24is this idea of how we mix the
- 57:27modalities we use with patients.
- 57:29So we spend a lot of time now discussing
- 57:33what modality is best for the patient,
- 57:36whether it's video or telephone and.
- 57:38Especially at what interval we should be,
- 57:41we should be contacting patients
- 57:43and in seeing them or having a
- 57:46key treatment contact with them.
- 57:48Other issues are we have patients who
- 57:50can't manage technology as well and
- 57:51or don't have the technology support.
- 57:53So we talk a lot about how to
- 57:54get them at the support,
- 57:56and there's multiple ways
- 57:58to do that within the VA.
- 58:00And especially for patients who might
- 58:02not want to participate in video,
- 58:04and there are a lot of those,
- 58:05how do we assess those reasons why and how
- 58:07do we push more patients toward videos?
- 58:10So we do talk a lot about that as well.
- 58:13So we do a lot of Tele Health in
- 58:16the home and on this file note,
- 58:19bringing it back to this digital landscape
- 58:21in this continuum as we move forward.
- 58:24Right now we were struggling with
- 58:26this issue of telephone versus video,
- 58:28but as we go forward,
- 58:30we're going to have more complex
- 58:32decisions to make,
- 58:33such as who is appropriate for
- 58:35other forms of digital therapy.
- 58:36Who should we use?
- 58:38Digital sensors on, who should we use?
- 58:40Wearable technology with stuff like that,
- 58:42so that.
- 58:43The I think what we've seen with covid,
- 58:46most recently in this,
- 58:48this real quick transition will
- 58:49have ended up accelerating us
- 58:52into these other decision-making
- 58:53realms in terms of training,
- 58:55so appreciate the time.
- 58:57And now I think we're open for we
- 59:00have some time for a few questions.
- 59:02So thank
- 59:03you. Thanks Eric. Yeah.
- 59:09Are there questions in the last few minutes?
- 59:13Some have been answered on the chat, but.
- 59:20Do you want to stop sharing Eric
- 59:22so we can see cancel OK hand up or?
- 59:39There was one question about how
- 59:41this might be relevant to other
- 59:42settings other than the VA.
- 59:43I don't know if any of you want
- 59:45to just say a word about that.
- 59:51So I guess what when they ask relevant
- 59:55to other settings they mean however.
- 59:58Was it the kind of teliha?
- 01:00:01Training that Jennifer and Eric were doing?
- 01:00:03Or was it more about Tele Health in general?
- 01:00:08Not sure if the person who asked
- 01:00:11the questions still on the call.
- 01:00:13Not sure, yeah, that's mostly,
- 01:00:16I guess house. Apparently
- 01:00:18asking about the digital divide console,
- 01:00:21that service has provided where looks
- 01:00:25like iPad for veterans or patients
- 01:00:28who are unable to access.
- 01:00:33You know, like a camera or
- 01:00:36technology looks like.
- 01:00:37iPads are provided and education
- 01:00:39how to use those iPads.
- 01:00:41I'm wondering if.
- 01:00:44I can speak to that real quick.
- 01:00:46We we at the Winsted Clinic in
- 01:00:49this small training clinic we
- 01:00:51use that I would guess sometimes
- 01:00:53the really what that does is it?
- 01:00:56It alerts our Tele health technician
- 01:00:58that we have a patient that may
- 01:01:01be in need of technology support
- 01:01:03and the Tele health technician can
- 01:01:05then interact with the patient and
- 01:01:08kind of figure out what's needed.
- 01:01:10Sometimes it's technology like
- 01:01:12patients need an iPad.
- 01:01:13Sometimes it's a little bit more
- 01:01:16difficult like they need bandwidth
- 01:01:17or Wi-Fi and stuff like that,
- 01:01:19and so we were able to trouble
- 01:01:22troubleshoot yet of that.
- 01:01:26And the idea of
- 01:01:28providing an iPad to the patient anymore.
- 01:01:33I've done this quite a bit
- 01:01:35now and I think Jennifer
- 01:01:36has also what we are.
- 01:01:39It really has been valuable for
- 01:01:41a lot of folks or the folks
- 01:01:43in the highly rural areas.
- 01:01:44Sometimes it's a struggle
- 01:01:45to get Lt E signal for them,
- 01:01:47but I definitely have a few
- 01:01:49veterans that I work with that.
- 01:01:53Alright, they alternate between the
- 01:01:55library parking lot and McDonald's
- 01:01:57parking lot where there's free.
- 01:01:59Wi-Fi and this works well, you know.
- 01:02:02So they have a VA provided laptop,
- 01:02:06iPad scuse. Me and.
- 01:02:18And also about legal and
- 01:02:20licensure ask aspects and you
- 01:02:21didn't talk much about it.
- 01:02:23I know you know a lot about it.
- 01:02:25I don't know if
- 01:02:27you want to say just
- 01:02:28words about that, so it's very
- 01:02:30complicated outside the VA.
- 01:02:32Kind of the, but with no within
- 01:02:34the VA there we generally need one
- 01:02:36license to go to work in any state
- 01:02:39and it doesn't even have to be in
- 01:02:41the state where you physically work.
- 01:02:46And that works for all the Tele Medicine.
- 01:02:49It gets more complicated
- 01:02:51for controlled substances,
- 01:02:52or he generally default to one state.
- 01:02:57Then there's been uncertainty
- 01:02:59where that is. Covid
- 01:03:02simplified this a lot.
- 01:03:04Most of these regulations were temporarily
- 01:03:07waived for the duration of the.
- 01:03:13Yeah, the pandemic public health crisis.
- 01:03:18And different states have some
- 01:03:20kind of reciprocity agreements,
- 01:03:21specially out West where there's
- 01:03:23a shortage of providers where
- 01:03:25they'll be kinda consortia.
- 01:03:26States where you get one medical license and
- 01:03:29you can use it in the neighboring state,
- 01:03:31but that doesn't apply in doing that.
- 01:03:34I don't think anyone.
- 01:03:36Nobody is really complicated.
- 01:03:40It's kind of a whole
- 01:03:41separate set of lectures. I
- 01:03:44do have some resources specific to
- 01:03:46each discipline on where to find out
- 01:03:48more about the licensure issues and
- 01:03:49how they are changing with kovid.
- 01:03:51So Shelly, if you want to email me
- 01:03:54or if it be helpful to send them out,
- 01:03:56I'd be happy to send them out.
- 01:03:59Broader to focus on the call,
- 01:04:01but I do sort of have a list of
- 01:04:03places by discipline where you can
- 01:04:05sort of get the actual language
- 01:04:07and what's allowable for how long.
- 01:04:09'cause most of the kovid loosening
- 01:04:10of restrictions have end dates.
- 01:04:34I think that maybe all of the
- 01:04:36questions right now.
- 01:04:40I think so, yeah. Thank you guys
- 01:04:44very much and thank you all for your
- 01:04:46attention and it's nice for us to
- 01:04:47be able to present this work so.
- 01:04:51Thanks box, thank you.