Yale Psychiatry Grand Rounds: October 23, 2020

October 23, 2020

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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.