In the Pacific Northwest, a paradigm shift is underway to help veterans access same day mental health care without leaving their home.

Peter Shore, PsyD
peter.shore@mac.com
Department of Veterans Affairs/Oregon Health & Science University

The Department of Veterans Affairs has provided mental health services via telehealth telecommunications technology since 2003.  Referred to as “Telemental Health,” it is a clinic-based visit whereby the provider is usually at a medical center and the veteran is at a VA Community Based Outpatient Clinic (CBOC).  Virtually every disorder and treatment modality has been conducted via telemental health in the VA.  However, many veterans struggle with getting to their nearest CBOC, especially veterans located in VISN 20 (Alaska, Washington, Oregon, and Idaho), the largest geographic area in the United States.

As a staff psychologist at the Portland VA Medical Center in December 2009, I was expected to deliver mental heatlh services via telemental health.  In my first week, several veterans located at a distant clinic indicated how difficult it was to make their appointments.  I was suprised because the purpose of telemental health was to decrease barriers to access.  I began to ask “why aren’t we seeing veterans in the homes?”  Over the next few months (and overcoming significant obstacles), I gained the support of VISN 20 leadership who allowed me to pilot veterans in their homes receiving mental health care via webcam, personal computer and secure/encrypted software (Cisco Telepresence MOVI).

By February 2010, I drafted the practice guidelines for Home-Based Telemental Health (HBTMH) and saw my first veteran.  Continuing to see veterans in their homes via HBTMH, I refined the practice guidelines which subsequently became the Standard Operating Procedure Manual (SOP).  In November 2011, the SOP was approved as VISN 20 policy.  From February 2010 to April 2012, approximately 250 veterans via 800 HBTMH appointments were seen by approximately 10 mental health providers trained at the Portland and Seattle VA Medical Centers.

The pilot had several key features.  I developed a protocol using a Patient Support Person (PSP), a provider whom the veteran would identify to contact in an emergency.  To date, there have been no emergency interventions; many veterans have indicated they draw comfort in knowing that a PSP is available in an emergency.  Another key feature was utilizing a Peer Support Specialist to assist veterans with technical issues on their personal computers.  To date, the Peer Support has logged over 2000 hours.

Many benefits were noted in the pilot, including low no-show appointments 3.1% of total in FY10 and .03% of total in FY11.  Additionally, approximately 80% of all enrolled veterans indicated they would not have received any mental health treatment if it weren’t available in their homes.  Anecdotally, mental health stigma was a non-issue.  Many lessons were learned along the way as we noted some significant limitations in our ability to grow, for example, veterans without a personal computer or access to broadband could not be accommodated.  Several other limitations to the pilot were evident and we wanted to find a way to achieve an ultimate vision.

In April 2012 I submitted a program proposal to the Veterans Health Administration Employee Innovation Competition to facilitate health care innovations in the VA to transform it to a veteran-centric, results-driven, and forward-looking organization.  My proposal focused on expanding the Portland VA HBTMH pilot across VISN 20, utilizing a centralized scheduling- and referral-system to access a registry of decentralized providers to establish a viable model for Remote Mobile Access Clinics (R-MAC); its mission was to increase access to mental health care while decreasing systemic barriers.

The 2012 annual VHA Innovation Competition received 3,841 proposals which were voted on by interested VA employees.  The HBTMH Innovation 699 proposal ranked 19 out of 3,841 and upon its approval I worked with an Innovation Coordinator to purchase 250 iPads and 50 Netbooks with mobile broadband service.  We also proposed purchasing 100 fax machines, 250 webcams, and 3 videoteleconferencing software solutions: Vidyo and AK Code Summit (both FIPS [Federal Information Processing Standard] 140-2 compliant). The underlying intention is to give providers and veterans technology choices to ensure treatment attrition is minimized.

By summer 2013, Innovation 699 hired a full-time psychologist, Peer Support Specialist, and Program Analyst, and approximately 50 VISN 20 mental health providers. With 300 mobile telecommunication devices and ongoing program evaluation, Innovation 669 intends to address two significant challenges: access and timeliness to receive Mental Health treatment.

The program designed to create same day access model, referred to as “Air Traffic Control” by our team, uses a centralized scheduling- and referral-system and works as follows: Any VA provider within VISN 20 submits a consult via a centralized mechanism.  The consult is triaged immediately and a decentralized provider identified via the program registry as a match receives the referral and contacts the veteran.  It doesn’t matter where the provider and veteran are located as long as they’re in VISN 20.  The provider and veteran mutually agree upon a course of treatment.  If needed, the provider applies for mobile device (iPad/Netbook).  During treatment, a Peer Support Specialist is available or on-call for 1:1 technical trouble-shooting.  Providers using an iPad have access to many mobile apps developed by the VA for use in ongoing adjunctive clinical care.

We anticpate several positive outcomes in addition to making mental health care easily accessible to all VISN 20 located veterans.  Previous experience with HBTMH suggests many enrolled veterans, receiving care via HBTMH will show a decrease in psychiatric symptoms (including suicidal ideation) and treatment attrition rates compared with those receiving regular telemental health. We believe we will see a significant increase in social connectedness as a result of the veterans interacting with technology more frequently.  Thus, we hope that these participating veterans will show an improvement in their everyday functioning.  Addtionally, we anticipate the elimination of travel reimbursements for enrolled veterans for their visits,  the creation of at least five new access points, demonstration of extended hours access, pilot comparative technologies, and the feasibility of an on-call mental health provider for triage.

The HBTMH innovation is crucial to exploring and developing new models of delivering a broad range of mental health services, especially to rural veterans, for  addressing their unmet needs and generally improving patient care efficiency.  We hope that this innovation will not only transform VA Health Care, but possibly serve as a sustainable model for other health care providing facilities.