Telepsychiatry for FQHCs: A boost to patient access and collaborative care Insight Article Patient Access Patient Care Technology Sign in to save MGMA Staff Members The role of federally qualified health centers (FQHCs) in serving the nation’s healthcare needs has grown substantially in recent decades. From 2000 to 2018, the number of patients served by Health Resources & Service Administration (HRSA) funded health centers has almost tripled (9.6 million in 2000 to 28.3 million in 2018), and more than 28 million people — or 1 in 12 nationwide — use an HRSA-funded health center for primary care. For the rural patient population, that rate is closer to 1 in 5.1 Whiteside County Community Health Clinic in Rock Falls, Ill., is one of the 1,400 FQHCs operating in the nation today. Beth Fiorini, RN, MS, chief executive officer of the clinic and public health administrator for the county’s health department, oversees the 154-employee organization. The clinic was established in 2006 and provides services on a sliding fee. Besides providing services to the self-pay patient, the Whiteside County Community Health Clinic — which is a nationally recognized patient-centered medical home (PCMH) — accepts children's health insurance programs, Medicaid, Medicare and third-party insurance payments across its three locations. In 2018 the clinic served 13,050 patients at more than 50,000 visits, Fiorini said. In recent years, the clinic focused on starting a behavioral health integration program, in which patients are evaluated at medical visits for depression and alcohol/drug abuse, and they are given time with a licensed clinical social worker (LCSW) to assess readiness and willingness for treatment. Other newer programs have included a medication-assisted treatment program for substance abuse patients, and a dedicated clinic for the LGBTQ community. With the growth in FQHC utilization, demand for services can be challenging amid a widespread clinician shortage, according to Dr. Irene Epshteyn, associate medical director, Regroup Telehealth. “FQHCs must grapple with clinician shortages, cost-of-care and geographic constraints. … Access to mental healthcare is very limited across the nation,” and it can be especially difficult for FQHCs that, by definition, work in underserved areas. Epshteyn pointed to a 2019 telepsychiatry survey conducted by Regroup that found that some of the top challenges for healthcare professionals are patient access to mental health services and improving patient satisfaction. Of the roughly 600 healthcare workers surveyed, only 28% noted they currently offer telepsychiatry, while less than half (47%) said they plan to offer telepsychiatry in the near future.2 Epshteyn said that telepsychiatry — provided by psychiatrists, psychiatric nurse practitioners (NPs), psychologists and LCSWs — offers promise to healthcare organizations, including FQHCs, that want to deliver quality behavioral health services in conjunction with existing primary care and other services. Epshteyn’s role at Whiteside is to provide psychiatric evaluations and follow-up medication management sessions, as well as psychiatric consultations and other services covered under the collaborative care model, fully integrated into the clinic’s existing behavioral health program. Most of the work is commonly done as direct patient care via video conferencing. Epshteyn highlighted that embedding a teleclinician into the existing workflow of an FQHC works best. This includes privileging, credentialing and access to the facility’s EHR system and e-prescribing software. “That’s how a clinician becomes part of the treatment team and builds long-term relationships,” Epshteyn noted, “through collaboration with the in-house health professionals. The goal is to mirror in-person practice, ensure coordination of care and provide as seamless of an experience as possible for the patient and the organization.” Steps for workflow integration In working at Whiteside, Epshteyn said that visualizing the typical patient flow is important for fitting telepsychiatry into the existing behavioral health program. When a session is scheduled at the front desk, Epshteyn receives a note through the EHR about that patient, which allows her to review the patient’s chart, including notes from the primary care physician and counselor. Simultaneously, an on-site nurse working as a patient navigator takes vitals from the patient, reconciles medications and escorts the patient to a room for the telepsych session. While in the room, the nurse uses the video conference platform to request the session, and Epshteyn accepts the request on her end, which launches front-facing cameras for both her and the session room. With access to the facility’s health IT systems, Epshteyn can chart directly into the EHR remotely, e-prescribe medication to a patient’s preferred pharmacy, and order labs or other diagnostics tests until the session is complete. The nurse receives a notification, enters the room and escorts the patient out of the room while coordinating any follow-up care, if necessary — “not much differs from a typical in-person visit,” Epshteyn said. A sustainable model Hiring a full-time psychiatrist or other behavioral health specialist might not make sense for many facilities, either based on demand or lack of resources, Epshteyn said. This makes the telepsychiatry model an attractive option for FQHCs, especially those that operate across multiple sites that would require a significant amount of travel for an in-person psychiatrist. It also makes it easier for patients who travel less compared to a situation in which he or she might need to travel to a distant site for in-person services. “Since FQHCs are often responsible for patient transportation and transfer costs, [telepsychiatry] can translate into cost savings for FQHCs,” Epshteyn said. “Reducing wait times and reaching a patient early on in an outpatient setting may ultimately prevent them from requiring more intensive care in more costly settings [such as] ERs and hospitals.” With the introduction of more reimbursement methods for telehealth services in recent years and the collaborative care model, FQHCs may want to consider having a primary care provider collaborate with a psychiatric consultant and mental healthcare manager to create and execute treatment plans, which has shown to improve patient outcomes and reduce stigma related to mental health, as well as result in cost savings, Epshteyn noted. “FQHCs are perfectly suited for this model since the existence of primary care services and a collaborative, multidisciplinary spirit is the very foundation of FQHCs,” she said. As Fiorini recalled, Dr. Epshteyn began by offering up to 12 hours a week of telepsychiatry services in late 2018. Her appointment slots quickly filled, and they decided to increase the services to two full days a week soon thereafter. To optimize Epshteyn’s time, the clinic worked to mitigate the sometimes high rate of no-show patients in behavioral health. Whitney Miller, LCSW, EMDR, behavioral health coordinator, Whiteside County Health Department, said that the clinic’s behavioral health receptionist contacts each scheduled patient twice before an appointment: one week ahead of the appointment and then again 24 hours prior to the appointment time. If the patient does not confirm within this time frame, he or she is rescheduled to a later date. The appointment slot is then offered to a new patient or a high-risk patient. When patients no-show, the behavioral health receptionist will attempt to contact them to find out why they missed their confirmed appointment, Miller said. If the patient is identified as high-risk and high-need, Dr. Epshteyn will have a nurse attempt to reach the patient to facilitate care. “Our goal is always to provide the best possible care and to reduce barriers,” Miller said. “If transportation or the inability to afford medication is the identified barrier, we will offer the patient a gas card or pharmacy gift card,” which is possible through FQHC-based grant funding. The behavioral health team also attempts to accommodate same-day appointments, especially when there's a same-day cancellation. The behavioral health therapist provides the names of patients who would like to meet with Dr. Epshteyn sooner than when they are currently scheduled to create a waitlist for when appointment slots open unexpectedly. Key considerations Technology: The Whiteside team said one IT team member was needed for setup of the video-conferencing platform, with assistance from the third-party vendor’s support team. After setup, an on-site nurse is able to operate the video conferencing system. Licensing and credentialing: Telehealth services in general are benefitting from the growth in interstate medical licensure compacts, allowing for physicians to practice in multiple states. Any organization considering the addition of a teleclinician would need to understand the scope of licensing and credentialing needs for that provider. Time: Different types of telepsychiatry services result in different session lengths, just as with in-person care. When accounting for patient preparation and charting, the Whiteside and Regroup team said that new patient diagnostic evaluations typically take an hour; child and adolescent medication management sessions often last 30 minutes; and adult medication management sessions are about 20 minutes in length. Notes: Bureau of Primary Health Care. “Health Center Program: Impact and Growth.” HRSA. Last reviewed: August 2019. Available from: https://bphc.hrsa.gov/about/healthcenterprogram/index.html. Regroup. “Mental Health Statistics and Telepsychiatry Trends to Watch in 2019.” Available from: https://cdn2.hubspot.net/hubfs/3282840/Sales_Collateral/Survey-Infographic/RegroupSurvey-Infographic-Mental-Health-Statistics-Telepsychiatry-Trends.pdf.