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States Explore Emerging Evidence to Learn New, Innovative Uses of Telehealth
The National Academy for State Health Policy (NASHP) recently launched the Telehealth Affinity Group, composed of state policymakers, that is examining emerging evidence from the Patient-Centered Outcomes Research Institute (PCORI) into innovative uses of telehealth to transform health care delivery systems in states.
State and federal policymakers are eager to explore emerging patient-centered outcomes research about new uses for telehealth beyond traditional care delivery, but they need additional information to evaluate PCORI studies and effectively apply their findings to the populations they serve.
For this study, a working group of parents and stakeholders from Federally Qualified Health Centers (FQHCs) and Community Mental Health Centers (CMHCs) in Los Angeles County designed a new referral process called the Telehealth-Coordinated Referral:
- After receiving a referral for mental health care from an FQHC, parents watched a five-minute video introducing them to the referred CMHC.
- At a follow-up appointment, the parent/s and child undergo the CMHC eligibility screening via a live teleconference with CMHC staff facilitated by a telehealth care coordinator, which is a new position funded by the grant.
States are motivated to implement telehealth policies that expand access to care and offer innovative approaches to care delivery. The importance of the topic is reflected in the robust investments that PCORI has made in its telehealth research portfolio. As of August 2019, PCORI has invested $381 million to support 88 comparative clinical effectiveness research studies in telehealth.
NASHP’s affinity group members represent nine states and a range of agencies, including Medicaid, state employee health plans, departments of insurance, offices of delivery system transformation, and departments of public health. These state officials offer extensive experience and expertise into telehealth and health care system innovations. The first convening of the group took place in August at NASHP’s 32nd Annual State Health Policy Conference in Chicago, where officials discussed a PCORI-funded study on a telehealth intervention that targeted behavioral health.
The study examined efforts to improve the mental health care referral process for children enrolled in Medicaid in Los Angeles County. This is how the intervention works:
- The primary care provider refers parent/s to a Community Mental Health Centers (CMHC).
- The parent/s watch a brief introductory video about the referred CMHC.
- The family then undergoes an eligibility screening through a teleconference (video chat) with a CMHC staff member during a follow-up appointment at their Federally Qualified Health Center (FQHC).
Compared with parents who had traditional referrals and screenings conducted over a follow-up phone call, the parents who watched the video and were screened by video chats at the FQHC were three-times more likely to complete the screening.
Patient-centered telehealth research, like this PCORI study, can help policymakers evaluate telehealth through a broader lens. Affinity group members explained that they often think of telehealth as “use of telecommunication technology to provide delivery of health care services,” but this study focused on telehealth as a tool to improve referrals and increase access to new services. As indicated by this study, new telehealth policies or investments may not necessarily dramatically change care delivery, but can greatly improve access or streamline existing processes.
Officials welcomed the opportunity to think about new and different uses of telehealth, and noted that telehealth can help address the practical challenges of any type of medical referrals – such as following up with providers or finding transportation to new health center locations – which can be even more onerous for families enrolled in Medicaid. Policymakers noted the study’s intervention offered a unique telehealth solution to referral challenges by creating a “warm,” technically streamlined hand-off between provider entities. The intervention also allowed new providers to connect with a family in a familiar location that the family already knew and trusted.
When considering new evidence, policymakers are interested in the return on investment (ROI) an intervention can provide. This is especially true in the case of telehealth interventions as substantial costs may be involved in setting up the technology infrastructure needed for its launch. For example, based on this study, affinity group members indicated it would be useful to understand the ROI of increased mental health care screening and subsequent access in order to make the case for funding the staffing and infrastructure needed for a similar intervention at an FQHC. Better understanding the challenges and context that a study addresses is also helpful for state officials who are considering emerging telehealth research. For example, members noted that reviewing the PCORI study alongside additional research findings into the importance of mental health care for young patients could enhance their understanding of how this study could be applied to future policy initiatives.
The cross-agency membership of the affinity group represents diverse patient interests, and when faced with new evidence, members are interested in how an intervention could effectively apply or translate to the specific populations they serve.
- Those representing commercially insured patients were interested in learning how this intervention could be implemented in the commercial sector.
- Officials serving rural communities and areas with provider shortages wondered if the intervention could include actual care delivery in another iteration to overcome access challenges.
Affinity group members also noted there was a lack of clarity on what specifically made this intervention successful — was it the introductory video, eligibility screening via teleconference, or having an additional staff member focused on the referral process? When considering how to implement new evidence-based approaches in their states, policymakers want to know which part of an intervention might be most impactful so they can effectively target populations and make the case for any related policies and investments.
When presenting new evidence on telehealth, researchers could improve the applicability of their findings by:
- Clearly describing the demographics of the population targeted in a study, including age, income, health status, etc.;
- Presenting contextual evidence to show the scope of the problem that an intervention seeks to address and the potential ROI of addressing the challenge; and
- Differentiating which part of a studied intervention is most effective and might be most successful if implemented in a policymaker’s community.
NASHP’s Telehealth Affinity Group will continue to meet and discuss emerging PCORI research on telehealth in the coming months. Affinity group members are interested in exploring new studies using telehealth to address behavioral health needs. Future blogs will highlight the group’s discussion of policy implications of new research into this topic and others.
How Supported Employment Can Address Mental Health Inequities in Minority Populations: Five States’ Experiences
Supported employment is used to help people with severe mental illness and other disabilities obtain and retain jobs. As states increasingly promote employment among public assistance recipients, could this model be expanded to new populations, including those with more common mental disorders or racial or ethnic groups who face health disparities? In this report, NASHP and Massachusetts General Hospital’s Disparities Research Unit examined how five states (CT, OK, TN, UT, and WA) are using their supported employment programs to tackle these issues.
Read or download: How Supported Employment Can Address Mental Health Inequities in Racial and Ethnic Minority Populations: Five States’ Experiences
Contact Malka Berro with any questions or to share your state’s supported employment efforts.
All the Right Moves: Transitioning Individuals Out of Psychiatric Institutions
Friday, August 17th
10:15am – 11:45am
When individuals with serious mental illness (SMI) transition out of psychiatric institutions, they often struggle with a lack of housing and social, health, and other supports, which can lead to repeated inpatient stays, incarcerations, and homelessness. This session highlights innovative state programs that successfully reintegrate individuals with SMI into the community by providing peer support and arranging housing, transportation, and other assistance. Panelists also discuss how changes to federal funding restrictions regulating inpatient transitions could help advance state efforts in this area.
Moderator
Dena Stoner, Senior Policy Advisor, Texas Health and Human Services
Dena Stoner, a Senior Policy Advisor for Texas Health and Human Services, has over 35 years of design and implementation experience, including long term services, acute care, managed care and behavioral health. She currently concentrates on behavioral health integration, including research and demonstration projects, Medicaid state plan and waiver initiatives. Her work has been featured in peer-reviewed publications. She also chairs the National Association of State Mental Health Program Directors’ Finance Policy Division, serves on the National Research Institute’s board of directors and is a member of the executive council of the National Academy for State Health Policy.
Speakers
Moira Tashjian, Associate Commissioner, Division of Adult Services
New York State Office of Mental Health
Wendy Tiegreen, Director of Medicaid Coordination & Health System Innovation, Georgia Department of Behavioral Health and Developmental Disabilities
Wendy White Tiegreen, M.S.W. is the Director of Medicaid & Health System Innovation for the Georgia Department of Behavioral Health & Developmental Disabilities. She has 25 years of experience working in public behavioral health services delivery and administration. Her career has been spent in leadership and Medicaid financing, notably negotiating with the Centers for Medicare & Medicaid Services in the establishment of peer supports. She is a regular presenter at national Medicaid and behavioral health management conferences and has also been a consultant for SAMHSA, NASMHPD, and more than half of all states related to behavioral health, Medicaid, and peer support.
Rob Cotterman, Assistant Commissioner of Mental Health Services, Tennessee Department of Mental Health and Substance Abuse Services
Rob is a veteran of the Tennessee Department of Mental Health and Substance Abuse Services, having dedicated 32 years of services at the Moccasin Bend Mental Health Institute
in Chattanooga. Rob has served as a psychiatric technician, rehabilitation therapist and supervisor, program director, Assistant Superintendent for Program Services, CEO, Director of Hospital Services and most recently Assistant Commissioner of Mental Health Services. In addition to his responsibilities at Moccasin Bend, Rob has served as an ancillary professor in the Graduate
School of Psychology for the University of Tennessee at Chattanooga and as a day treatment counselor for Chattanooga Psychiatric Clinic, now Fortwood Center. Rob is a graduate of Tennessee
Government Executive Institute and holds a Master of Science degree in Industrial/Organizational Psychology from the University of Tennessee at Chattanooga. He earned his Bachelor of Arts in Counseling Psychology from William Jennings Bryan College. Rob served on the Board of Directors for several community organizations that include: the AIM Center for Mental Health, Hamilton County Homeless Healthcare Center, and Hamilton County Mental Health Court Advisory Board. In his free time, Rob enjoys spoiling his toy poodles, bowling, and working to preserve and maintain his historic 120-year-old home.
Staying Afloat: Keeping Moms Connected to Opioid and Substance Abuse Services
Thursday, August 16th
3:30pm – 5:00pm
Opioid use among women of childbearing age and the rate of neonatal abstinence syndrome have risen dramatically in recent years. States are expanding substance use disorder services for pregnant and parenting women to ensure they receive a continuum of care that promotes their long-term recovery and the well-being of their children.
Speakers
Ana Novais, Rhode Island Department of Health
Ana P. Novais, holds a master degree in Clinical Psychology, UCLN, Belgium. Ana has worked for the RI Department of Health since 1998, as an Education and Outreach Coordinator and as the Chief for the Office of Minority Health.
In March 2006 as the lead for the Division of Community, Family Health and Equity, Ana oversaw the areas related with Health Disparities, Access to Care, Maternal and Child Health, Chronic Disease Management, Health Promotion, Environmental Health; and developed and implemented the “Health Equity Zones” initiative.
In August 1, 2015 Ana become the Executive Director for the Department.
Allen Brenzel, Medical/Clinical Director, Dept for Behavioral Health, Developmental & Intellectual Disabilities
Dr. Brenzel currently serves as the Medical Director for the Kentucky Department for Behavioral Health, Developmental & Intellectual Disabilities and is an Associate Professor of Psychiatry and Pediatrics at the University of Kentucky. He has developed broad health policy expertise in many areas and has served in state government for over 20 years. This has included working to modernize the State Medicaid Plan to include a full continuum of behavioral health and substance abuse services. In partnership with other state agencies, Dr. Brenzel has worked on reducing prescription drug abuse, addressing buprenorphine utilization and diversion, disseminating naloxone rescue kits, and developing guidelines for Kentucky’s Harm Reduction and Syringe Exchange Programs. He was the CO-PI for the Kentucky, SAMHSA MAT-PDOA grant which has implemented a coordinated care model to care for woman with an opioid use disorder who are pregnant or parenting.
Donna Hillman, CSAT O-STR Project Lead, SAMHSA
Donna is the CSAT Project Lead for the State Targeted Response to the Opioid Crisis project. She is the former State Director for the Kentucky Division of Behavioral Health and has over ten years of experience as a Licensed Professional Clinical Counselor. She was appointed by the Governor to the Agency for Substance Abuse Policy, a group of state agency and community coalition leaders working on coordination of services and supports for persons with MH/SUD. She was responsible for state-specific certification and oversight of state narcotics programs. Following her work at the state, she worked as the clinical program manager for a peer-run long term residential SUD recovery facility for women. She was awarded a B.S. in Psychology by Michigan State University and a M.S. in Community Counseling from the University of Akron (Ohio). Donna is also a person in long-term recovery.
This session is supported through a cooperative agreement with the Maternal and Child Health Bureau, Health Resources and Services Administration (HRSA)
Mental Health and Opioid Crisis Programs Win Funding Hikes, Efforts to Stabilize Insurance Markets Fail
The new $1.3 trillion budget bill that finances the federal government through September increased funding for a number of health programs that directly impact states, including rural programs to combat the opioid crisis. There were no appropriations made to stabilize Affordable Care Act (ACA) insurance markets.
Under the budget, the Department of Health and Human Services (HHS) receives $78 billion, a $10 billion increase, and the Centers for Medicare & Medicaid Services (CMS) receives $4 billion for administrative expenses, the same as in 2017. Below is a summary of key health related spending in the federal budget.
Opioid crisis: Funding to combat the opioid crisis received a $2.55 billion hike to reach $3.6 billion. The Substance Abuse and Mental Health Services Administration (SAMHSA) received a $1.3 billion increase, bringing it to $5 billion. The legislation maintains the ban on using federal funds for the purchase of syringes and needles, but allows communities with marked increases in HIV and viral hepatitis infection rates to use federal funds for services such as substance-use counseling and treatment referrals.
The SAMHSA budget includes $1.9 billion for the Substance Abuse Block Grant, similar to last year’s appropriation, an $11 million increase in criminal justice funding (bringing it to $89 million, which includes $70 million for drug courts), and $1.7 billion to address opioid and heroin abuse (an increase of $1.5 billion), including $500 million for the state opioid response grants authorized in the 21st Century Cures Act, along with funding for programs authorized in the Comprehensive Addiction and Recovery Act.
One of the new initiatives was $105 million to expand the National Health Service Corps (NHS) to offer opioid and substance use disorder treatment in rural and underserved areas. NHS substance use disorder counselors will be eligible for loan repayment. About $30 million will be devoted to the new Rural Communities Opioid Response initiative within the Office of Rural Health.
Mental health programs: Funding for mental health programs increased about 17 percent to $3.2 billion, which includes $100 million for Certified Community Behavioral Health Clinics. That program, midway through a two-year demonstration program at 67 centers, has been used to combat the opioid crisis.
The bill also increases funding for Mental Health First Aid to $19 million and gives first responders training to help connect people having mental health or addiction crises to community help.
According to the National Council for Behavioral Health, funding was maintained for the Primary and Behavioral Healthcare Integration program, which has provided screening and treatment for conditions like diabetes and heart disease for more than 98,000 individuals living with serious mental illness or addiction at more than 213 sites.
Among the mental health programs funded by the 21st Century Cures Act, including the Mental Health Block Grant, are the National Traumatic Stress Network, the National Child Traumatic Stress Initiative, Mental and Behavioral Health Training Grants, Assisted Outpatient Treatment, and the National Suicide Prevention Lifeline. Of the new funding, 15 percent will go to states with the highest mortality rates related to opioid-use disorders.
The Health Resources and Services Administration receives $7 billion, including $315 million for the Children’s Hospital Graduate Medical Education program, $110 million for the Healthy Start program, and $652 million for the Maternal and Child Health Block Grant.
The legislation increased funding for the National Institutes of Health (NIH) by $3 billion, bringing it to $37 billion, and the Centers for Disease Control and Prevention (CDC)’s budget increased $1.1 billion, bringing it to $8.3 billion.
Impact on ACA’s public health provisions: Much of CDC’s increase results from reallocating $801 million from the ACA’s Prevention and Public Health Fund and $240 million from its Nonrecurring Expenses Fund. The CDC’s Public Health Preparedness and Response programs will get a $45 million boost, bringing it to $1.45 billion.
New ACA oversight imposed: Congress did not fund efforts to reduce premiums through cost-sharing reduction payments, nor did it fund any reinsurance programs that would allow states to spread the financial risk for high-risk individuals across insurance markets. Congress did impose more reporting requirements on ACA programs.
- CMS must now notify Congressional committees two business days before any ACA-related data or grant opportunities are released to the public.
- New “transparency” language requires the Administration to publish ACA-related spending by category since its inception.
- The Administration must publish information on the number of employees, contractors, and activities involved in implementing, administering, or enforcing ACA provisions.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
