Developing Telepractice Proposals for Health Care & Schools

Transcription

1 Developing Telepractice Proposals for Health Care & Schools Janet Brown, Michael Campbell, Vickie Pullins November 22, 2008 Session 2540 ASHA Convention

2 ASHA and Telepractice Janet Brown, MA CCC-SLP Director, Health Care Services in SLP

3 Preview Overview of ASHA, telepractice, and current issues Information for developing telepractice programs Information for ensuring clinical quality

4 ASHA s Policy Documents (2004) for SLP Speech-Language Pathologists Providing Clinical Services via Telepractice: - Position Statement - Technical Report - Knowledge and Skills

5 Telepractice (aka Telehealth, Telemedicine, TeleSLP) Telepractice is the application of telecommunications technology at a distance by linking clinician to client, or clinician to clinician for assessment, intervention, and/or consultation.

6 Quality of Service Telepractice (telehealth) is an appropriate model of service delivery for the profession of speech-language pathology [and audiology] The quality of the services delivered via telepractice must be consistent with the quality of services delivered face-to-face. --Position Statement

7 Challenges in Definition Is it a direct service or ancillary to the service (e.g. electronic worksheets) If it is a direct service, is it the same as what would be provided face-to-face?

8 What About Distance Supervision? Not called telepractice Council for Clinical Certification (CFCC) has approved distance supervision as an acceptable means of supervision Doesn t meet Medicare requirement for student supervision (in the room)

9 ASHA s Activities in Telepractice Since 1998 Medicare application Telepractice brochure, DVD, web pages - American Telemedicine Association Center for Telehealth and E-Health Law

10 State Licensure Most state licensure laws don t address telepractice - Growing trend for state boards to become aware - Different definitions being used by each state - Requirements affirm that SLP must be licensed in their state

11 Current Initiatives Developing model language for state licensure Forming a committee to develop guidance on professional issues surrounding telepractice Discussing terminology

12 For More Information

13 Developing Telepractice Proposals for Health Care and Schools Michael Campbell The University of North Carolina at Greensboro

14 Getting Started Support from organization/stakeholders Become educated Check with state licensing board Must consider: Client users Clinician users Service delivery environment Training necessary Develop a business plan (template at Business and Finance ATA website)

15 Business Models

16 Telepractice Settings University Healthcare Hospital Skilled Nursing Facilities Outpatient Home Health Public Schools

17 Sustainability Fixed Expenses Equipment lease or purchase Space lease or purchase Salaries Variable Expenses Training expenses Marketing costs Supplies Travel Revenue

18 Break Even Relationship between initial investment outlays and required volumes to reach profitability Intersection of total income and total costs How many consultations do I need to perform to cover my costs?

19 Break Even Analysis Revenues equal expenses ATA Business and Finance SIG entations/business%20&%20finance%20si G%20Breakeven%20Analysis%20Tool.xls

20 Funding Sources and Reimbursement

21 Possible Funding for Telepractice Contracts Private Pay Insurance Medicare/Medicaid Conrad Bill introduced 4/3/08 Medicaid Reimbursement Is now available in 27 states Gives states flexibility in determining what may be reimbursed

22 Grant Possibilities Office for the Advancement of Telehealth (OAT) Universal Service Administration Company (USAC), Rural Health Care Division Appalachian Regional Commission, Telemedicine Program Congressional Earmark Funding, US Department of Education Corporate Grant Writers working with vendors

23 Technology

24 Telepractice Types Store and Forward Tele Monitoring Video Conferencing

25 Store and Forward Equipment Capture Device Audio Video Still Image Text Storage Device Computer Network Storage (Server)

26 Connection Types Local Area Network (LAN) Internal network Network that you own and control Uses Ethernet based technology Covers small geographic area High speech connections between network devices and buildings

27 ...Connection Types Wide Area Network (WAN) External network Leased not owned More expensive to operate generally May not be available between rural and urban areas Connection can be made between LANs

28 WAN Wide Area Networks are the set of connecting links between Local Area Networks.

29 WAN Types Common Wide Area Network technologies Plain Old Telephone Service (POTS) Digital Subscriber Line (DSL) Cable Integrated Services Digital Network (ISDN is HIPAA Compliant) T1 (HIPAA Compliant)

30 Bandwidth Bandwidth = bits/second Greater the bandwidth = more information = higher image and audio quality Measured in (bps) Bits Per Second K = kilo = 1,000 M = mega = 1,000,000 = million G = giga = 1,000,000,000 = billion

31 POTS Plain Old telephone Service Most common network in use today Sometimes the only source of communication in underserved areas Maximum bandwidth of 56 kilobits per second

32 ISDN Integrated Services Digital Network An international communications standard for sending voice, video, and data over digital telephone lines ISDN is a digital phone line ISDN number looks just like a telephone number ( )

33 Two types of ISDN: Basic Rate Interface 128 kbps max. Site to site 384 kbps min. for video conferencing (3xBRI) Primary Rate Interface 1.5 mbps max. 1 PRI = 12 x BRI Multisite Supports high definition video...isdn

34 Internet Protocol (IP) Method of addressing network devices IP is a higher level protocol that can be transmitted over different connection types, T 1, DSL, Cable and ISDN can be used to transmit IP information IP is more flexible than ISDN IP address: ( )

35 Advantages of IP Improved reliability Decreased cost of ownership Predictable usage fees Call speed flexibility Tighter security

36 T 1 Dedicated leased line T 1 is a point to point connection Flat rate service 1.5 mbps maximum

37 Virtual Private Network (VPN) A cost effective and secure way for remote networks to communicate with each other across the Internet VPN offers less reliability, performance and security than traditional WAN connections, such as T 1 and ISDN

38 Internet2 Furnishes a 100Gbps network backbone to more than 210 U.S. educational institutions, 70 corporations and 45 nonprofit and government agencies. Provides the U.S. research and education community with a network that satisfies their bandwidth intensive requirements.

39 Security comply or.

40 Privacy and Security under HIPAA Privacy is what you have already promised to do Security is about how you fulfill that promise Networks are how the authorized (and unauthorized) get PHI Improper network activity can specifically be identified as a security incident Network security is of paramount importance

41 Sources of Security Threats Insiders/Outsiders = 70% / 30% Malicious, dishonest, corrupt, distracted, disgruntled, negligent Naturally curious, poorly trained, terminated Hackers and crackers Computer criminals

42 Security Tools for HIPAA Compliance Firewalls Boarder controller IDS/IPS Secure switches Anti virus Two factor authentication Secure VPN IEEE i/Robust Security Network (RSN) is coming for wireless

43 Speech and Hearing Program Site Program Firewal l Rural Public School INTERNE T Site Program Firewal l Server

44 Telepractice Security Security is more than just a Login You must be ready to: Protect Detect Respond.to any type of adverse event

45 Regulatory and Legal Issues

46 Professional Liability Insurance Is telepractice covered? Are there any limitations to location? Who is responsible? Watch out for exclusions and limitations for damages. Carrier should be notified when a clinician is planning to provide services via telepractice ATA endorses TelMed through Campania Group ( )

47 Informed Consent ASHA recommends and some states require that the clinician who has ultimate authority over the care of the patient receive the patient s informed consent before delivering care through telepractice

48 The Joint Commission The Joint Commission developed telemedicine standards, effective 1/01/01 and revised 1/01/04 Applies to hospitals and ambulatory care facilities Practitioners who treat patients via telemedicine must be credentialed with the organization that receives the telemedicine service. Medical staff of the receiving facility determines which telemedicine services are appropriate.

49 HIPAA and Issues Unique to Telepractice Covered entities must enter into business associate agreements with technical providers (non covered entities) who assist with the delivery of healthcare by telemedicine. Programs will need to do a reasonable risk assessment with respect to data transmission consistent with HIPAA security policies.

50 Stark Law Clinician refers a patient to a facility in which (s)he has a financial interest (i.e. conflict of interest).

51 Anti Kickback Laws Prohibit anyone from receiving or paying anything of value to influence a clinical decision. Referrals Placing telepractice equipment at a site with the anticipation of receiving referrals Use of space / lease arrangements Always check with legal counsel.

52 Research Needs Development of assessment and treatment protocols Compare procedures with traditional interventions Assessment of technology and various settings Cost benefit analysis Client, caregiver and clinician satisfaction Education of clients, community, clinicians, healthcare professionals and students

53 Helpful Links ASHA Telepractice Documents: American Telemedicine Association (ATA): ATA Telerehabilitation Special Interest Group: The Center for Telehealth & E Health Law (CTeL) : Office for the Advancement of Telehealth (OAT): Health Resources and Services Administration (HRSA):

54 ...Helpful Links Telehealth Resource Center: Universal Service Administration Company (USAC): Appalachian Regional Commission (ARC): Agency for Health Care Research and Quality; Office of Rural Health Policy:

55 Clinical Challenges of Tele Vickie Pullins LinguaCare Associates, Inc.

56 Eliciting Target Phonemes Adequate visual/auditory cue Difficult without manual manipulation

57 Groups of More Than 2 Difficult to keep on task Increased distraction with equipment Difficult to elicit the target number of productions

58 Carry over in the Classroom Lack of weekly contact with teachers Facilitator not communicating with teachers

59 Utilizing Paraprofessionals Technical training Familiar with therapy materials Behavior management Liaison with school staff

60 Caseload Selection Middle School Students Fluency Language Articulation Autism Learning Disabilities Behavior Disorders Down Syndrome

61 Outcomes 163 scheduled sessions 126 completed sessions 18 students treated 9 students completed goals and were dismissed from speech/language therapy

62 Quality Control Satisfaction Surveys Completed Parents Students Administrators Teachers Results: Parents: 95% Very Satisfied Students: 99% Very Satisfied Administrators: 100% Very Satisfied Teachers: 64.5% Satisfied 35.5% Very Satisfied

63 Documentation Daily log with accuracy counts Daily documentation of use of Poly Com HDX 4000 via T 1, ISDN Lines Daily documentation of number of sessions scheduled and number of sessions completed Daily documentation of downtime recorded in minutes Daily documentation of on site sessions and care coordination for Medicaid Reimbursement

64 Conclusion Telespeech is a valid venue of service for areas with no access to on site services Greater teacher involvement is needed Additional technology is needed to enhance therapy materials utilized

65 Telespeech has been amazing just to watch the students be more alert, not only in seeing another person talk to them on t.v. but also enable them to learn and enhance their skills in speech and language.