Harbor is a nonprofit mental health and substance use disorder treatment provider based in Toledo, Ohio, that has been addressing community needs for more than 100 years. It serves more than 23,000 individuals annually.
Lighthouse Telehealth is a subsidiary of Harbor, formed in 2018 to meet the growing demand for telehealth. It also includes all IT, revenue cycle management and employee assistance program contracts.
Access to psychiatric care has been a challenge across the country. The National Alliance on Mental Illness statistics show that: One in five individuals faces a mental health or substance use issue; one in 20 adults lives with a serious mental illness; suicide is the third leading cause of death in youth ages 10-24, and the tenth leading cause of death for adults; and the average delay between the onset of mental health symptoms and intervention is eight to 10 years.
Clearly, psychiatric care is a much needed service, and access to this care is an issue.
“A lack of timely access to psychiatric care can lead to increased use of emergency departments, inpatient admissions, increased costs in treating patients, and poor outcomes for individuals, families and communities,” said Sandy Hall, president of Lighthouse Telehealth. “In addition, there are a limited number of available psychiatrists to treat these conditions.”
According to the National Council Medical Director Institute, the pool of board certified psychiatrists is decreasing due to an aging psychiatric population (59% of practicing psychiatrists are 55 or older), the small percentage of medical school graduates who are selecting psychiatric residency programs, and the decreasing percentage of psychiatrists working in the public sector and traditional payer models.
"Rather than just a telephonic intervention, the clinician was able to visibly assess the patient using our Vidyo telehealth platform and could see that the patient had relapsed and was at serious risk of overdose."
Sandy Hall, Lighthouse Telehealth
“In addition to the challenges realized above, Harbor patients were experiencing significant wait times for psychiatric appointments,” Hall said. “Leaders at Harbor acknowledged these challenges and built a plan to improve access to psychiatric care for patients. The plan included an expansion of the current provider base and the implementation of a telehealth platform that would allow access to psychiatric care from anywhere in the country.”
The IT vendors that Harbor used to provide telehealth services include IDSolutions, which provided a HIPAA-compliant video platform (Vidyo), and Streamline Healthcare Solutions, which provided Harbor’s web-based electronic health record, SmartCare.
Lighthouse worked with IDSolutions on a cost-effective and easy-to-implement telehealth videoconferencing system that the telehealth providers could use to increase access to care for patients, Hall said.
Lighthouse leveraged internal strengths and resources to build a team of certified, national telehealth providers and joined them with existing multidisciplinary professionals at Harbor to provide timely care to patients in need, either in person or via the new telehealth platform.
“The vision was clear: Provide timely and quality patient care with Harbor team members and ensure continued use of a single electronic health record for our patients,” Hall explained.
“This meant the team would review and plan for changes in patient registration, scheduling, facilities and expanded utilization of SmartCare functionality. This included setting up and implementing the use of electronic prescribing of controlled substances in SmartCare for our prescribers.”
Harbor established a diverse, interdepartmental logistics team. This included human resources, credentialing, billing, medical, support and scheduling staff, and clinical, nursing, IT, and quality team representation. The team meets regularly to evaluate progress, identify challenges, review regulatory changes, analyze data and implement new systems. It is a culture of continual quality improvement.
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MEETING THE CHALLENGE
Harbor created “Tele Patient Rooms” at multiple office locations. It installed the Vidyo equipment, camera, speaker and wall-mounted screen for telehealth sessions. Telehealth providers had Vidyo installed on their computers and were also provided with cameras and speakers to enhance the video and communication quality. Providers were able to control the camera in the “Tele Patient Room” so they could closely observe and evaluate the patient throughout the session.
“The rooms were furnished in a different manner than the traditional outpatient clinic rooms, paying close attention to lighting, safety, comfort and privacy,” Hall explained. “As we progressed, we also worked to establish a standard ‘Tele Patient Room’ look and feel across the various sites. We designated each of these rooms as a ‘resource’ in the EHR that was directly linked to the scheduled service. This prevented double-booking of the ‘Tele Patient Rooms.’“
Using the EHR and internal resources, Lighthouse developed telehealth-specific consent forms and unique telehealth procedure codes and programs, indicated which insurance plans covered telehealth using custom fields in the application, and used staff specialties to clearly identify telehealth providers. With these various configurations in place, the organization was able to fully use the appointment search functionality when scheduling new and existing patients.
Custom fields also were added to service notes so that telehealth providers could indicate a distance from patients where required and specify the telehealth delivery type.
“Harbor worked with Streamline Healthcare Solutions to develop an improved patient arrival notification within the EHR,” Hall said. “This allowed us to set up specific medical assistant/nursing staff alerts based on specific provider appointments. Notifications could be configured by day, by site and/or by specific provider. With this in place, our telehealth provider as well as our onsite staff were alerted when the patient had checked in for their service.”
Lighthouse developed client-level alerts and flags in the EHR to ensure staff were aware of insurance plans covering telehealth or not covering it in order to monitor completion of telehealth consent forms, track patients who had been offered but declined telehealth services, and identify those patients who were receiving telehealth services remotely.
“Emergency planning also was part of our quality improvement process,” Hall said. “We provided remote practitioners with backup equipment and established fluid communication protocols.
Harbor has since expanded its use of telehealth and established successful partnerships with major hospital systems, emergency departments and other behavioral health agencies. We work together to offer convenient, high-quality telehealth services for a growing number of communities.”
As part of the organization’s telehealth journey, Harbor has been able to design, improve and implement efficient and effective telehealth workflows and systems for a variety of patients, she added.
Harbor initially increased the number of practicing telehealth providers from one to 50. Since COVID-19 hit, this number has increased to more than 300 licensed telehealth providers.
“Harbor worked diligently to build a team of quality providers, invested resources in the organizational infrastructure, and conducted business process analysis to improve workflows needed to support our telehealth practitioners,” Hall said. “Our objective was to create a patient-friendly experience.”
On the access to care front, the psychiatric care shortage in America is staggering. Before Harbor began to provide telehealth services, the average wait time for a psychiatric evaluation was 120 days for adults and 90 days for children. Harbor now is able to provide a psychiatric evaluation within seven days of a request and routinely offers same-day appointments.
“One insurance company tracked 138 of its members who received telepsychiatry services from Harbor in 2017 and found a trend indicating reduced utilization of emergency department visits, from 266 visits to 228 visits; decreased psychiatric inpatient stays, from 115 to 60; and an overall average decrease in cost per member of $2,555,” Hall added.
USING FCC AWARD FUNDS
Earlier this year, Harbor was awarded $328,126 for laptop computers, tablets, a patient wellness application license, mobile data plans, video telehealth licenses and other telehealth equipment to continue treatments during the COVID-19 crisis by using telehealth to perform comprehensive mental health and substance use assessment and treatment for all patients, including psychiatric evaluations and pharmacological management, psychological testing and evaluations, and primary care services.
When the COVID-19 pandemic hit in March, Harbor quickly reviewed its inventory, surveyed staff, and evaluated technology and resource needs to support a remote workforce. Having close to eight years of telehealth experience with a small group of clinical staff, Harbor immediately expanded the scope of its HIPAA-compliant telehealth service-delivery model and equipped staff to work remotely in order to provide telehealth services to all patients.
“Flexibility in insurance rules and other regulations allowed us to expand our use of telehealth across various locations. Patients could now be at home for treatment sessions while staff could be remote – and across service lines. Some treatment-type billing codes were not previously permitted via telehealth,” Hall said.
“Our message to staff was clear: While telephonic and asynchronous methods were now being permitted under some emergency rules, we expected our clinical staff to use the HIPAA-compliant platform we had been using whenever possible. And if not possible, we needed to know why.”
And that is how Harbor identified an immediate need for its patients. Many of them did not have a device or connectivity available to participate in a secure synchronous video telehealth-treatment session.
“We worked with Sprint/T-Mobile and ordered 4,000 data-enabled tablets for our patients,” she explained. “We had the tablets imaged and configured in kiosk mode. This included having the Vidyo app installed for the telehealth session and ready to go on the tablet, Outlook and Gmail apps so patients could access e-mail, a Chrome browser, and Harbor’s myStrength patient-wellness app. The distinct setup limited patients from being able to download other apps or programs on the device, but allowed them to fully engage in telehealth treatment sessions.”
The myStrength app provides an additional level of support for the patients between treatment sessions and is used as a supplement to regular mental health and substance use treatment. The app offers an individualized experience for patients at no cost to them with a variety of interactive applications focused on the mind, body and spirit.
“It includes evidence-based self-help resources for emotional health and overall wellbeing, and web and mobile tools to support goals,” Hall said.
“Our myStrength app also has built-in links to contact Harbor and other emergency resources as needed. Since launching myStrength, we have had more than 700 individuals create user accounts. Our most recent report also indicates that Harbor users are logging in more than other organization averages in the first 30 days of use, as well as a higher average of total logins for returning users.”
Harbor’s patient population is very vulnerable during the current COVID-19 pandemic. Many of the individuals have struggled with the stay-at-home orders, resulting in exacerbated symptoms. Treatment continuity, ongoing assessment of current mental status, risk to self or others, medication monitoring, pharmacological efficacy, and risk of relapse have been very important.
Many of these patients have a serious and persistent mental illness and require frequent services and close medication monitoring. Providing these services via telehealth has helped to ensure the social distancing of staff and patients.
“In just five months, Harbor has provided telehealth services to 15,259 individuals representing 95,694 distinct telehealth services,” Hall reported.
“Comparing that same date range to 2019, pre-COVID-19 and prior to the full expansion of our telehealth services, Harbor provided telehealth services to 4,184 individuals representing 14,397 distinct telehealth services. That represents an increase of more than 264% in individuals receiving telehealth treatment and a 564% increase in distinct telehealth services provided.”
Continued delivery and expansion of telehealth services was critical for patients. One example of the need for synchronous, video-based telehealth services was in Harbor’s intensive outpatient program, designed for patients with substance use disorders where treatment group sessions are conducted multiple times per week.
“During one group session, a patient who was issued one of the data-enabled tablets purchased through this grant was using the Vidyo app to participate,” said Hall.
“Rather than just a telephonic intervention, the clinician was able to visibly assess the patient using our Vidyo telehealth platform and could see that the patient had relapsed and was at serious risk of overdose. Our clinician acted quickly and enlisted the help of another team member to contact 911 for paramedic evaluation of the patient.”
The clinician maintained visual observation and communication with the patient until the paramedics arrived. She also was able to redirect group members to another Vidyo telehealth session so they could continue to receive the support needed while she remained engaged with this patient until the situation was resolved.