Overview

The Telehealth Counseling Clinic is a telehealth clinic that uses psychology doctoral students from Texas A&M University to provide free virtual therapy to underserved patients in the Brazos Valley area of Texas.

Organization Name

Telehealth Counseling Clinic at Texas A&M University

Organization Type

• Academic Hospital
• Academic Medical Center
• Community outpatient clinic
• Integrated healthcare system/network

National/Policy Context

• Texas A&M University is an academic university, which supports the Telehealth Counseling Clinic (TCC) through a collaboration between the School of Public Health and the College of Education. The clinic serves the larger Brazos Valley area.
• Texas is ranked 49^th in the United States for mental health spending per capita, according to the Henry J. Kaiser Family Foundation.
• The counties served, including Brazas, Leon, Grimes, Madison, and Washington, are Health Resources and Services Agency (HRSA) designated mental health professional shortage areas.
• Many patients were using emergency departments as their primary care setting for problems such as for panic disorder, anxiety, and suicidal ideation, overburdening hospitals with inappropriate ED use.
• TCC was established in 2009, and has since provided 900 clients with approximately 9,000 free counseling sessions.
• TCC’s affiliation with Texas A&M University allows it to qualify for many of the grants it has received, which fund TCC.
• TCC has one director, Dr. Carly McCord, 3 paid graduate students who help with clinic operations; the counselors who provide therapy are all psychology doctoral students who volunteer.

Patient Population Served and Payor Information

• 65% uninsured, 5% private insurance, 30% Medicare/Medicaid
• Insurance does not accept billing for doctoral student psychology sessions so insurance status/payor does not affect who gets care.

Leadership

• Dr. Jim Burdine, Professor of Health Promotion and Community Health sciences, and Dr. Timothy Elliot, Professor of Counseling Psychology, envisioned telehealth services and established the first satellite counseling clinic for Leon County in 2009.
• Dr. Carly McCord, a doctoral student at the time, helped launch the original clinic and currently is the Director of the Telehealth Counseling Clinic, overseeing its operations and training of doctoral students in telepsychology.

Funding

• HRSA grant: have applied for and received two HRSA grants, which fund the counseling services doctoral students provide
• Medicaid 1115 Waiver: provides funding for delivery reform and innovation for unmet community needs through academic health science centers, accounting for 70-75% of current funding.
• 20% of funding has come from university fundraising.
• Grants and contracts provide 5-10% of funding.
• May begin fundraising throughout the community in the future due to grants running out.

Research + Planning

• The Center for Community Health Development at the Texas A&M School of Public Health, led by Dr. Jim Burdine, conducts a needs assessment for the Brazos Valley every couple years, which consistently finds a lack of specialty services, including mental health, for the seven-county area.
  • This survey’s findings inspired the creation of TCC.
• Planning involved identified key community stakeholders who helped TCC set up satellite clinics, where clients go to videoconference with their counselors, and access points, which advertise and sign patients up.
• They also had to identify contributing resources to sustainability, such as a brick and mortar place to house the access point, workforce, and belief from community that mental health matters and patients would be referred to services.
• Metrics to monitor throughout therapy sessions were established, specifically: number of sessions, no shows, and decrease in depression scores.
• Counseling was set as 1 session/week for 45-50 minutes, with 20 sessions as the maximum.

Tools or Products Developed

• A model of telehealth based on consolidated telehealth competencies from literature – paper pending.

Training

• Texas A&M’s Psychology doctoral program trains its students in telepsychology, with training including the following:
  • Telehealth 101: introduction to what telehealth is and examples of how it is implemented
  • How to handle emergencies from a distance
  • Multicultural considerations of working in rural areas
• All doctoral students who participate in TCC have received this telepsychology training.
• TCC also leads a continuing education program, which is an online program for existing professionals for telehealth counseling.

Tech Involved

• Cisco University
• Electronic medical record
• Titanium Schedule
• Video conferencing

Team Members Involved

• Administrative Assistant
• Clinical Trainee or Student
• Psychologist

Workflow Steps

Daily Workflow – Steps:

• Access points are areas set up in satellite communities, such as at community resource centers or government offices. The administrative staff at the access points are members of the respective communities who advertise TCC services and help the patient complete the paperwork to register, and fax it back to the TCC hub in College Station, TX.
• Patients go to satellite clinics where they use interactive videoconferencing technology to speak with their therapists who are at the TCC hub. Patients can also speak with counselors on the phone.
• Doctoral students conduct a phone screening before patients have first counseling session to make sure they are a good fit for telehealth and can be treated as outpatients.
  • The only exclusionary criteria for patients is that they do not want telehealth, preferring to see an in-person provider. In this case, patients are referred to an in-person therapist.
  • Students screen for immediate crisis/need to be an inpatient.
• Once therapeutic relationship is established, students provide counseling 1/week for 45-50 minutes. Counseling can be for an individual, group, or couple.
• Number of average sessions is 9, and 20 sessions is the limit.
• PHQ 9 is used weekly to track depression scores.
• Students are required to document treatment plan and termination summary in Titanium Schedule.

Budget

• $100K to $500K

Budget Details

• Salary for clinic director.
• Salary for 3 paid graduate assistants who help run clinic operations.
• Doctoral students who provide services are volunteers ($0).
• Cost for running clinic outside of salaries: EMR fees, licensure fees, phone, internet, equipment like computers/monitors, office materials, and travel to counties and conferences.

Where We Are

• This intervention is currently ongoing, with plans to add satellite clinics for Burleson and Robertson counties, the two remaining counties in the Brazos Valley.
• TCC hopes to work with local hospital systems to quantify cost saving and ED divergence. TCC recognizes that this is happening anecdotally, since patients are using the ED less for their mental health needs, but have no supporting data.
• TCC hopes to start using mobile devices for video conferencing, rather than having patients travel to satellite clinics.

Outcomes

• Change in depression scores, measured with PHQ 9.
• Health-Related Quality of Life (HRQOL) measures

Future Outcomes

• Qualitatively measure cost-saving from decreased ED utilization for outpatient mental health problems.

Benefits

• Improved access to care:
  • Over 90% of clients who reside in rural counties report that they would not receive counseling without TCC’s services.
  • In Brazos County, which is not rural, 75% of clients report that they would not receive counseling without TCC’s services.
• Many have suicidal ideation and depressive symptoms, along with comorbid medical conditions, whose quality of life improves as a result of treatment.
• Preventing unnecessary ED utilization, contributing to cost-saving for healthcare systems.

Unique Challenges

• Communities occasionally remain resistant to the idea of mental health therapy as an overall part of health.
• Some potential clients who would not travel far to see a mental health provider also do not travel to a satellite clinic to receive care.

Personnel Challenges

Personnel Challenges:

• Funding is a consistent challenge, as grant money runs out and there is currently no way to bill insurance companies for doctoral student-led sessions.

Metrics

Key Quality Measures:

2018 MIPS Quality Payment Program (QPP) Measures: Providers participating in the QPP are required to report their performance on at least six metrics chosen from a list provided by CMS. Providers may be able to improve their performance on a number of these metrics by integrating behavioral health programs into primary care. Sample metrics include:

•  Depression Remission at Twelve Month
  • The percentage of patients 18 years of age and or older with major depression or dysthymia who reached remission 12 months (+/- 30 days) after an index visit
• Screening for Clinical Depression and Follow-Up Plan
  •  Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

More details about measures included in the QPP set can be found here.

Medicare Shared Savings Program (MSSP) ACOs: Clinics associated with an MSSP ACO are required to report their performance on measures for Depression Remission at Twelve Months and Screening for Clinical Depression and Follow-Up Plan. More information about these measures and requirements can be found here.

Patient Centered Medical Home (PCMH): Integrating a behavioral health program such as Collaborative Care for Depression into primary care may help practices meet a number of NCQA Patient Centered Medical Home 2017 Standards. Potential opportunities include:

•  KM-03- Conducts depression screenings using a standardized tool
• KM-04- Conducts behavioral health screenings or assessments for at least 2 of the following: anxiety, alcohol use disorder, substance use disorder, pediatric BH screening, post-traumatic stress disorder, ADHD, postpartum depression
• CM-04- A person-centered care plan is established for care management patients.
• CC-10- A behavioral health provider is integrated into the practice’s delivery system

More information can be found here.

HEDIS Depression-Related Measures: Related HEDIS measures for 2018 include:

•  Depression Screening and Follow-up for Adolescents and Adults
• Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults
• Depression Remission or Response for Adolescents and Adults
• Unhealthy Alcohol Use Screening and Follow-Up

More information can be found here for depression measures and here for the alcohol use measure.

NYS Medicaid Collaborative Care Quality Metrics: For providers interested in further assessing the quality of their Collaborative Care for Depression and Anxiety programs, New York State’s Office of Mental Health has a robust set of measures for tracking the quality of these programs that is larger than other measure sets listed here. Among others, metrics for programs include a population screening rate, clinical improvement rate, and change in treatment or psychiatric consultation rate (for patients not showing clinical improvement).  More information about the 2018 metrics can be found here.

Direct Billing: Providers may be able to directly bill for many of the services provided through Collaborative Care for Depression programs.  For example, as of 2017, providers can bill CMS for counseling and care management services using BHI-specific codes (more information available here).

Other Opportunities:Providers may be able to improve performance on chronic disease control measures through behavioral health integration efforts.  For example, a 2014 BMJ Open systematic review and meta-analysis found that participation in collaborative care programs targeting comorbid depression and diabetes significantly improved patients’ depression scores as well as their HbA1c levels.  In addition, behavioral health integration may represent an opportunity for providers to improve patient satisfaction.  A 2010 NEJM randomized, controlled trial of Collaborative Care found that participating patients were significantly more satisfied with the care they received through the program for diabetes, coronary heart disease, and depression than controls.