Free Request for Approval to Use TeleHealth-F-62589 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62589 (Rev. 07/08)

STATE OF WISCONSIN

REQUEST FOR APPROVAL TO USE TELEHEALTH
Completion of this form is optional.
Name - Agency Certification Number Date Application Completed

Address - Agency (Street or P.O. Box)

City

State

Zip Code

Name - Person Completing This Form

Telephone Number

FAX Number

Name - Agency Director

Email Address - Person Completing This Form

Office Use Only

C
(1) APPLICABILITY This request for approval applies only to mental health and substance abuse programs, currently certified or seeking certification under DHS subchapters, who are anticipating the use of TeleHealth as a means of service provision to increase access to services. a. The agency is currently certified under DHS subchapters for the provision of mental health and / or substance abuse services. Yes b. If not certified, has the agency submitted an application for certification to DHS. Yes No No

NC

NA

COMMENTS

(2) GENERAL Programs requesting to use interactive TeleHealth for clinical mental health and substance abuse services must be certified under DHS subchapter pertinent to their clinical specialty or facility. The plan submitted in compliance with certification requirements for any service or facility must include provisions pertinent to the use of TeleHealth if the program is seeking certification including the use of TeleHealth. The program / agency shall have in place a written document indicating how TeleHealth services are integrated into the overall plan for providing inpatient, outpatient, community support services, comprehensive community services, day treatment, and crisis mental health and substance abuse services. The plan shall identify appropriate sites where consumers may access services (originating sites). These sites may include: hospitals, emergency care centers, outpatient clinics and mental health and substance abuse facilities, skilled nursing homes, schools, county Health and / or Human / Social Service offices, and other county offices

F-62589 (Rev. 07/08)

Page 2

Office Use Only

C
appropriate for private clinical evaluations and services. The plan includes: A description of how interactive TeleHealth services will be used in the overall strategy for mental health and substance abuse services. Yes No

NC

NA

COMMENTS

How using interactive TeleHealth services will address the specific needs and strengths of consumers. Yes No

A description of services that can be provided via TeleHealth services. Yes No

Criteria for selecting and identifying providers at the agencies to use TeleHealth services. Yes No

Criteria for selecting and identifying consumers appropriate for TeleHealth services. Yes A listing of appropriate originating sites. Yes The agency has a plan on file with DHS. Yes No No No

The plan includes specific references to the use of TeleHealth. Yes No

(3) PERSONNEL Only health personnel who are qualified under DHS subchapters may conduct appropriate mental health and substance abuse services via TeleHealth technologies (hereafter referred to as interactive TeleHealth services) for the purposes of diagnosis, treatment, and evaluation. A regular staff member of the program must be available to present the consumer during clinical visits via TeleHealth unless another county public safety, public health, or Human / Social Service presenter trained in the use of TeleHealth is available. Consultants, presenters, and any staff involved in interactions via TeleHealth with consumers present shall have training in the psychodynamics, legalities and patient rights pertaining to the use of TeleHealth technologies. Persons providing consultations via TeleHealth are members of the agency and qualified under DHS

F-62589 (Rev. 07/08)

Page 3

Office Use Only

C
subchapters. Yes No

NC

NA

COMMENTS

All persons presenting during TeleHealth services are adequately identified in the agency's plan. These persons are identified by position, not by name. Yes No

(4) PROGRAM OPERATION AND CONTENT TeleHealth technologies are used to provide access to services as outlined in DHS subchapters in: a. Outpatient Crisis CCS CSP Day Treatment Yes Yes Yes Yes Yes No No No No No

b.

Services are available 24 hours / day. Yes No

c.

If services at the agency are required 24 hours / day and not available via TeleHealth, are written guidelines available in the agencies plan for obtaining in-person services? Yes No

d.

If access by interactive TeleHealth services is the primary method for providing outpatient, CSP, CCS, day treatment, or crisis mental health and substance abuse services, are trained staff available at all times for services? Yes No

(5) ORIENTATION AND ONGOING TRAINING Each agency shall develop and maintain training in TeleHealth applications to include technology, clinical presentation, security and privacy, and documentation requirements specific to the clinical applications. Staff involved in service provision or presenting consumers shall receive training covering all the required components. An orientation for staff using TeleHealth must include the following components in addition to any required clinically oriented mental health and substance abuse orientation: Historical uses of TeleHealth History of TeleHealth Clinical Applications in TeleHealth Telecommunications Technology Technology Codecs Cameras Consumer Peripherals Transmission equipment Audio equipment

F-62589 (Rev. 07/08)

Page 4

Office Use Only

C
Presenting Techniques Clinical services Safety and Security During Service Provision Privacy and Confidentiality Documentation Consumer Rights Back-up Procedures Patient Preparation for TeleHealth The required training elements are in place. Yes No

NC

NA

COMMENTS

At a minimum, annual inservicing is conducted regarding any changes or updates in TeleHealth applications including state legislative or regulatory changes. Yes No

(6) CLINICAL POLICIES AND PROCEDURES Each program must have in place clinical policies and procedures that address the following operational components of conducting mental health and substance abuse services via TeleHealth: Preparation of Videoconference System and Cameras Purpose: To serve as a guide for setting up videoconferencing system and cameras for a TeleHealth visit. The intent of this guideline is to provide direction to the visit to improve efficiencies for the consumer, provider and the TeleHealth presenter. The Policy: Describes what is needed to prepare the room so everything is ready when the consult begins to avoid any technical problems. Yes No

Describes the equipment needed and how it works. Yes No

TeleHealth Operations ­ Preparing for a TeleHealth Consult Purpose: To serve as a guide for obtaining and setting up equipment for any TeleHealth visit. The intent of this guideline is to provide direction to the visit in order to improve efficiencies for the consumer, provider and the TeleHealth presenter. The Policy: Describes the process for preparing charts and forms, room and equipment. Yes No

Describes what is needed to ensure the consumer chart and any other forms that may be needed for the consult, i.e. appoint forms, technology reports, prescription forms, etc. are available and accessible.

F-62589 (Rev. 07/08)

Page 5

Office Use Only

C
Yes No

NC

NA

COMMENTS

Details what is needed to prepare the room, positioning the chair, lighting that may be needed, privacy signage. Yes Consumer Information, Security Policy Purpose: To indicate the clinic respects and will protect every consumer's right to have all information they share with health professionals kept confidential. The Policy: Explains the confidentiality policy. Yes No No

Explains how technological problems are addressed before and during the TeleHealth consult. Yes Documentation During a TeleHealth Visit Purpose: To serve as a guide for documentation during a TeleHealth visit. The intent of this guideline is to ensure compliance with documentation requirements for clinical consultations. The Policy: Documents TeleHealth consumer care in a medical record including prescriptions ordered. Yes No No

Maintaining Technical Integrity During the Interactive TeleHealth Consult Purpose: The purpose of this guideline is to ensure that video and audio quality is maintained at a level sufficient for clinical care during interactive TeleHealth consultations. The Policy: Defined the staff and their roles and responsibilities including the role of the TeleHealth presenter. Yes Defined how to address technical failures. Yes Defined how to report failures. Yes Conducting a TeleHealth Service Purpose: To serve as a guide for conducting a TeleHealth service. The intent is to provide direction to the visit to improve efficiencies for the consumer, provider and the presenter (this could be a nurse clinician or other agency staff trained to assist the consumer with the TeleHealth consult). No No No

F-62589 (Rev. 07/08)

Page 6

Office Use Only

C
The policy addresses: Procedures for starting the consult Documentation of any meds ordered and the treatment provided Reasons for the use of TeleHealth An explanation of what occurs with new consumers, established consumers, charts, treatment plans, grievance policy, medication consents, etc. Medication consent procedures Conducting the visit Minimum Transmission Standards Purpose: To establish the minimum standards acceptable for a real-time, interactive videoconference TeleHealth services. Suggested minimum standards are transmission speeds of 256kbps or higher over ISDN or proprietary network connections including VPNs, fractional T1, or T1 or comparable cable bandwidths such as 10 or 40 mb. Programs using transmission speeds of less than 256kbps should have a documented justification that explains the financial feasibility barriers to high cost transmission lines. a. The program transmits services via proprietary lines. Yes b. No

NC

NA

COMMENTS

The program transmits services at speeds equal to or higher than 256kbps. Yes No

c.

If the program does not transmit services equal to or higher than 256kbps, what is the reason? Economically not feasible and services would otherwise not be available Transmission lines for higher speeds not available Other ­ Specify:

(7) CONFIDENTIALITY Maintenance, release, retention, and disposition of consumer service records are kept confidential as required under Chapter 51.30, Wis. Stats., HFS 92, where applicable 42 CFR Part 2, and federal HIPAA requirements. Yes (8) CONSUMER RIGHTS All programs using interactive TeleHealth services shall comply with Chapter 51.61, Wis. Stats., and HFS 94, WAC, on the rights of consumers, and federal HIPAA requirements. Consumers are given the choice of in-person versus interactive TeleHealth consultations. Yes No No

F-62589 (Rev. 07/08)

Page 7

Office Use Only

C
(9) CONSUMER SATISFACTION A satisfaction survey will be conducted for consumers and appropriate family members who use interactive TeleHealth services for access to mental health and substance abuse services. Recommendations include an internal report no less than quarterly and an annual report to the certification agency. The agency / program has a satisfaction survey tool specific to interactive TeleHealth services. Yes No

NC

NA

COMMENTS

The results are disseminated to provider, presenter and administrative staff. Yes No

There is evidence of program changes and improvements in response to satisfaction feedback. Yes No