TY - JOUR
AU - (Ret.), Jeffrey Tebbs, ANC USA,
AB - Abstract Background In 2015, the Army mandated 100% digital storage of telehealth consent forms (DA4700) in the Health Artifact and Image Management Solution (HAIMS) system, and a telebehavioral health (TBH) hub clinic set an aim to accomplish this by improving adherence to referral procedures essential to expanding patient access to videoconferenced (VC) behavioral health care. Methods The Knowledge-to-Action (KTA) planned action framework underpinned development of a two-phase, PDSA (Plan-Do-Study-Act) quality improvement project to increase the rates of TBH new intake consent form completeness and upload adherence. First, a provider education initiative addressed form uploads. Second, TBH consultants prepared (signed and sent) intake forms to referring sites for their patients to finalize during the initial VC encounter. A chart review of consecutive new intake encounters compared data extracted from CY2015 Q1 baseline records (n = 65) with data from CY2016 Q1 improvement period records (n = 40). A total of 352 forms were reviewed. Results Referrals (N = 118) that resulted in kept new VC TBH intake visits (n = 105), originated from three military behavioral health clinic referral sites. In CY2016 Q1, all DA4700 consent forms were uploaded to HAIMS. Telehealth treatment and medication consent form upload adherence increased from 94% and 68%, respectively, to 100% (p > 0.05). Form completeness increased from 36% to 95% (p < 0.001), and multiple linear regression analysis predicted an average 59% increase across the three referral sites (sr2 = 0.54). Conclusion Consultant preparation of telehealth new intake consent forms effectively improved form completeness and increased adherence to new intake referral processes essential to this hub clinic expanding patient access to TBH care. Introduction Synchronous videoconferenced (VC) telehealth care, introduced more than 60 yr ago,1,2 is increasingly available via encrypted Internet connections3 to facilitate patient access to behavioral health care.4 As high-definition video capabilities become ubiquitous, the potential for telebehavioral health (TBH) care to help overcome barriers to care, such as transportation, stigma, remote location, and limited access, is increasing.5–10 Adoption of VC TBH care, however, is progressing more slowly than predicted,11,12 and pragmatic TBH clinical application is proving to be more complex than may have been previously understood.8,13 Concerns identified in the extant literature include patient and provider burden,1,14 scheduling, and site interoperability.12,15 A TBH delivery antecedent essential for expanding patient access to care, that has received little attention in the literature, is the referral process.16–18 New specialty care referrals can be challenging under usual care conditions, with 20% disagreement about referral appropriateness between referring and consulting providers.16,19 Some evidence-based referral process improvement interventions have been explored. Referral template use, for example, has been found to have improved referral quality by 18% (p < 0.001).20 Use of a standardized referral severity assessment tool, on the other hand, has not evidenced improvement in mental health referral quality (OR 1.18, p = 0.05).19 According to a Cochrane review, the interventions most likely to improve referral processes are (1) specific guidelines accompanied by (2) standardized referral forms and (3) consultant involvement in teaching referring providers about referring to their specialty.16 In the emerging field of VC telehealth, where consultants can be more than a thousand miles from referring sites and patients, physical resources may not be as readily available as they would be for in-person behavioral health encounters. For this reason, confidence in TBH processes, supported by adherence to new intake referral procedures, may not only foster the sustainment of a relatively new VC TBH treatment and therapy service but also improve patient access to quality behavioral health care. The purpose of this project, therefore, was to increase new intake referral process adherence through the improvement of TBH new intake consent form completeness and upload adherence rates. Background In 2014, a TBH VC hub clinic in a large military medical center, located in the Pacific Northwest of the United States, implemented a standard operating procedure (SOP) for new TBH intake referrals.21 New intake referrals followed by a new intake visit were conceptualized as being complete when forms required for the visit (Telehealth Informed Consent [DA4700], Privacy Act [DA8001], Limits of Confidentiality [DD2005], and Psychoactive Medication Consent [local form], when medications were prescribed) had been signed as indicated on the forms, correctly dated on or before the intake visit, and uploaded into the electronic health record (EHR). Traditionally, in-person behavioral health consent transactions not requiring a witness occur immediately before treatment and are completed by both the patient and the treating provider at the same time and location. TBH new intake referral processes, however, require that the distance between the patient and the consultant be accommodated. At the time of referral to TBH, the newly referred patient and the physical intake forms are collocated at the referring clinic site with the referring provider. TBH consultants are located at the TBH hub clinic. In order for telehealth consent to occur before the initial TBH VC visit, hub site intake processes rely on referring sites to facilitate intake form completion. In practice, when processes were engaged this way, informed consent transactions occurred at the time of referral, before assignment of a TBH consultant, and weeks before the initial VC interview. To ensure consent at the time of the VC TBH intake, immediately before the intake interview, the TBH treating provider repeated the consent process and documented accordingly in the electronically signed EHR note. According to the hub clinic SOP, referring clinic personnel would then upload intake forms into the EHR. Without a standardized location in which to store TBH documents, form monitoring was difficult, and adherence to new intake referral processes was not well understood. In 2015, the Army’s Medical Command (MEDCOM) Office of the Surgeon General (OTSG) mandated telehealth informed consent forms be uploaded to a specific EHR module: the Health Artifact and Image Management Solution (HAIMS),22 at a compliance rate of 100%.23 A review of existing hub clinic referral processes found that much of the referral improvement evidence in the related literature had been incorporated into the TBH referral process. For example, the TBH team had developed and distributed to referring sites a detailed referral SOP accompanied by a standardized TBH-specific referral form. Referral process education between site coordinators and clinic leaders was also found to be active and ongoing. The strategy of consulting providers directly educating referring providers about intake referral process adherence, however, had been less frequently employed. This approach was therefore selected as an initial evidence-based approach to accomplishing this project’s aim to increase telehealth consent form uploads to 100% by improving TBH new intake referral process adherence. Methods This two-phase performance improvement project employed a Knowledge-to-Action (KTA) planned action theoretical framework to underpin an iterative approach to improving TBH referral process adherence.20,24 The project took place in the adult TBH outpatient clinic of a large medical center that offered clinic-based, voluntary behavioral health care via encrypted, synchronous, bidirectional VC to four remotely located, military referral clinic sites. Services included evidence-based psychotherapy (e.g., cognitive behavioral therapy) and psychotropic medication management. The TBH hub clinic serves military treatment eligible adults able to independently make care decisions, referred to TBH by a Department of Defense (DoD) health care provider. Referrals were originated by referring providers for patients when both were physically present at a DoD behavioral health clinic site remote to the hub clinic, where standard, in-person behavioral health treatment was also offered to the patient as a treatment option. Electronic records of adult patients referred to this TBH hub clinic for new intake during the Pre-improvement Baseline and Improvement Periods, were eligible for inclusion in this project and were reviewed using the Armed Forces Longitudinal Technology Application system. The performance improvement team was composed of a doctorate of nursing practice (DNP) student, and all TBH personnel assigned to the hub clinic: the clinic manager, a master’s prepared psychiatric-mental health nurse practitioner (PMHNP), a DNP PMHNP, two doctorally prepared clinical psychologists, and a psychiatrist. In October 2015, the TBH team set a specific aim to improve referral process adherence by increasing telehealth consent form uploads to HAIMS to 100%23 within 6 mo. The team met weekly until the conclusion of Improvement Period 2 (February 29, 2016), to collaboratively address quality improvement steps for process initiative development and implementation (Plan-Do-Study-Act cycles),25 as outlined in the Institute for Healthcare Improvement, Model for Improvement.26 These steps were then related to FOCUS-PDCA quality assurance guidelines familiar to TBH hub clinic providers: Find a process to improve; Organize a team; Clarify processes; Understand variation and capability; Select a strategy; continuously address progress by Planning, Doing, and Checking improvements in order to Act in a way that sustains improvement.27 Measures New intake records from periods exposed to similar external factors (training, holidays, seasonal weather, etc.) were included in this project. Baseline data were extracted from consecutive eligible records during the first quarter of calendar year 2015. Data for Improvement Periods 1 and 2 were therefore tracked during two consecutive, 1 mo run cycles, the first quarter of the following calendar year (2016). Scheduled new intake visits not initially kept, but that were rescheduled and kept, were counted as a single kept intake. Prospective, kept new intake records were assessed within 72 hr of each VC TBH intake visit, and data were extracted using the same spreadsheet tool used to collect Pre-improvement Baseline data. These data included (1) kept new intakes: new intake encounters expressed as a percentage of new intake referrals, (2) forms complete: of the forms required, the percentage of forms found to have the correct date, patient, and provider signatures as indicated on each form, (3) form upload adherence: the percentage of forms required, uploaded within 72 hr after each kept new intake, (4) informed consent adherence: of the DA4700 forms required, the percentage of forms uploaded within 72 hr after each kept new intake, and (5) medication consent adherence: the percentage of Psychoactive Medication Consent forms required, uploaded within 72 hr after each kept new intake. Evaluation During Improvement Period 1 (January 1–31, 2016), form upload nonadherence prompted the TBH hub site facilitator to prepare a standardized process education email for the consulting TBH provider to review and use to inform the referring provider of upload requirements. During Improvement Period 2 (February 1–29, 2016), the consulting provider prepared new intake consent forms and sent them to the referring site to be finalized by the patient during the initial VC encounter, immediately before TBH treatment. Run chart data were analyzed using Institute for Hospital Improvement guidelines.26 SPSS version 23 was used for data analysis. Chi-squared test was used to compute goodness of fit and tests of independence for categorical data (α = 0.05). Fisher’s exact test was used to calculate p-values when expected frequencies were <5. Multiple linear regression with sequential predictor entry was used to control for referral sites and evaluate process improvement initiative effects (e.g., form completeness). There was some concern for small group dependence because data were drawn from kept new intake referrals initiated by three referral sites. Referral site category data were coded into a set of two predictors and explicitly controlled for (as fixed effects) to avoid residual non-independence. Another concern was for group dependence related to provider; however, the processes of interest involved administrative function more than provider skill. Provider, therefore, was not entered into the regression model as a variable. For ease of result interpretation, referral sites and improvement conditions were effect coded. Referral Site 3 generated the most kept new intake records (n = 84) and served as the reference site. The Pre-improvement Baseline period with the most kept new intake records (n = 65) was used as the reference period. Referral site predictors were entered into Block 1, and main effects (Improvement Periods 1 and 2) were added in Block 2. Subjects for this project were new intake records, and improvement period initiatives targeted adherence to an established SOP. Although Institutional Review Board approval was not required, the military medical center’s Department of Clinical Investigations, Center Judge Advocate, and Department of Behavioral Health approved this project as a quality improvement project. Results Referrals for TBH new intake visits were initiated by four referral clinic sites (N = 118). Referral Site 1 produced no referrals resulting in kept new intake visits and was excluded from further analysis. All kept new intake records from the three project periods, inclusive of 352 forms, were included (Table I). Of 118 new intake TBH referrals, 105 (89%) resulted in kept new TBH intake records (p < 0.001). Pre-improvement Baseline and Improvement Period 1 and 2 groups’ kept new intake rates were not significantly different from each other (p > 0.05). Kept new intake rates and informed consent upload adherence rates during the Pre-improvement Baseline period were above 92% (p’s < 0.001, respectively). The baseline medication consent adherence rate, on the other hand, was 68% (p > 0.05), and the forms complete baseline rate was significantly lower than might have been expected had these forms been completed at random (36%, p < 0.001). Table I. Telebehavioral Health New Intake Referral Process Adherence Process Adherence  New Intake Referrals: N = 118, 352 Forms Required  Pre-improvement Baseline Period (n = 70, 217 Forms)  Improvement Period 1 (n = 30, 91 Forms)  Improvement Period 2 (n = 18, 44 Forms)  No. (%)  No. (%)  No. (%)  Kept new intakes  65 (92.86)*  26 (86.67)  14 (77.78)  Informed consent adherence  61 (93.85)*  26 (100.00)  14 (100.00)  Medication consent adherence  17 (68.00)  12 (85.71)  2 (100.00)  Forms complete  79 (36.41)*  31 (34.07)  42 (95.45)*  Process Adherence  New Intake Referrals: N = 118, 352 Forms Required  Pre-improvement Baseline Period (n = 70, 217 Forms)  Improvement Period 1 (n = 30, 91 Forms)  Improvement Period 2 (n = 18, 44 Forms)  No. (%)  No. (%)  No. (%)  Kept new intakes  65 (92.86)*  26 (86.67)  14 (77.78)  Informed consent adherence  61 (93.85)*  26 (100.00)  14 (100.00)  Medication consent adherence  17 (68.00)  12 (85.71)  2 (100.00)  Forms complete  79 (36.41)*  31 (34.07)  42 (95.45)*  Forms required: Telehealth Informed Consent [DA4700], Privacy Act [DA8001], Limits of Confidentiality [DD2005], and Psychoactive Medication Consent [local form] when medications were prescribed during the visit. Kept new intakes: of new intake referrals, the percentage of documented new intake encounters. Informed consent adherence: of the DA4700 forms required, the percentage uploaded within 72 hr after intake. Medication consent adherence: of the Psychotropic Medication Consent forms required, the percentage uploaded within 72 hr after intake. Forms complete: of the total forms required, percentage of forms with correct date, and patient and provider signatures. Pre-improvement Baseline Period: January through March, 2015. Improvement Period 1: January, 2016. Improvement Period 2: February, 2016. *p < 0.001. Table I. Telebehavioral Health New Intake Referral Process Adherence Process Adherence  New Intake Referrals: N = 118, 352 Forms Required  Pre-improvement Baseline Period (n = 70, 217 Forms)  Improvement Period 1 (n = 30, 91 Forms)  Improvement Period 2 (n = 18, 44 Forms)  No. (%)  No. (%)  No. (%)  Kept new intakes  65 (92.86)*  26 (86.67)  14 (77.78)  Informed consent adherence  61 (93.85)*  26 (100.00)  14 (100.00)  Medication consent adherence  17 (68.00)  12 (85.71)  2 (100.00)  Forms complete  79 (36.41)*  31 (34.07)  42 (95.45)*  Process Adherence  New Intake Referrals: N = 118, 352 Forms Required  Pre-improvement Baseline Period (n = 70, 217 Forms)  Improvement Period 1 (n = 30, 91 Forms)  Improvement Period 2 (n = 18, 44 Forms)  No. (%)  No. (%)  No. (%)  Kept new intakes  65 (92.86)*  26 (86.67)  14 (77.78)  Informed consent adherence  61 (93.85)*  26 (100.00)  14 (100.00)  Medication consent adherence  17 (68.00)  12 (85.71)  2 (100.00)  Forms complete  79 (36.41)*  31 (34.07)  42 (95.45)*  Forms required: Telehealth Informed Consent [DA4700], Privacy Act [DA8001], Limits of Confidentiality [DD2005], and Psychoactive Medication Consent [local form] when medications were prescribed during the visit. Kept new intakes: of new intake referrals, the percentage of documented new intake encounters. Informed consent adherence: of the DA4700 forms required, the percentage uploaded within 72 hr after intake. Medication consent adherence: of the Psychotropic Medication Consent forms required, the percentage uploaded within 72 hr after intake. Forms complete: of the total forms required, percentage of forms with correct date, and patient and provider signatures. Pre-improvement Baseline Period: January through March, 2015. Improvement Period 1: January, 2016. Improvement Period 2: February, 2016. *p < 0.001. During Process Improvement Period 1 (provider education initiative), telehealth informed consent upload rates improved 6% from the Pre-improvement Baseline rate to 100% (p > 0.05) and remained at 100% through Improvement Period 2. Psychoactive medication consent form upload adherence improved by 18% to 86% during Improvement Period 1, and during Improvement Period 2, improved to 100% (p’s > 0.05). During Improvement Period 2 (consultant form preparation initiative), the rate of consent forms complete evidenced the greatest change, increasing from a baseline rate of 36% to 95% (p < 0.001). On the corresponding run chart, this was interpreted as an astronomical data point, a change signal warranting further analysis of form completeness data (Fig. 1). Figure 1. View largeDownload slide Telebehavioral Health New Intake Referral Process Adherence Periods. Process Adherence: Upload of Telehealth Informed Consent [DA4700] and Psychoactive Medication Consent [local form] forms, within 72 hr after a documented new intake visit with all intake forms completed. Informed Consent: of the required DA4700 telehealth consent forms, the percentage uploaded within 72 hr after a new intake visit. Med Consent: of the required Psychoactive Medication Consent forms required, the percentage uploaded within 72 hr after a new intake visit. Forms Complete: correct date, patient and provider signatures on each of four required forms, (A) [DA4700], (B) Privacy Act [DA8001], (C) Limits of Confidentiality [DD2005], and (D) Psychoactive Medication Consent when medications were prescribed during the visit. Pre-improvement Baseline: January through March, 2015. Improvement Period 1: January, 2016. Improvement Period 2: February, 2016. *p < 0.001. Figure 1. View largeDownload slide Telebehavioral Health New Intake Referral Process Adherence Periods. Process Adherence: Upload of Telehealth Informed Consent [DA4700] and Psychoactive Medication Consent [local form] forms, within 72 hr after a documented new intake visit with all intake forms completed. Informed Consent: of the required DA4700 telehealth consent forms, the percentage uploaded within 72 hr after a new intake visit. Med Consent: of the required Psychoactive Medication Consent forms required, the percentage uploaded within 72 hr after a new intake visit. Forms Complete: correct date, patient and provider signatures on each of four required forms, (A) [DA4700], (B) Privacy Act [DA8001], (C) Limits of Confidentiality [DD2005], and (D) Psychoactive Medication Consent when medications were prescribed during the visit. Pre-improvement Baseline: January through March, 2015. Improvement Period 1: January, 2016. Improvement Period 2: February, 2016. *p < 0.001. Form completeness data were evaluated for significant correlations. As shown in Table II, Referral Site 2 significantly correlated with the form completeness outcome (r = 0.23, p < 0.05), indicating that records from this site were significantly associated with completed intake forms. Referral Site 2 was also correlated with improvement periods 1 and 2 (r’s = 0.28, 0.30; p’s < 0.01, respectively). Importantly, there was a significant negative relationship between Improvement Period 1 and the form completeness outcome (r = −0.20, p < 0.05), while there was a significant positive relationship between Improvement Period 2 and the form completeness outcome (r = 0.78, p < 0.01). Improvement periods 1 and 2 both negatively correlated with each other (r = −0.23, p < 0.05), as they both shared a reference category (the Pre-improvement Baseline period). Table II. Telebehavioral Health New Intake Form Completeness Descriptives and Zero-Order Correlations Measure  Mean  (SD)  1.  2.  3.  4.  5.  Outcome   1. Form completeness  0.43  (0.27)  —          Block 1 predictors   2. Referral Site 2  0.11  (0.32)  0.23*  —         3. Referral Site 4  0.09  (0.28)  −0.15  −0.11  —      Block 2 predictors   4. Improvement Period 1  0.25  (0.43)  −0.20*  0.28**  −0.18  —     5. Improvement Period 2  0.13  (0.34)  0.78**  0.30**  −0.12  −0.23*  —  Measure  Mean  (SD)  1.  2.  3.  4.  5.  Outcome   1. Form completeness  0.43  (0.27)  —          Block 1 predictors   2. Referral Site 2  0.11  (0.32)  0.23*  —         3. Referral Site 4  0.09  (0.28)  −0.15  −0.11  —      Block 2 predictors   4. Improvement Period 1  0.25  (0.43)  −0.20*  0.28**  −0.18  —     5. Improvement Period 2  0.13  (0.34)  0.78**  0.30**  −0.12  −0.23*  —  N = 105. Form completeness: of the total forms required ((A) Telehealth Informed Consent [DA4700], (B) Psychoactive Medication Consent [local form], (C) Privacy Act [DA8001], (D) Limits of Confidentiality [DD2005] when medications were prescribed during the visit), the percentage of forms found to have the correct date, and patient and provider signatures. Referral sites and improvement periods were dummy coded with Referral Site 3 serving as the reference site. Pre-improvement Baseline (January through March, 2015) served as the reference period. Improvement Period 1: January, 2015. Improvement Period 2: February, 2016. *p < 0.05; **p < 0.01. Table II. Telebehavioral Health New Intake Form Completeness Descriptives and Zero-Order Correlations Measure  Mean  (SD)  1.  2.  3.  4.  5.  Outcome   1. Form completeness  0.43  (0.27)  —          Block 1 predictors   2. Referral Site 2  0.11  (0.32)  0.23*  —         3. Referral Site 4  0.09  (0.28)  −0.15  −0.11  —      Block 2 predictors   4. Improvement Period 1  0.25  (0.43)  −0.20*  0.28**  −0.18  —     5. Improvement Period 2  0.13  (0.34)  0.78**  0.30**  −0.12  −0.23*  —  Measure  Mean  (SD)  1.  2.  3.  4.  5.  Outcome   1. Form completeness  0.43  (0.27)  —          Block 1 predictors   2. Referral Site 2  0.11  (0.32)  0.23*  —         3. Referral Site 4  0.09  (0.28)  −0.15  −0.11  —      Block 2 predictors   4. Improvement Period 1  0.25  (0.43)  −0.20*  0.28**  −0.18  —     5. Improvement Period 2  0.13  (0.34)  0.78**  0.30**  −0.12  −0.23*  —  N = 105. Form completeness: of the total forms required ((A) Telehealth Informed Consent [DA4700], (B) Psychoactive Medication Consent [local form], (C) Privacy Act [DA8001], (D) Limits of Confidentiality [DD2005] when medications were prescribed during the visit), the percentage of forms found to have the correct date, and patient and provider signatures. Referral sites and improvement periods were dummy coded with Referral Site 3 serving as the reference site. Pre-improvement Baseline (January through March, 2015) served as the reference period. Improvement Period 1: January, 2015. Improvement Period 2: February, 2016. *p < 0.05; **p < 0.01. As can be seen in Table III, Block 1, which included referral site predictors, accounted for significant variation in form completeness, R2 = 0.07, p < 0.05. Block 2, which included improvement period main effects, also accounted for significant upload completeness variation above and beyond referral site effects, R2change = 0.54 (p < 0.001). These final model results, inclusive of all predictors, indicated that the mean form completeness across referring sites was estimated at 54% (SE = 3%), which was significantly different from zero, holding all other variables constant (t[100] = 19.20, p < 0.001). Given the significance of Block 1, it was interesting that the referral site variables did not uniquely predict form completeness (slope coefficient t-tests p’s > 0.05). Table III. Telebehavioral Health New Intake Form Completeness Model Fit   Block 1  Block 2  R2total  R2adj  b  sr2  R2change  R2total  R2adj  b  sr2  Model fit  0.07*  0.05      0.54***  0.61***  0.59      Coefficients   Intercept      0.44***          0.54***     Referral Site 2      0.16**  0.07        0.03  <0.01   Referral Site 4      −0.14*  0.04        −0.04  <0.01   Improvement Period 1                −0.22***  0.23   Improvement Period 2                0.40***  0.54    Block 1  Block 2  R2total  R2adj  b  sr2  R2change  R2total  R2adj  b  sr2  Model fit  0.07*  0.05      0.54***  0.61***  0.59      Coefficients   Intercept      0.44***          0.54***     Referral Site 2      0.16**  0.07        0.03  <0.01   Referral Site 4      −0.14*  0.04        −0.04  <0.01   Improvement Period 1                −0.22***  0.23   Improvement Period 2                0.40***  0.54  N = 105. Block 1 F-change test df = 2, 102; Block 2 df = 2, 100. Form Completeness: of the total forms required ((A) Telehealth Informed Consent [DA4700], (B) Psychoactive Medication Consent [local form] when medications were prescribed during the visit, (C) Privacy Act [DA8001], (D) Limits of Confidentiality [DD2005] as indicated), the percentage of forms found to have the correct date, and patient and provider signatures. Referral sites and improvement periods were effect coded with Referral Site 3 serving as the reference site. Pre-improvement Baseline (January through March, 2015) served as the reference period. Improvement Period 1: January, 2016. Improvement Period 2: February 2016. *p < 0.05; **p < 0.01; ***p < 0.001. Table III. Telebehavioral Health New Intake Form Completeness Model Fit   Block 1  Block 2  R2total  R2adj  b  sr2  R2change  R2total  R2adj  b  sr2  Model fit  0.07*  0.05      0.54***  0.61***  0.59      Coefficients   Intercept      0.44***          0.54***     Referral Site 2      0.16**  0.07        0.03  <0.01   Referral Site 4      −0.14*  0.04        −0.04  <0.01   Improvement Period 1                −0.22***  0.23   Improvement Period 2                0.40***  0.54    Block 1  Block 2  R2total  R2adj  b  sr2  R2change  R2total  R2adj  b  sr2  Model fit  0.07*  0.05      0.54***  0.61***  0.59      Coefficients   Intercept      0.44***          0.54***     Referral Site 2      0.16**  0.07        0.03  <0.01   Referral Site 4      −0.14*  0.04        −0.04  <0.01   Improvement Period 1                −0.22***  0.23   Improvement Period 2                0.40***  0.54  N = 105. Block 1 F-change test df = 2, 102; Block 2 df = 2, 100. Form Completeness: of the total forms required ((A) Telehealth Informed Consent [DA4700], (B) Psychoactive Medication Consent [local form] when medications were prescribed during the visit, (C) Privacy Act [DA8001], (D) Limits of Confidentiality [DD2005] as indicated), the percentage of forms found to have the correct date, and patient and provider signatures. Referral sites and improvement periods were effect coded with Referral Site 3 serving as the reference site. Pre-improvement Baseline (January through March, 2015) served as the reference period. Improvement Period 1: January, 2016. Improvement Period 2: February 2016. *p < 0.05; **p < 0.01; ***p < 0.001. More interestingly, while Improvement Period 1 uniquely, negatively predicted form completeness, Improvement Period 2 uniquely, positively predicted form completeness. To understand the nature of these relationships, model-implied values for both groups across the three project periods (Pre-improvement Baseline, Improvement Period 1, Improvement Period 2) were computed. Referral sites and improvement periods were not significantly correlated in the final block (p’s > 0.05, respectively), as shown in Table III. In contrast, predicted form completeness across the three sites increased by 59% from the Pre-improvement Baseline to Improvement Period 2 (p < 0.001), holding all else constant. In other words, TBH kept intakes, referred to this medical center’s TBH hub clinic, from three specific sites, during an improvement period where consulting TBH providers prepared and signed intake forms, showed significant positive effect, on average, for new intake form completeness (sr2 = 0.54). Discussion This two-phase quality improvement project demonstrated how, through the use of the KTA planned action theoretical framework to guide iterative process initiatives, the TBH hub clinic improved adherence to its new intake referral processes and complied with the Army mandate that DA4700 forms be uploaded to HAIMS. Because the baseline DA4700 upload adherence rate was high, the maximum possible upload rate increase was too small to evidence statistically significant change. Baseline medication consent form upload adherence, on the other hand, was not significantly different from form uploads that might have occurred at random. Although the medication consent upload adherence rate increased considerably, the number of visits involving psychotropic medication prescription was insufficient to demonstrate significant change. Of concern to the TBH team during this first project phase was that baseline form completeness rates declined from an already low completion rate. The team felt comfortable that patient’s were voluntarily signing consent forms before treatment, and that the consultant providers were explaining telehealth risks and benefits to ensure consent at the time of intake and documenting this in the shared EHR. Nevertheless, incomplete consent forms seemed not to support program sustainment because without being evaluated while pairing them with a VC TBH intake note, these forms might be interpreted as suggesting patient participation without a full understanding of risks. When discussing incomplete new intake forms, the TBH team noticed that while patient signatures were uniformly present, consenting provider signatures seemed to be present with less consistency. This raised questions about provider consensus regarding TBH new intake consent processes and presented an opportunity to clarify an important element of the consent process. Some team members expressed a view that aligned with the status quo: patients referred to this TBH service should (1) be informed about telehealth before the first VC TBH visit and (2) have an opportunity to sign the telehealth consent form in the physical presence of a referring provider, who was (3) also expected to sign the consent form at the time of referral. The counterargument was that (1) the VC platform itself was not treatment requiring consent, (2) TBH consultants routinely repeated informed consent processes via VC immediately before the initial intake interview, and (3) in their electronically signed note, TBH consultants were already documenting consent at the time of intake in their electronically signed note. An analogy became prominent in these discussions: just as a surgeon, interested in patient-centered decision-making, consents his/her surgical candidates,28 the treating TBH consultant should consent their patients for treatment via VC. VC-enabled telehealth treatment consent protocols exist in research literature, and with this in mind, it seemed possible to the TBH team that telehealth informed consent processes could be adjusted to more closely replicate in-person behavioral health care. The TBH team reached consensus that consultant preparation of consent forms could mitigate the risk and/or the perception of inadequate consent processes, and a TBH psychologist suggested that consultants could prepare and sign intake forms for their patients to complete during the intake VC, before treatment. After developing and implementing this initiative, the team noted: form upload rates remained high, CY2016 Q1 forms stored in a standard (HAIMS) location were more readily verifiable than the forms uploaded in CY2015 Q1, and TBH provider burden for continued adherence monitoring was deemed to be reasonable by consultants. This led to a suggestion from the TBH psychiatrist to modify the clinic’s internal peer review checklist to include both form upload adherence and completeness items. Limitations This project had several limitations. The number of 1-mo Improvement Periods (run cycles) was limited by a statement of mutual understanding and training agreement between the university sponsoring the DNP student and the medical center. Discussions with TBH team members about this project began in August of 2015. The first run cycle (Improvement Period 1) was January 2016, and communication between consulting and referring site personnel about the intention to track intake form uploads was not avoided. For example, administrative site coordinators, responsible for physical form uploads, communicated regularly. A Hawthorne effect was therefore possible. Subjects for this project were new intake records, and improvement period initiatives targeted adherence to an established SOP, so individual patient demographic data were not identified or evaluated. Other than tracking whether or not psychotropic medication had been prescribed during the intake visit, diagnostic case mix and types of behavioral health therapy were not differentiated. Similarly, referral site staff mix over time was not tracked. Most TBH referrals and kept intakes were attributed to a single referral site, and form completeness outcome data were not normally distributed. In addition to specific referral process improvements, regression analysis results are specific to the characteristics of the three of the four possible referring sites and were considered fixed effects. So, regression findings are not generalizable to other referring sites. Future research should therefore examine, in addition to other specific types of referral improvements, longer term, rather than shorter term, improvement effects. Despite these documented limitations, the overall performance improvement efforts may include approaches and lessons learned that could be applicable to other sites addressing similar challenges. Conclusion This project improved adherence to this VC TBH hub clinic’s established new intake referral SOP, and within 6 mo, met a goal for all new telehealth consent forms to be uploaded to HAIMS. In doing so, the quality improvement team clarified a key point of process variation and took steps to sustain project gains. While further study is indicated, this project’s findings support consultant preparation of consent forms to increase adherence to new intake referral processes essential to expanding patient access to VC behavioral health care. Acknowledgments The author acknowledges the following for significant contributions to this project: Meghan Davis, TBH site coordinator, Gregory Kramer, PhD, Kristin Lindstrom, PsyD, Simon Pincus, MD, and Eileen Poupore, DNP. Presentations Presented as an oral presentation at the 2016 Military Health System Research Symposium, Kissimmee, FL (abstract number: MHSRS-16–0729), as a poster presentation at the 2016 Association of Military Surgeons of the United States Annual Meeting, National Harbor, MD (abstract number: 6430), and as an oral presentation at the 5th Annual Pacific Regional Behavioral Health Summit, Honolulu, HI (date: 09/09/16). Funding This work was supported in part by the National Institutes of Health, National Institute for Nursing Research Aging and Informatics Training Grant Program (Grant number:T32NR014833, principal investigator (for the training grant): Demiris) and the Jonas Nurse Leaders Scholarship Foundation (2016–2018 cohort). 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All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
TI - Videoconferenced Telebehavioral Health Referral Process Adherence
JF - Military Medicine
DO - 10.1093/milmed/usx141
DA - 2018-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/videoconferenced-telebehavioral-health-referral-process-adherence-g02Lvs60C0
SP - 92
EP - 98
VL - 183
IS - suppl_1
DP - DeepDyve
ER -