As Required By Section 1009(d) Of The Substance Use .

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REPORT TO CONGRESSREDUCING BARRIERS TO FURNISHING SUBSTANCE USE DISORDER (SUD)SERVICES USING TELEHEALTH AND REMOTE PATIENT MONITORING FORPEDIATRIC POPULATIONS UNDER MEDICAIDFINAL REPORTAs Required by section 1009(d) of theSubstance Use-Disorder Prevention that Promotes Opioid Recovery and Treatmentfor Patients and Communities Act (Pub. L. 115-271)May 15, 2020

Section 1009(d) of the SUPPORT for Patients and Communities Act required the Secretary ofHealth and Human Services (HHS), acting through the Administrator of the Centers forMedicare & Medicaid Services (CMS), to issue this final report. The Office of the AssistantSecretary for Planning and Evaluation (ASPE) and their contractor RTI International preparedthis final report in consultation with CMS. While this report includes programs and cites to lawsadministered by federal agencies, it is not a federal endorsement of specific programs. Allresearch included in this report was completed in 2019 prior to the COVID-19 national publichealth emergency.

CONTENTSSectionPageEXECUTIVE SUMMARY.ES-1Background .1Purpose and Scope .2Data and Methods .5Data Collection .5Environmental Scan . 5Case Studies . 8Data Analysis .10Results .12Overview of Environmental Scan Results .12Environmental Scan and Discussion Results by Question .14What Are the Best Practices, Barriers and Potential Solutions for UsingServices Delivered Via Telehealth to Diagnose and Provide Servicesand Treatment for Children With SUD, Including OUD? (ResearchQuestion #1) . 14What Are the Differences, If Any, in Furnishing Services and Treatment forChildren With SUD Using Services Delivered Via Telehealth andUsing Services Delivered in Person? (Research Question #2) . 18Delivery of Pediatric Behavioral Health Treatment via Telehealth .23Program Examples . 23Policy and Reimbursement Considerations .26Telehealth Policies that Influence Delivery of SUD Treatment . 26Medicare and Medicaid Coverage . 29Federal Models and Programs to Support Telehealth . 33Privacy and Confidentiality Considerations . 35Key Informant Discussions .38Overview of Key Informant Discussion Results .38What Are the Best Practices, Common Barriers and Potential Solutions for UsingServices Delivered via Telehealth to Diagnose and Provide Services andTreatment for Children with SUD, Including OUD (Research Question 1)? .38Best Practices . 38Detailed Best Practices Emphasized by Key Informants. 41Reducing Barriers to Using Telehealth for Pediatric PopulationsFinal Report

Barriers and Solutions. 43What Are the Differences, If Any, in Furnishing Services and Treatment forChildren with SUD Using Services Delivered via Telehealth and UsingServices Delivered in Person? (Research Question 2) .48Utilization rates, costs and avoidable inpatient admissions andreadmissions . 48Quality and Satisfaction . 49Case Studies.52Case Study Programs .52Case Study 1: The Medical University of South Carolina’s TelehealthOutreach Program . 52Case Study 2: University of Kansas Medical Center’s Telehealth ROCKSSchools, Rural Outreach for Children of Kansas . 55Case Study Results by Question .62What Are the Best Practices, Barriers and Potential Solutions for UsingServices Delivered Via Telehealth to Diagnose and Provide Servicesand Treatment for Children With SUD, Including OUD? (ResearchQuestion #1) . 62What Are the Differences, If Any, in Furnishing Services and Treatment forChildren With SUD Using Services Delivered Via Telehealth andUsing Services Delivered in Person? (Research Question #2) . 64Discussion .67Best Practices: .67Videoconferencing . 67Support Staff . 68School-based Models. 68Barriers, Solutions and Information Gaps.68Quality and Fidelity . 68Patient Safety . 69Acceptance of a Telehealth Program. 69Financing . 69Consent for Services . 70Cost Studies . 70Summary .70References .R-1Reducing Barriers to Using Telehealth for Pediatric PopulationsFinal Report

APPENDIXESKey Informant Interview Guide . A-1Case Study Interview Guides .B-1EXHIBITSSummary of Evidence from Available Literature . 12Reducing Barriers to Using Telehealth for Pediatric PopulationsFinal Report

EXECUTIVE SUMMARYIntroductionSection 1009(d) of the SUPPORT Act requires the Secretary of the Department of Health andHuman Services, acting through the Administrator of the Centers for Medicare & MedicaidServices (CMS), to provide a report to Congress identifying best practices and potential solutionsfor reducing barriers to using services delivered via telehealth to furnish services and treatmentfor substance use disorder (SUDs) among pediatric populations under Medicaid. The Office ofthe Assistant Secretary for Planning and Evaluation (ASPE) and their contractor ResearchTriangle Institute (RTI) International drafted this final report in consultation with CMS.Although generally telehealth has become more prevalent in the last decade, uptake is not yetwidespread (Bashshur, Shannon, Bashshur, & Yellowlees, 2016; Benavides-Vaello, Strode, &Sheeran, 2013; Dorsey & Topol, 2016), particularly among pediatric populations with SUD.Understanding the barriers to the use of telehealth and best practices to overcome these barriersamong the pediatric population is critical to increasing access to SUD services for thispopulation.MethodsRTI conducted an environmental scan, interviewed key researchers, clinicians, and healthcareadministrator informants via phone, and conducted two in-person case studies to identify bestpractices, barriers and potential solutions for using services delivered via telehealth to diagnoseand provide services for pediatric patients with SUD. Differences in service provision forchildren with SUD using services delivered via telehealth and using services delivered in personwere also explored with respect to utilization rates; costs; avoidable inpatient admissions andreadmissions; quality of care; and patient, family, and provider satisfaction.ResultsBest PracticesBest practices are still evolving and emerging; however, there are a few general principles fortelehealth applicable to behavioral health, including the need for organizational readiness,engagement of clinical and administrative staff, investment in technology, efforts to increaseReducing Barriers to Using Telehealth for Pediatric PopulationsFinal ReportES-1

technology acceptance, and support of ongoing service delivery. Key informants also mentionedworkforce shortages, balancing face-to-face and telehealth sessions, having a designatedtelehealth coordinator, and engagement of families, specifically.BarriersThe environmental scan revealed that the lack of technology investment and technologyacceptance are barriers to the provision of services via telehealth. Ongoing service delivery,capacity issues, licensing and credentialing requirements can also be challenging. Keyinformants added that barriers often exist due to state limits and restrictions on reimbursementfor telehealth services. They also noted workforce shortages and concerns about the loss of nonverbal cues or other SUD-related cues are barriers (e.g., the patient’s smell, hygiene, or visualindicators of self-harm). A specific barrier that emerged in the case studies were state laws thatprohibited prescribing any controlled substances for students in a school-based clinic other thanattention-deficit/hyperactivity disorder (ADHD) medications.Potential SolutionsIdentification of systems and processes to support coordination within and across organizationsmay help address the barriers associated with capacity and ongoing service development. Thekey informants stressed the value of having a dedicated telehealth program coordinator tofacilitate solutions to common barriers, and the importance of site-based staff to supporttelehealth programs was emphasized in the case studies. Initiatives to increase technology access(e.g., broadband internet) and decrease technology costs may help address barriers to servicedelivery. Training of clinical and administrative staff and patients may also improve technologyacceptance.Utilization RatesThe environmental scan showed that utilization rates may be higher at schools with versuswithout services delivered via telehealth for students with special health care needs and in ruralareas versus urban areas. The case studies showed that the telehealth program representativesfeel that their patients are much more likely to persist in treatment than face-to-face patients,with one program reporting a 90% completion rate. Further study is needed to obtain more robustReducing Barriers to Using Telehealth for Pediatric PopulationsFinal ReportES-2

estimates of the net changes in health care utilization associated with telehealth-delivered mentalhealth or substance use disorder (MH/SUD) services.CostsInformation specific to the total cost of care and treatment was limited. Few studies provided anyquantifiable results on the costs of telehealth models. While case study participants also did nothave formal economic data available, they noted that payers and other providers had not reportedexcess costs or use of other services among their patients. They also noted that, beyond nearterm health care cost savings, they felt strongly that their programs would ultimately save societyresources by reducing inefficient use of misapplied community resources (e.g., teacher time) andreducing the long-term costs associated with untreated pediatric disorders. On average, theprogram representatives believe that the cost of their services delivered via telehealth was equalto that of in-person services, even including some fixed technology costs.Avoidable Inpatient Admissions and ReadmissionsThere was limited information in the environmental scan about how telehealth for pediatricpatients with SUD impacts avoidable inpatient admissions and readmissions. Results are variedwith respect to whether telehealth interventions increase or decrease use of urgent or emergencycare.Quality of CareOverall, the quality of telehealth care is similar to that of face-to-face care, both generally and inbehavioral health, specifically. Case study participants felt that the quality of their programs wasas good as or better than face-to-face delivery.Patient, Family and Provider SatisfactionTelehealth use and satisfaction is influenced by both pediatric patients’ and their caregivers’access to technology, knowledge of available resources, and willingness to interact with thetechnology, all factors that may be influenced by the potential user’s educational,socioeconomic, health, and other personal characteristics. Key informants agreed that telehealthas a modality for pediatric SUDs is often preferred by patients over traditional encounters.Reducing Barriers to Using Telehealth for Pediatric PopulationsFinal ReportES-3

Telehealth satisfaction and uptake is also influenced by provider factors such as training andtechnology acceptance.The environmental scan also yielded examples of programs that demonstrate the potentialadvantages of providing services via telehealth, including the reduction of unnecessary patienttransfers, improved access to services through school-based care, and provision of training,expertise, and/or certification opportunities to providers in areas that are relevant to the patientsthey are treating.Many of the resources reviewed in the environmental scan called for regulatory changes topromote the uptake of telehealth delivery methods to treat SUDs. The scan identified a numberof policies, many of which support the use of telehealth more generally and were not unique topediatric patients with SUD. Those policies that did specifically address telehealth servicedelivery methods emphasized the treatment of opioid use disorder (OUD) and medicationassisted treatment (MAT). Policies governing privacy and protection of personal data influencetelehealth models, particularly for pediatric patients and their parents and for sensitive care areaslike SUD and mental health.Medicaid coverage for services delivered via telehealth varies by state according to factors suchas the setting where the patient is located, types of services, provider type, and whether theservice was delivered synchronously or asynchronously. Some states restrict reimbursement forservices delivered via telehealth for behavioral health issues. All states providing Medicaidcovered services delivered via telehealth include some form of coverage and reimbursement forcertain mental health services.Discussion/ConclusionMuch of the evidence base for the use of telehealth with pediatric patients comes from treatmentof mental disorders, which provides valuable lessons learned and next steps forward. Overall,programs are successfully providing quality services to patients who may not otherwise haveaccess. Many questions remain, however, around best practices in different settings withdifferent pediatric patient disorders, optimal staffing and financial viability.Reducing Barriers to Using Telehealth for Pediatric PopulationsFinal ReportES-4

[This page intentionally left blank]Reducing Barriers to Using Telehealth for Pediatric PopulationsFinal ReportES-5

BACKGROUNDSubstance use disorder (SUD) among the pediatric population (ages up to 21) has beenidentified as a significant public health concern. As of 2018, an estimated 3.7 percent ofadolescents aged 12 to 17, and 12.9 percent of young adults aged 18 to 20, had an SUD(SAMHSA, 2019). Substance use during adolescence is associated with short- and long-termnegative effects on functioning and well-being. Brain development may be delayed or alteredwith consequences that can persist throughout adulthood (Chassin et al., 2010; Eiden et al., 2016;Squeglia, Jacobus, & Tapert, 2009; Tapert, Caldwell, & Burke, 2004). Substance usingadolescents are more likely to experience worse mental health and have behavioral problems (Aliet al., 2015; Bouvier et al., 2019; Poon, Turpyn, Hansen, Jacangelo, & Chaplin, 2016; Schuler,Vasilenko, & Lanza, 2015; Trim, Meehan, King, & Chassin, 2007; Volkow, Baler, Compton, &Weiss, 2014) and to have poorer academic outcomes (Heradstveit, Skogen, Hetland, & Hysing,2017; Kelly et al., 2015). Adolescents with early onset heavy substance use are most likely toremain heavy users as they transition into adulthood (Derefinko et al., 2016; Winters et al.,2018). Despite evidence for the effectiveness of many different treatment modalities foradolescents (Nelson, Ryzin, & Dishion, 2015; Wu, Zhu, & Swartz, 2016), only 14.1 percentreceived any form of SUD treatment. Among all adolescents with an SUD, those with opioid usedisorder (OUD) are the least likely to receive treatment (Winters et al., 2018; Wu et al., 2016).Adolescents face many barriers to accessing treatment, including stigma, which may preventadolescents or their guardians from seeking help; logistical limitations, such as a lack oftransportation or locally available specialty treatment providers; and financial limitations, such asbeing uninsured or underinsured. Among many strategies to reduce barriers to treatment access,telehealth models of service delivery have the promise of expanding access, improving treatmentengagement and retention, enhancing the clinical outcomes of evidence-based services, andreducing costs (Bashshur et al., 2016; Benavides-Vaello et al., 2013; Wu et al., 2016).Although generally telehealth

Final Report ES-4 Telehealth satisfaction and uptake is also influenced by prov ider factors such as training and technology acceptance. The environmental scan also yielded examples of programs that demonstrate the potential advantages of providing services via telehealth , including the reduction of unnecessary patient

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