Adressing the Healthcare Crisis Through Telehealth Evaluating Needs

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Introduction

  • Many people miss out on adequate care;
  • Key barriers: lack of insurance, high costs of care, long wait times, lack of transportation;
  • Challenges addressing chronic conditions;
  • Patients in rural areas do not receive the needed level of care;
  • Need to treat patients regardless of access barriers;
  • An immediate and pragmatic solution is needed;
  • Different forms of communication technology may be used.

Evaluating General Needs

  • Telehealth projects can give rural residents better access to disease prevention and management projects (Wu, 2016);
  • Need to address the following challenges in rural health:

    • Stroke care and cardiac rehabilitation;
    • Diabetes management and prevention;
    • Tobacco cessation;
    • Vision care for diabetic patients;
    • Management of epilepsy (CDC, 2019).

Benefits of Telehealth for Rural Patients

  • Providing quality services at lower costs (Schulte, Majerol & Nadler, 2019);
  • No need for rural patients to travel long distances to visit providers;
  • Integrated care for chronic conditions through self-management;
  • Accessing emergency care in real time for necessary evaluations;
  • Home monitoring to engage patients in chronic condition management in times between hospital visits;
  • Using interpreter services to cater to diverse rural patients with language barriers.

Telehealth Focus: Diabetes Management in Rural Patients

  • Projected US cases by 2050: 48.3 million (Ciemins, Coon, Peck, Holloway, & Min, 2011);
  • Risk of diabetes burden limiting financial resources in rural health care;
  • Consistent and intensive management can reduce disease burden;
  • Routine clinical practice settings struggle in achieving effective disease management;
  • Rural providers and patients have limited access to the latest methods of diabetes management due to financial barriers;
  • There is a limited number of specialty providers who deal with diabetes specifically.

Developing a Care Services Plan

  • The care services plan addresses chronic disease management in rural patients;
  • Offering patients remote healthcare services;
  • Allowing nurses train and educate patients in self-monitoring and management;
  • Increasing access to health care for convenience and cost reduction;
  • Using the latest telehealth trends for chronic disease management;
  • Tailoring telehealth to patient preferences and needs.
  • Identify a champion  a program leader at a healthcare organization to work on the plans success (Hillestad & Berkowitz, 2020);
  • Integrate the plan with technology and financial components;
  • Identify core services:
  • Consistent video/audio calls between rural patients and care providers;
  • Regular clinical outcomes monitoring: blood pressure, BMI, blood glucose, lipid levels;
  • Synchronizing data to providers/patients/EMR.
  • 24/7 Medical help offered by nurses and clinicians;
  • Desktop, phone, and tablet applications;
  • Ability to access healthcare services anywhere;
  • Virtual visits on chronic disease management to be scheduled;
  • Digital applications for patients and service providers;
  • Mobile apps for younger generations of patients/ telephone hotline for older patients.

Developing a Care Services Plan: Care Protocols

Diagnosis of type 2 diabetes:

  1. Video/phone calls between patients and care providers every 2 weeks;
  2. Daily testing for blood sugar  recording data digitally;
  3. Daily mild physical activities + following a nutrition plan;
  4. Synchronous + asynchronous telehealth;
  5. Adjusting the call schedule based on the arising health challenges;
  6. Pre-scheduling a clinical visit (once every 2 months) based on patient location and transportation capabilities.

High risk for type 2 diabetes:

  1. Video/phone calls between patients and care providers every 4 weeks;
  2. Monthly blood testing for blood sugar recording data digitally;
  3. A routine of physical exercises, healthy diet, holistic care.
  4. Synchronous + asynchronous telehealth;
  5. Pre-scheduling a clinical visit (if needed) based on patient location and transportation capabilities.

Developing a Business Plan

  • Cost reduction: no need for regular hospital visits;
  • Video-conferencing are inexpensive and does not require significant investment;
  • Data is captured and stored on patients computers: no need for a complex database system;
  • Interactions can be as simple or as sophisticated as the participants of the care process need them to be;
  • Investing in personnel training to use telehealth effectively (expense);
  • Increasing healthcare revenues over a prolonged time period through chronic disease management.

Key Stakeholders for Plan Success

Stakeholder category

  1. Onsite providers: Nurses, physicians, social workers; Stakeholder category
  2. Information Technology Staff: An IT team of support and administrative personnel; Stakeholder category
  3. Patients/payers: Rural patients diagnosed with/have higher risks of type II diabetes; Stakeholder category
  4. State regulators: Local healthcare legislators working on adapting telehealth services for remote communities; Stakeholder category
  5. Remote providers: Any additional personnel who work remotely with patients.

Risk Analysis

  • Need for on-side telemedicine equipment at healthcare facility;
  • Limited access of rural patients (especially older individuals) to digital communication technologies;
  • Expenses of setting up and maintaining telemedicine equipment on-site;
  • Care limitations in emergency situations;
  • Certain types of illnesses require face-to-face physical assessments;
  • Limitations in connecting (bonding) with telehealth specialists.

Regulatory Issues

Possible issues associated with prescribing medication to patients via telemedicine appointment: ¢Lacking an established relationship between patients and providers:

  • Providers may not know patients medical history;
  • Issues with adjusting medication dosages without a comprehensive assessment;
  • Limited access of rural patients to drug stores where they can purchase appropriate medication;
  • Possible mistakes in medication prescribing since patients and providers do not meet in person.

Licensure Issues

  • Legal practice of medicine may be limited to one state: patients and healthcare providers should be in one state;
  • Malpractice issues: providers defending themselves against legal actions in the state where hold a license;
  • Issues associated with inadequate/non-existent reimbursements and concerns of malpractice;
  • Fee-for-service concerns associated with government-run health plans for diabetes management;
  • Need for specific definitions of legal practice in telehealth through a license in different states.

Developing a Business Plan: Providers

  • Paying for professional fees associated with direct care services: pay-forperformance (P4P):
  • Reimbursing telehealth providers for achieving high levels of performance/improvement in performance;
  • Continuous measurement of performance and care outcomes for the target patient population;
  • Integrating a value-based purchasing program to encourage service providers to follow best practices;
  • Subsidizing rewards for high-performing providers at the expense of lowperforming providers.

Developing a Business Plan: Patients

  • Pricing for patients: no upfront payments;
  • Decrease fees for recurring consultations to increase patient satisfaction and build connections with providers;
  • Provide a patient loyalty program to encourage the adherence to a healthcare plan;
  • Provide fee discounts for vulnerable patients (duty to prove vulnerability);
  • Increase fees for emergency services;
  • Increase fees for specialized services that go beyond nurses specialization.

Planning Technology

  • Secure and dependable connection to the Internet;
  • Custom software (Electronic Medical Records);
  • Custom-configured peripherals and hardware;
  • Devices: tablets, desktop/laptop computers, smartphones;
  • Self-monitoring devices (depending on patients needs and capabilities);
  • Adjusting to the latest trends in telehealth to cater to the specific needs of patients.
  • Testing equipment before it is purchased;
  • Comparing different solutions to determine performance variances;
  • Visiting vendors to identify equipment options;
  • Requests for Proposals (RFP) to determine whether start-up companies offer appropriate equipment and services;
  • Establish network protocols for security procedures to protect patient data;
  • If needed, hire additional staff to support the implementation of telehealth by healthcare professionals (IT support personnel).

Training Personnel

  • Arrange training with the software vendor;
  • Include all relevant staff in training;
  • Develop a list of technical FAQs to facilitate personnels work;
  • Appoint power users who would support other staff members in complex situations;
  • Encourage practice runs to test out the system;
  • Complete continuous training and system refresh to adjust to the changing environment of telehealth.

Testing Care and Technology Plans

  • Developing a pilot plan to test the solution;
  • Performing a pilot program with a selected number of healthcare professionals and patients;
  • Conducting an online patient satisfaction survey to test the effectiveness of the pilot program care;
  • Surveying healthcare personnel on the effectiveness of the pilot program;
  • Adjusting service requirements and options based on the results of the survey;
  • Implementing the telehealth plan after the initial issues are addressed.

Testing Care and Technology Plans: The Pilot

  • Involving 10 nurses from several healthcare institutions;
  • Involving 2 patients per nurse = 20 patients diagnosed with type 2 diabetes living in a rural area;
  • Paying for any technological solutions necessary to establish a telehealth program;
  • Reviewing the feedback of patients and providers on the pilot program;
  • Comparing the clinical outcomes (glycemic control, blood pressure, BMI) before and after the pilot program;
  • Identifying points for improvement for the future program.

Evaluating Outcomes: Criteria

  • Increased collaboration between patients and healthcare providers?
  • Addressed the chronic health challenge of diabetes among rural patients?
  • Increased adherence to treatment and self-management?
  • Creation of appropriate plans for treatment and in-hospital visitations?
  • Increased short-term expenses on technological solutions?
  • Increase patient and provider awareness of telehealth use?
  • Decreased long-term costs on spent on hospital visits and doctors appointments?

Expected Outcomes

  • Increased attention of patients to consistent interventions;
  • Increased attention to positive diabetes care outcomes: reducing/ normalizing blood pressure, balancing BMI, consistent monitoring of blood glucose, consistent monitoring of lipid levels;
  • Increased knowledge of patients about daily diabetes management;
  • Improved health behaviors: diet and exercise, medicine intake, holistic practices (Lepard, Joseph, Agne, & Cherrington, 2017);
  • Increased supportive role of healthcare providers in maintaining diabetes management and prevention procedures.

Future Usage of Knowledge

  • Adapting the proposed project to other chronic illnesses that affect rural patients;
  • Educating patients and providers on the benefits of telehealth in selfmanagement and treatment adherence;
  • Including older patients in telehealth programs to decrease the need for them to spend time on traveling to healthcare facilities for routine check ups;
  • Engaging younger patients in self-care and chronic disease management with the help of telehealth solutions;
  • Broadening the capabilities and P4P opportunities of healthcare providers.

References

CDC. (2019). Telehealth in rural communities. Web.

Ciemins, E., Coon, P., Peck, R., Holloway, B., & Min, S. J. (2011). Using telehealth to provide diabetes care to patients in rural Montana: Findings from the promoting realistic individual self-management program. Telemedicine journal and E-health: The Official Journal of the American Telemedicine Association, 17(8), 596-602.

Hillestad, S., & Berkowitz, E. (2020). Health care market strategy. Jones & Bartlett Learning.

Lepard, M. G., Joseph, A. L., Agne, A. A., & Cherrington, A. L. (2015). Diabetes self-management interventions for adults with type 2 diabetes living in rural areas: a systematic literature review. Current Diabetes Reports, 15(6), 608.

Schulte, A., Majerol, M., & Nadler, J. (2019). Narrowing the rural-urban health divide. Web.

Wu, B. (2016). What are the benefits and advantages of telemedicine?

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