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 plan’s 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:
- Video/phone calls between patients and care providers every 2 weeks;
- Daily testing for blood sugar – recording data digitally;
- Daily mild physical activities + following a nutrition plan;
- Synchronous + asynchronous telehealth;
- Adjusting the call schedule based on the arising health challenges;
- Pre-scheduling a clinical visit (once every 2 months) based on patient location and transportation capabilities.
High risk for type 2 diabetes:
- Video/phone calls between patients and care providers every 4 weeks;
- Monthly blood testing for blood sugar– recording data digitally;
- A routine of physical exercises, healthy diet, holistic care.
- Synchronous + asynchronous telehealth;
- 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
- Onsite providers: Nurses, physicians, social workers; Stakeholder category
- Information Technology Staff: An IT team of support and administrative personnel; Stakeholder category
- Patients/payers: Rural patients diagnosed with/have higher risks of type II diabetes; Stakeholder category
- State regulators: Local healthcare legislators working on adapting telehealth services for remote communities; Stakeholder category
- 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 personnel’s 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?