Adressing the Healthcare Crisis Through Telehealth Evaluating Needs

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:

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 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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