Telehealth Models for Increasing Access to and Engagement with Care Outside of Healthcare Settings
In this model, telehealth is used as a tool to help patients access care outside of clinical settings and to
better engage patients in the care that they receive. Using telehealth to reach patients in non-healthcare
settings, outside of medical facilities, can be critical to overcoming persistent barriers to care, including
lack of access to transportation and stigma associated with seeking help for a condition. The stay-at-home
orders and physical distancing requirements associated with the COVID-19 pandemic highlighted the importance of
using telehealth to receive care outside of healthcare settings.
Rural communities have implemented or expanded telehealth programs in several different types of nontraditional
Skilled nursing facilities and other long-term care facilities
School-based health centers
There are two key types of telehealth applications used for engaging and reaching patients in nontraditional
Live-video telehealth – Instead of traveling to a clinic to meet with a provider via
telehealth, patients use a device such as a tablet, computer, or smartphone to receive care at home or at
another convenient location. For example, Greater
Oregon Behavioral Health, Inc. offers patients access to a telehealth platform that they can access
from their personal devices. Patients can schedule appointments and meet with mental health specialists via
live-video telehealth from their home, work, or other location of their choice.
Remote patient monitoring technology – Remote patient monitoring helps providers
assess the health status of a patient from a distance and helps patients manage their own health. Remote
patient monitoring technologies typically collect information about physiological characteristics and vital
signs, such as weight and blood pressure. For example, a patient who has cardiovascular disease may use a
blood pressure cuff that transmits readings to a data repository. The patient's care team can review the
monitoring data to track the patient's progress and, if necessary, intervene before any issues get worse.
Other examples of remote patient technologies used in rural areas include telehealth-enabled scales,
glucometers, pedometers, and pulse oximeters.
Both live-video telehealth and remote patient monitoring programs may involve the use of mobile health (mHealth)
applications and technology. mHealth includes devices such as smartphones and tablets as well as software
applications that patients can download onto devices. For example, the Veterans Health Administration launched
to Anywhere initiative to increase access to home-based care for veterans with limited access to care,
including veterans living in rural communities. Anywhere to Anywhere uses the VA Video Connect smartphone application to connect
veterans to providers.
Rural communities are using several strategies to increase access to care in non-healthcare settings as well as
improve patient engagement in care:
Care transitions and post-acute care – Telehealth technology can be used to increase
patient and family engagement in care transitions. For example, one rural program uses telehealth technology
to communicate with young patients and their families after discharge from the hospital setting. Tablet
technology is used to connect the patient and their family to the inpatient care team through telehealth
calls. This program implemented TeamSTEPPS®
to create a standardized communication system. An evaluation
of this program found high patient engagement and patient satisfaction with communication via
Chronic disease management – A key application of telehealth is the ability to
improve the management of chronic
health conditions, such as diabetes, congestive heart failure, and chronic obstructive pulmonary
disease (COPD). For example, the Bridges to Care Transitions-Remote Home
Monitoring and Chronic Disease Self-Management program uses remote patient monitoring technology to
track vital signs among patients with chronic diseases and behavioral health issues who are discharged from
Direct-to-consumer telehealth – Direct-to-consumer telehealth offers patients 24/7
access to virtual care. Patients use a smartphone, tablet, or computer to access a telehealth platform and
connect to providers. Direct-to-consumer models allow the patient to directly initiate the telehealth visit.
The Health Resources and Services Administration offers a best practice guide
on direct-to-consumer telehealth.
Caregiver support – Some telehealth interventions focus on engaging caregivers and
decreasing the burden of providing care in resource-limited rural settings. For example, one program in
rural Illinois tested the Telehelp
Line for Caregivers, which involved a call-in helpline and a structured telephone intervention to
increase knowledge about caregiving, promote problem-solving skills, and offer social support. Caregivers
who participated in the intervention reported significantly less stress than control group caregivers.
Medication adherence – Some mHealth applications focus on increasing medication
adherence. Applications could use an alarm, screen notification, or text message to remind patients to take
their medication. Some also allow for personal tracking of medication intake, which could also involve
external monitoring by a care team for adherence.
Home-based care – Home-based telehealth is an important strategy for
providing care for people with mobility limitations or lack of access to transportation, including many older
adults. Rural hospitals may also use home-based care to overcome capacity issues. The Hospital-at-Home model helps rural patients access
different types of care and treatments in their homes.
Examples of Rural Telehealth Programs for Engaging and Reaching Patients in Different Settings
Alaska Veterans Telehealth and Biofeedback
Services uses mHealth technology to offer veterans access to a stress-reduction
training via biofeedback to address trauma. Participants use a monitoring device linked to a smartphone
application to measure and track heart rate variability as a marker of stress-reduction. Protocols for
screening and participation in the program were developed in alignment with the VA's regional telehealth
Greater Oregon Behavioral Health,
Inc. uses a telehealth platform that allows patients in rural Oregon to connect to
behavioral health services from their personal devices, such as smartphones, tablets, or computers. Patients
use the platform to communicate with behavioral health clinicians via video conference or text from any
The Summit Healthcare Telemedicine
uses remote patient monitoring to regularly assess the health of patients with congestive heart failure.
Patients use telehealth-enabled technology to track their vital signs, which are transmitted to a central
database. Staff from Summit Healthcare's Home Health Department review the data and follow up with patients
A rural pilot project assessed
ImPACT Online, a telehealth-based intervention for young children with autism spectrum
disorders (ASD). The telehealth component is a website for parent education. The pilot found high levels of
parent engagement and satisfaction with the telehealth program.
The Bridges to Care Transitions project supports
remote home monitoring and chronic disease self-management using telemonitoring equipment that is shipped to
the patient's home. Initial results show high levels of patient participation in self-monitoring and
increased self-care as well as high patient satisfaction.
Considerations for Live-Video Telehealth
Connectivity may be an issue for rural programs seeking to offer access to live-video telehealth in home
settings. In order to address limited access to broadband in rural Oregon, the Direct to Patient Tele-Behavioral Health Services
program offers a text-based option for behavioral therapies. Patients without access to internet services may
find it easier to connect with providers through text messages.
Considerations for Remote Patient Monitoring Technologies
The COVID-19 pandemic accelerated the adoption and use of remote patient monitoring technologies, partly due to
the relaxation by the Centers for Medicare & Medicaid Services (CMS) of some regulations related to remote
patient monitoring during the public health emergency. The Center for Connected Health Policy tracks federal and state Medicaid reimbursement
policies for remote patient monitoring. Rural programs may benefit from building partnerships with
private payers and state Medicaid programs to discuss benefits of using telehealth to better engage patients in
monitoring chronic health conditions. For example, a payer could be willing to fund a pilot remote patient
monitoring program with the goal of decreasing hospitalizations for diabetes-related complications.
In order to achieve the best possible outcomes from remote patient monitoring, rural program staff may need to
carefully consider how to integrate data from these technologies into clinical workflows. For example, staff may
find it burdensome to consistently log on to a separate database to review monitoring data. To address this
issue, some remote patient monitoring programs integrate data directly into electronic health records and create
alerts when predetermined threshold values are exceeded. Rural practices may also need to develop protocols to
instruct staff how to respond to abnormal data readings, such as reaching out to patients and caregivers by
phone or video conference.
The Mid-Atlantic TRC's Remote Patient
Monitoring Toolkit offers an interactive overview of the role of executives, providers, nurses, and
technicians in implementing and sustaining a remote patient monitoring program.
Considerations for Patient and Family Engagement
Telehealth can be applied to increase patient and family engagement in healthcare, but it is important for
programs to recognize the potential implications for the patient and family. For example, video technology
provides healthcare providers with a view into the patient's home and their living conditions. Additionally, the
administration and management of technology may place additional burdens on some patients and families.
Additional implementation considerations including licensing and reimbursement are discussed in
Module 4: Implementation and
Module 6: Funding & Sustainability.
Program Clearinghouse Examples
Resources to Learn More
Health IT Patient Engagement Playbook
Guidebook for healthcare providers, hospital administrators, and healthcare staff offering recommendations and
best practices on using health information technology (HIT) with patients. Focuses on portal development,
patient enrollment, secure messaging, integrating electronic health records (EHRs), patient use of wireless
technologies, and building patient trust. Includes a section on HIT in rural settings.
Organization(s): Office of the National Coordinator for Health Information Technology
Literature Review: The
Triple Aim and Home Telehealth for Patients with Chronic Diseases
Overview of literature related to health outcomes, quality of care, and cost savings associated with managing
chronic conditions through home telehealth.
Organization(s): Center for Connected Health Policy: The National Telehealth Policy Resource Center
mHealth App Selection
Describes mHealth applications and resources to assist with evaluating vendors, product information, and testing
application features. Offers mHealth application standards and references to help with implementation and
deployment of the technology. Includes examples of product assessment on three mobile glucometer
Organization(s): National Telehealth Technology Assessment Resource Center (TTAC)
Telehealth and Remote Patient Monitoring Use in Medicare and
Selected Federal Programs
Highlights the impact of remote patient monitoring programs on health outcomes and barriers that affect uptake
of telehealth and remote monitoring among Medicare patients. Discusses rural-specific implications throughout
Organization(s): Government Accountability Office (GAO)