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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.

Rural communities have implemented or expanded telehealth programs in several different types of nontraditional settings:

  • Homes
  • Workplaces
  • Skilled nursing facilities
  • School-based health centers
  • Correctional facilities

There are two key types of telehealth applications used for engaging and reaching patients in nontraditional settings:

  • Live-video telehealth – With this approach 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 the Anywhere 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 TeamSTEPPsĀ® to create a standardized communication system. An evaluation of this program found high patient engagement and patient satisfaction with communication via telehealth technology.
  • 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, a chronic disease management pilot for diabetes found that patient engagement increased through the use of trackers that connect to EHRs and daily, personalized text messages regarding physical activity behaviors.
  • 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. For example, Anthem Blue Cross and Blue Shield offers many members access to the LiveHealth Online platform, which enables round-the-clock access to clinics that can address routine medical concerns and behavioral health support.
  • 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 SMS 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 for older adultsHome-based telehealth is an important strategy for improving access to care for older adults, who may have greater limitations to travel due to mobility issues. For example, the LivingWell@Home program is a remote patient monitoring program for rural older adults in South Dakota, Minnesota, Iowa, North Dakota, and Nebraska. Vital sign, movement, and sleep data are transmitted to the Good Samaritan Society monitoring center, which alerts the patient's primary care home to any changes in their health status.

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 program.
  • 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 location.
  • The Summit Healthcare Telemedicine Program 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 when necessary.
  • 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.
  • Another rural pilot project assessed the Telepsychology-Service Delivery for Depressed Elderly Veterans intervention, which used in-home videoconferencing technology to provide psychotherapy to participants. The pilot found no significant differences between the outcomes of the control group, which received in-person care, and the telehealth group. The in-home telehealth intervention was successful in reducing the symptoms of depression among the participants, who lacked access to in-person care due to transportation and mobility issues.
  • 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.

Implementation Considerations

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

Rural programs may struggle to receive reimbursement for remote patient monitoring technologies and mHealth programs. For example, lack of payment and coverage are major barriers to implementing remote patient monitoring programs for Medicare beneficiaries. Programs should be aware of evolving rules and guidelines that affect reimbursement for remote patient monitoring. The Center for Connected Health Policy offers an interactive map with the option to filter by 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 Telehealth Resource Centers (TRCs) offer resources to rural programs seeking to implement telehealth strategies that reach patients outside of the medical setting:

  • 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.
  • The Northwest Regional TRC's Remote Patient Monitoring: An NRTRC Toolkit provides a list of questions for communities seeking to implement a remote patient monitoring program. Considerations include building a patient profile, operationalizing the monitoring equipment, and staffing the care team.

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.

Patient and family engagement is a national priority. Addressed in the Centers for Medicare and Medicaid Services (CMS) National Quality Strategy – Goal 2 to “Strengthen persons and their families as partners in their care.” CMS has also developed a Person and Family Engagement Strategy to guide the agency's efforts in supporting patient and family engagement in its policies and programs.

Additional implementation considerations including licensing and reimbursement are discussed in Module 4: Implementation and Module 6: Sustainability.

Program Clearinghouse Examples

Resources to Learn More

Health IT Playbook
Website
Online guidebook for healthcare providers on using health information technology (HIT) to its best advantage. Includes discussions on choosing, implementing, and upgrading electronic health records (EHRs), using health information exchanges (HIEs) and Certified Health IT products, implementing patient engagement via telehealth/telemedicine, and more. 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
Document
Provides an 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
Website
Describes mHealth applications and resources to assist with evaluating vendors, product information, and testing application features. Offers mHealth application standards, references, and literature to help with implementation and deployment of the technology. Includes examples of product assessment on three mobile glucometer applications.
Organization(s): National Telehealth Technology Assessment Resource Center

Telehealth and Remote Patient Monitoring Use in Medicare and Selected Federal Programs
Document
Discusses the impact of remote patient monitoring programs on health outcomes and barriers that affect uptake of telehealth and remote patient monitoring among Medicare patients. Discusses rural-specific implications throughout the report.
Organization(s): Government Accountability Office
Date: 4/2017