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
Skilled nursing facilities
School-based health centers
There are two key types of telehealth applications used for engaging and reaching patients in nontraditional
Live-video telehealth – With this approach of traveling to a clinic to meet with a
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
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 telehealth
Chronic disease management – A key application of telehealth is the ability to
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 adults – Home-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
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.
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.
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
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
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 Playbook
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
Organization(s): Office of the National Coordinator for Health Information Technology
Review: The Triple Aim and Home Telehealth for Patients with Chronic Diseases
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
mHealth App Selection
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
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