Telehealth Models for Increasing Access to Specialty Care
In this model, telehealth serves as a leading tool for increasing access to specialty care. Specialists offer
more advanced care than primary care providers, but access is restricted based on physician referral,
geographic location, and insurance type. Specialists also tend to be located in urban areas and
there are fewer of them when compared to primary care providers. Rather than staffing remote
locations with specialty providers, telehealth allows
to connect with rural patients and providers virtually. This expands rural patients' access to specialty care
and enables rural providers to engage and connect with specialty providers, allowing them to better serve their
Benefits For Patients
Telehealth connects patients to specialized medical services that may be otherwise unavailable in their
community. Telehealth also allows patients to avoid the time associated with traveling
long distances in order to see a specialty service provider in-person. Additionally, patients can avoid
extra visits, scheduling, and wait periods if the specialist is regularly available for telehealth appointments.
demonstrates that telehealth can help rural individuals receive effective care in many areas. Some of the
specialty care services available to rural patients include dental care, cardiology, endocrinology, genetic
counseling, dermatology, psychiatry, oncology, ophthalmology, and obstetrics. Many specialty care services are
also available for children. See Increasing
Access to Care Among Children and the Rural Early Childhood Health
Promotion Toolkit for more information.
Benefits For Providers
Telehealth has many benefits for rural providers. Live-video teleconference and e-consultation are two
telehealth methods most often used by rural providers to connect with specialty providers. Telehealth consults
enable primary care providers and frontline physicians located in rural areas to receive real-time support from
specialists, which increases their ability to make
better diagnoses and develop appropriate care plans. In addition to real-time support, electronic
technology helps specialists to make diagnoses by creating access to resources, such as
radiologic images and two-dimensional images that
can be shared with specialists to review and perform diagnoses. E-consultation involves the use of
web-based programs or shared electronic medical records to improve quality of care and reduce
specialty care costs.
Examples of how rural communities are using telehealth to increase access to specialty care services include:
Telehealth for Health Monitoring and Chronic Care Management – Telehealth allows
providers to better connect with patients and help them monitor and manage their
health. CMS defines
chronic care management as:
“the care coordination that is outside of the regular office visit
for patients with multiple (two or more) chronic conditions expected to last at least 12 months
or until the death of the patient, and that place the patient at significant risk of death, acute
exacerbation or decompensation, or functional decline.”
Telehealth interventions, such as those
focused on diabetes
and HIV/AIDS, have shown
great promise for health monitoring and management. Through these interventions, patients receive
assistance via live video and remote patient monitoring with self-management, including
monitoring blood glucose, taking prescribed medication, and following diet and exercise plans via
live teleconferencing. Other examples of
chronic care management conditions that may be monitored via telehealth include asthma,
arthritis, hypertension, cardiovascular disease, and depression. Additionally, remote patient
monitoring allows providers to regularly monitor patients and work to identify health risks and
receive treatment sooner.
Provider Support and Training – Telehealth connects providers in rural
support and training
through a hub-and-spoke model, which is centralized around the concept of one larger “hub”
hospital with smaller “spoke” hospitals. Through this model, primary care clinicians receive
support and training to provide specialty care services. The model was first introduced through
Project ECHO and provides evidence-based programs for many complex
conditions, including diabetes and tuberculosis.
Telehealth for Connecting with Community Health Workers – Telehealth also serves as a
platform to provide remote access to community health
It enables CHWs to continue bridging
healthcare gaps and challenges facing rural communities. For example, Project ECHO connects primary
clinical teams, including CHWs, with specialty care teams for managing patients and training.
Examples of Rural Specialty Care Telehealth Programs
The School-based Consultations for Rural
Pediatric Telehealth (SCRiPT) Network uses telehealth to increase access to specialty
care — including behavioral healthcare — at rural school-based health centers across the
country. The SCRiPT
Network facilitates treatment recommendations and referrals through telehealth, as well as training for
school-based health center staff.
The Virtual Infusion Project
increases access to infusion and oncology care in South Dakota, Iowa, Minnesota, and Nebraska. Nurses at
rural infusion centers connect to advanced practice oncology nurses via telehealth to ensure that patients
can receive quality care close to home.
- The Summit Healthcare Telemedicine
is implementing a broad range of telehealth approaches to improve access to specialty care for local
residents of Navajo County, Arizona. With a focus on building partnerships and networks, the program
model provides integrative care and has implemented multi-specialty telehealth programs, including
those that provide chronic care management via remote patient monitoring.
- The TeleEmergency Program offers
rural Critical Access Hospitals and community hospitals access to 24/7 live-video consultations with
clinicians. Rural hospitals in New Hampshire, Vermont, and Maine can use the consultation service to ask for
guidance, seek second opinions, and coordinate transfers to trauma centers.
The University of Mississippi Medical Center's Center for
Telehealth created a telehealth center to deliver quality specialty services to rural,
underserved areas of Mississippi. The center uses a telemedicine connection to connect physicians to
patients in rural hospitals in real time.
In an effort to bring services to rural, elderly populations, the SD
eResidential Facilities Healthcare Services Access Project implemented telehealth
services to reach patients at long-term care facilities. Technology, including two-way video, a camera, and
other specialized equipment, was used to help keep patients in their own facilities. The project was created
by Avera Sacred Heart Hospital and four of its affiliates and implemented at
sites in South Dakota, Iowa, Minnesota, and Nebraska.
The Marshfield Telehealth
in northern Wisconsin enables patients with end-stage renal disease to access needed care. Marshfield Clinic
TeleHealth (MCT) is providing advanced specialty services to rural residents. Created in 1997, MCT now
serves 54 locations.
Kidney Transplant Clinic at the Iowa City VAMC allows patients who have had
kidney transplants to receive annual follow-up exams remotely. This has resulted in the reduction in travel
time and costs for kidney transplant patients. The Kidney Transplant Telehealth Clinic was created in August
2012 and was designed to reduce travel time for annual appointments for transplant patients living in Puerto
The Kentucky TeleHealth Network includes over
member sites with more than 20 medical, surgical, and mental/behavioral health services offered. The
statewide telehealth network is a decentralized model that allows any site to request membership free of
charge if they use secure videoconference technology.
The Catalina Island Telemedicine Center connects island
residents to specialty medical care in California, including services such as diabetic consultations,
retinal imaging, and pain management. An analysis of the telemedicine program found that, on an annual
average, 12 patients receive diabetic education, 41 patients receive eye screenings, and 12 patients per
month receive telepsychiatry services.
The Kansas Asthma Initiative is a partnership providing
education and professional development opportunities via telehealth for healthcare providers and caregivers
of asthma patients. The asthma teleECHO program began in 2016 and focuses on providing continuing education
and professional development, decreasing unplanned asthma-related healthcare usage, and improving adherence
to guidelines for asthma diagnosis and treatment.
The University of Arkansas created the IDHI High Risk Pregnancy
Program (formerly known as ANGELS: Antenatal & Neonatal Guidelines, Education and
Learning System) to increase access to care for
pregnant women in Arkansas. This evidence-based program has increased rural women's access to care by
linking patients with physicians and high-risk pregnancy services at the University of Arkansas for Medical
Sciences (UAMS). The program established a statewide telemedicine network for e-consultations with medical
experts. Other defining components include referrals to tertiary and/or emergency care at UAMS, a 24-hour
call center staffed by registered nurses, follow-up home care for families of high-risk infants, and
supplemental education opportunities for providers.
Created in 1989, the New Mexico Mobile Screening Program for
Miners screens miners for respiratory and other health conditions, provides
self-management information, and makes follow-up calls three months after a miner's visit. Each screening
clinic is equipped with an advanced digital communication system for telemedicine and enables meetings with
pulmonary specialists, if recommended by a screening provider. Telemedicine also offers miners access to
specialty care from the University of New Mexico Health Services Center.
Eastern Oklahoma VA Health Care System (EOVAHCS) and the Cincinnati VA Medical Center's Tele-ICU
Monitoring Center have partnered to provide Tele-ICU for
Veterans. Through this program, remote patient monitoring access is provided 24/7 for rural veterans
in the intensive care unit and emergency department. Funded by the VA
Office of Rural Health, the program uses teleconferencing equipment to allow providers the ability
to videoconference, provide consultations, and access patients' bedside data.
Project ENABLE (Educate, Nurture, Advise, Before Life
Ends) provides access to palliative care in rural communities. Participants receive an
initial in-person palliative care consultation with a specialty-care trained provider and then receive a
series of weekly tailored sessions delivered by phone with nurse coaches.
While telehealth has increased access to specialty care providers, provider capacity, licensure, and
reimbursement remain leading issues to receiving appropriate specialty care. Successful rural telehealth
programs recommend dedicating personnel to navigate credentialing and licensing requirements for providers.
payment policies for telehealth currently limit the types
of services for which providers are reimbursed. Policies also include restrictions on the geographic and
practice settings where services are provided. Coverage by private payers may also affect reimbursement for
different telehealth specialty services.
Specialty Care Guidelines
Specialty care disciplines have their own guidelines
and considerations for proper treatment. Connecting primary care providers with specialists allows them to
receive the relevant expertise to successfully treat patients. For example, a set of guidelines
reviewed by the American College of Radiology (ACR), the American Association of Physicists in Medicine (AAPM),
and the Society for Imaging Informatics in Medicine (SIIM) document the technical standard for transmitting and
reviewing medical imaging.
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
Breaking the Barriers to Specialty
Care: Practical Ideas to Improve Health Equity and Reduce Cost
Compiles briefs and resources focused on improving access to specialty care for rural and low-income patients.
Includes examples of case studies, program data, and recommendations that work to expand and support expanded
access to specialty healthcare services. Registration is required to access the report.
Author(s): Bhavaraju, N., Nanni, J., Carlson, C., Sholk, J., Peterson, K., & Smith, L.A.
Organization(s): Bristol-Myers Squibb Foundation, FSG
Access to High Quality Sepsis Care in a South Dakota Emergency Telemedicine Network
Explores whether emergency department-based telemedicine networks using real-time access to sepsis experts can
improve outcomes and decrease variation in care. Discusses a pilot program for Critical Access Hospitals (CAHs)
in South Dakota-based Avera Health's 140-hospital network in 12 states. Includes statistics for patients with
positive sepsis screens from September 2016 to March 2017.
Author(s): Mohr, N.M., Skow, B., Wittrock, A., et al.
Organization(s): Rural Telehealth Research Center
Marshfield Telehealth Program Reaches Rural Kidney
Patients in Northern Wisconsin
Highlights a renal disease telehealth program in Wisconsin, which is serving low-income nursing home residents
as well as patients who can travel to their local clinic for telehealth services.
Author(s): Helseth, C.
Organization(s): Rural Health Information Hub
Citation: Rural Monitor
New Opportunities and
Challenges for Teleaudiology Within Department of Veterans Affairs
Provides an overview of teleaudiology and the delivery of audiological services through telemedicine
practice for rural and inner-urban areas. Includes discussion on how the Veterans Administration is
researching and incorporating teleaudiology within its healthcare program.
Author(s): Jacobs, P.G., Saunders, G.H.
Citation: Journal of Rehabilitation Research & Development, 51(5), vii-xii
Project Extension for Community Healthcare
Outcomes (ECHO) in Multiple Sclerosis: Increasing Clinician Capacity
Discusses the findings of a pilot program conducted in the Pacific Northwest looking at the utilization of
Project ECHO to support the capacity of clinicians in rural areas to effectively treat patients with multiple
sclerosis (MS) in underserved areas.
Author(s): Johnson, K.L., Hertz, D., Stobbe, G., et al.
Citation: International Journal of MS Care, 9(6), 283–289
Telegenetics Program Planning Toolkit
Acts as a guide and outlines the processes to developing and implementing a telegenetics program in any facility
type. Offers templates and other resources to assist with the planning process. Contains program evaluation
information to monitor and improve the program. Registration is required to access the toolkit.
Organization(s): Mid-Atlantic Telehealth Resource Center
Teleophthalmology: Ophthalmologists Talk Remote Eye Care
Discusses the role of remote eye care technology in meeting rural eye care needs. Highlights the use
of teleophthalmology in rural Oregon. Also features a collaboration of the Joslin Diabetes Center and
the Indian Health Service to address diabetic retinopathy using remote surveillance.
Author(s): Miller Temple, K.
Organization(s): Rural Health Information Hub
Citation: The Rural Monitor