Telehealth Models for Increasing Access to Specialty Care

Specialists offer more advanced care than primary care providers, but access may be 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. Telehealth connects patients to specialized medical services that may be otherwise unavailable in their community. Additionally, patients can avoid extra visits, scheduling, and wait periods if the specialist is regularly available for telehealth appointments.

The National Advisory Committee on Rural Health and Human Services 2015 policy brief, Telehealth in Rural America, discusses how telehealth can help rural individuals receive effective care in many areas. Some of the specialty care services available to rural patients via telehealth include dental care, cardiology, endocrinology, genetic counseling, dermatology, psychiatry, oncology, ophthalmology, and obstetrics.

Telehealth for Live-video Teleconference and E-Consultation
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. E-consultation involves the use of web-based programs or shared electronic medical records to improve quality of care and reduce specialty care costs.

Telehealth for Health Monitoring and Chronic Care Management
Telehealth allows providers to better connect with patients and help them monitor and manage their health. 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 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.

The Health Resources and Services Administration offers telehealth best practice guides for managing chronic conditions and HIV care.

Telehealth for Provider Support and Training
In this model, telehealth connects providers in rural communities with support and training through a hub-and-spoke model, which is centralized around the concept of one larger "hub" hospital with smaller "spoke" hospitals. 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 workers. 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 TeleEmergency Program offers rural Critical Access Hospitals and community hospitals access to 24/7 live-video consultations with emergency medical 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.
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 Kentucky TeleHealth Network includes over 400 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.

Examples of Rural Specialty Care Telehealth Programs for Chronic Health Conditions

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 Telehealth 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 Rico.
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.

Examples of Rural Specialty Care Telehealth Programs Specific Populations

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 Summit Healthcare Telemedicine Program 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 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.

Implementation Considerations

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

Specialty care disciplines have their own guidelines and considerations for proper treatment. For example, the American Society of Clinical Oncology released Telehealth Standards in Oncology in 2021 that provide recommendations for patient selection, establishing a doctor-patient relationship, and other topics.

Program Clearinghouse Examples

Resources to Learn More

Breaking the Barriers to Specialty Care: Practical Ideas to Improve Health Equity and Reduce Cost
Document
A series of five briefs focused on achieving equity in health outcomes from disease by 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 access to specialty healthcare services.
Author(s): Bhavaraju, N., Nanni, J., Carlson, C., et al.
Organization(s): Bristol-Myers Squibb Foundation, FSG Reimagining Social Change
Date: 6/2016

Improving Access to High Quality Sepsis Care in a South Dakota Emergency Telemedicine Network
Document
Describes a pilot program implemented by Avera Health, a regional health system of Sioux Falls, S.D., to increase the use of telemedicine in emergency departments (EDs) of critical access hospitals (CAHs). Program objectives treated ED patients with sepsis by offering specialty care in real-time and assessed quality of their care and clinical outcome. 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 (RTRC)
Date: 8/2017

Project Extension for Community Healthcare Outcomes (ECHO) in Multiple Sclerosis: Increasing Clinician Capacity
Document
Discusses the findings of a pilot program conducted in the Pacific Northwest looking at utilization of the ECHO telehealth model to support the capacity of clinicians treating patients with multiple sclerosis (MS) in rural and underserved areas.
Author(s): Johnson, K.L., Hertz, D., Stobbe, G., et al.
Citation: International Journal of MS Care, 19(6), 283-289
Date: 2017

Telegenetics Program Planning Guide and Toolkit
Website
Outlines the processes for developing and implementing a genetic testing and counseling program. Offers a stepwise framework, templates and other resources to assist with the planning process, and contains evaluation information to monitor and improve the program. Registration is required to access the toolkit.
Organization(s): Mid-Atlantic Telehealth Resource Center, NYMAC Regional Genetics Network

Teleophthalmology: Ophthalmologists Talk Remote Eye Care Solutions
Document
Discusses the role of remote eye care technology in meeting rural ophthalmology needs. Highlights the use of teleophthalmology in rural Oregon. Features a collaboration of the Joslin Diabetes Center and the Indian Health Service (IHS) to address diabetic retinopathy using remote surveillance.
Author(s): Miller Temple, K.
Organization(s): Rural Health Information Hub (RHIhub)
Citation: Rural Monitor
Date: 1/2019