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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 specialists 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 patients.

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.

Research 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 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.
  • Telehealth for Provider Support and Training – 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. 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 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 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 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 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.
  • A nonprofit founded in 2012, the Alabama Partnership for TeleHealth (APT) is part of a charitable telehealth network working to support and promote new and existing telehealth programs serving Alabama's rural and underserved populations. The network offers needs assessments, telehealth education and training, discounts on telehealth software and hardware, and state telehealth summits to further promote telehealth through presentations and discussions.
  • In an effort to bring services to rural, elderly populations, the SD eResidential Facilities Healthcare Services Access Project is implementing telehealth services to reach patients at long-term care facilities. Technology, including two-way video, a camera, and other specialized equipment, is used to help keep patients in their own facilities. The project was created by Avera Sacred Heart Hospital and four of its affiliates and uses the practice models and studies of eLongTermCare (eLTC). The project has been implemented at sites in South Dakota, Iowa, Minnesota, and Nebraska.
  • Avera eCARE created a service that provides rural healthcare providers in South Dakota with 24-hour virtual access to specialty care physicians, nurses, and pharmacists. A variety of services are available through the program, including eCARE Emergency, eCARE Pharmacy, and eCARE Specialty Clinic. As a result of Avera's services, over 2 million residents have gained remote access to physicians and specialized services. The program serves 410 sites across 18 states.
  • The Marshfield Telehealth Program 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.
  • 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.
  • 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.
  • 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.
  • Created by East Carolina University (ECU), TeleTEAM in North Carolina is a telehealth model connecting patients to offsite diabetes care during primary care office visits at local clinics. Through the program, patients access behavioral therapists, dietitians, clinical pharmacists, and a medical diabetologist. An early programmatic study showed that HbA1C levels decreased by 1.1% by the time of the three-month office follow-up visit.
  • 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.

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. Additionally, Medicare 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. The Northeast Telehealth Resource Center compiles Resources for Clinical Telehealth Guidelines, Standards, Policies for programs to consider when implementing a specialty service. 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: Sustainability.

Program Clearinghouse Examples

Resources to Learn More

Breaking the Barriers to Specialty Care: Practical Ideas to Improve Health Equity and Reduce Cost
Document
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
Date: 6/2016

Improving Access to High Quality Sepsis Care in a South Dakota Emergency Telemedicine Network
Document
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
Date: 8/2017

Marshfield Telehealth Program Reaches Rural Kidney Patients in Northern Wisconsin
Document
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
Date: 2/2012

New Opportunities and Challenges for Teleaudiology Within Department of Veterans Affairs
Document
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
Date: 2014

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 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
Date: 2017

Telegenetics Program Planning Toolkit
Website
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 Solutions
Document
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
Date: 1/2019