The Georgia Partnership for Telehealth hosted another exceptional conference at the Jekyll Island Club Hotel on March 22–24, 2017. We were inspired by the speakers and vendors, enjoyed the environment, and valued getting to know other key players in the telehealth industry. But most significantly, we recognized the importance of connectivity, collaboration and buy-in from key stakeholders (especially providers and community members), and the continuing obstacle of reimbursement, despite demonstrated resource savings. Other challenges to establishing a thriving telehealth practice in any context, urban or rural, include regulatory impediments and state licensure barriers.
However, by having a dedicated telehealth champion in each organization, and by challenging regulators and payors to change the regulatory landscape and push for payment for these services—ultimately reducing costs to the communities served and the healthcare system in general—telehealth will continue to increasingly deliver better patient outcomes and optimize resource use.
The future is bright for telehealth in Georgia, but we must continue to work together to move the solutions forward. Telehealth has come a long way in the last decade, and the possibilities over the next decade seem nearly endless. Read on below for our specific takeaways from each of the engaging conference sessions.
- Top Telemedicine Grants: Tips & Tricks to Win Them
With the saying “what’s bad is good,” Barbara Catenaci of Avizia (a telehealth solutions provider) described how to support state and federal grant applications using evidence-based data to identify needs and gaps in current coverage and services. Maximizing grant applications, both in quantity and quality, is key to funding an important telehealth project. Though many grants have upwards of a 50% acceptance rate, generally for every $1 million a healthcare technology project needs, the program should apply for $75 million in grants to get funded. But there is money available out there—last year, the federal government gave away $26 billion in discretionary grants.
Ms. Catenaci also advised writing a grant application around an existing project; do not write a project specific for the grant (do not write “equipment dump” grants). She also suggested that an applicant plans to submit grant 3-5 days in advance to anticipate any last-minute obstacles. She also reminded applicants to review the priorities of specific grants, both in the application year and in the past. For example, school-based health centers have typically been a funding priority for HHS Telehealth Network Grant Program (TNGP). Finally, and perhaps most important, when writing a grant application, follow the directions!
- Fran Gary, Anthem / Amerigroup, Keynote
Fran Gary from Anthem and Amerigroup offered the keynote and remarked that telehealth claims in Georgia have risen from 111 in 2010 to 30,000 in 2016. She emphasized that healthcare is local, so practitioners must be able to reach where the patients are, and as part of this effort, Ms. Gary’s organization has established a goal of putting telehealth centers in every Georgia elementary school within 3 years (they have already visited 59 school boards). One of the biggest challenges for school-based health centers is getting schools to bill as presenting sites, which is essential to pay for their nurses and keep them open.
Besides schools, the next priorities and opportunities for telehealth are behavioral health (specifically addressing the opioid crisis and children’s mental health issues) and teledental. Positive that we can overcome the challenges of closing rural hospitals, overall Ms. Gary’s presentation was upbeat and optimistic about the future of telehealth in Georgia.
- Two Georgias Initiative – Achieving Rural Health Equality
Gary Nelson, President of the HealthCare Georgia Foundation, emphasized the need for healthcare in rural areas with his discussion of the Two Georgias Initiative and the increasing disparity between rural areas and metropolitan Atlanta. Ninety-three of 109 Georgia counties have primary care shortages, 92 have dental shortages, and 98 have mental health shortages. Addressing concerns from county commissioners about closing county hospitals, he described the Community Health Improvement Plan (CHIP) to bring parity back to healthcare throughout Georgia, because “the health of Georgians should not be determined by their zip code.”
- The Role of Telehealth in an Evolving Health Care Environment
Alan Morgan, the CEO of the National Rural Health Association came from Washington, DC to address his organization’s efforts to put the focus on rural healthcare. With the American Health Care Act and Obamacare repeal vote looming and scheduled to occur during his presentation, Mr. Morgan began by highlighting several problems facing rural America: life expectancy declines sharply with rurality; suicide rates, the opioid crisis, and behavioral health problems all increase with rurality; and rural is different—it is “not a small version of urban”—and must be treated accordingly. Mr. Morgan identified the big four challenges as reimbursement, licensure, clinical adoption, and community acceptance, and he then also highlighted a fifth challenge—internet access—both in rural health clinics and increasingly in homes.
Although rural populations are declining in some places, the number of students in rural schools is increasing, so despite hospital closures and cuts under sequestration and the Affordable Care Act, the need in rural areas remains. Accordingly, the National Rural Health Association has proposed the Save Rural Hospitals Act and worked on other efforts to better healthcare in rural areas. Regulatory relief and a focus on wellness are promising changes. Mr. Morgan emphasized that there is a business case for keeping people well, and that a new provider type, the Primary Health Center—a cross between an urgent care center and an emergency room—has great promise if it can be utilized and funded.
- Care Managed Organization Discussion Panel
Jimmy Lewis, CEO of Hometown Health and GPT Board Member, led a discussion with several CMO representatives about their organizations’ uses of telehealth. Kisa Fenn with Wellcare Health said that their biggest applications were currently maternal fetal monitoring and behavioral health. She also reiterated the push for school-based health centers, indicating that they have already reached 100% of children in Appling County, Georgia, through telehealth in schools. Collaboration, not competition, is key for Ms. Fenn. Dr. William Alexander from Anthem and Amerigroup told the room that they still need more telepsychiatry and behavioral health practitioners. Marty Fallon from the Peach State Health Plan said that a key factor for telehealth engagement is having a champion on the ground. The panel agreed that there is no single profile for this champion—it can be anyone—but it is absolutely essential to a good telehealth program.
The entire panel agreed that medicine in rural areas must change and the future for rural healthcare must include telehealth.
- Telehealth: Secure the Doors for Takeoff
Angel Bourdon from Palmetto Health discussed how to grow a successful telehealth program, which they have done in South Carolina, beginning with a USDA grant for a school-based pilot program with an emphasis on health education, engagement, and collaboration. Chris Gooditis from Blue Cirrus Consulting then discussed the technical considerations, including bandwidth, data flow, encryption, security, and HIPAA. He emphasized that the telehealth provider must be smart about evaluating business partners, use good business associate agreements, and adopt a risk-based—not compliance-based—approach, “treating the disease, not the symptoms.”
- The Grassroots Approach to Developing a Telehealth Program
Dr. Reg Gilbreath and Isabelle Magnin shared the “bottom-up” grassroots approach that Navicent Health has used to develop its successful telehealth program. They discussed the strong business case for the use of telehealth, citing a projected shortage of 90,000 physicians by 2025 and interest of 76% of patients in telehealth options. Despite challenges, the regulatory and reimbursement environment is improving, and grassroots efforts that empower users and align with the increased consumer demand for ease of access, convenience, and efficiency in health care provide powerful forces in support of telehealth programs.
Dr. Gilbreath and Ms. Magnin shared several checklists that organizations can use in evaluating and establishing a telehealth program, including a general “Telehealth Checklist” (with such considerations as identifying patients who could be served by telehealth technologies and verifying providers’ eligibility and credentialing), an “Operations and Implementation Checklist” (focusing on technical infrastructure and training), and a “Marketing and Growth Checklist” (which emphasized a theme of the conference—a telehealth champion—as well as leveraging social media and re-evaluating efforts along the way).
- Home Telehealth for Reduction of Heart Failure Patient Hospital Readmission
Shelley Hawkins, PhD, APRN, from the University of Tennessee Health Science Center shared compelling research regarding the efficacy of home telehealth services for reducing the rate of hospital readmission for patients with heart failure. She compared readmission for patients who engaged with the telehealth option during their 30-day post-discharge follow-up period (in addition to receiving standard home health nursing care visits) versus patients who received only the standard home health nursing care services during the same time. Telehealth patients’ blood pressure, heart rate, weight, and answers to six health status questions were reviewed daily, and alerts were generated for nursing follow-up if the results fell outside of certain parameters. The study showed that the patients in the telehealth program had statistically significant reduction in all-cause readmissions at 30 days post-discharge. In addition to sharing the results of the current study, she emphasized the need for additional large, randomized controlled studies with chronic condition patient populations. Results of such studies could be used to support the case for reducing the current regulatory and reimbursement hurdles facing telehealth.
- TeleHealth Economics: Making a Case for TeleHealth for Non-Life Threatening ER Visits
Vehe Hoboyan, PhD presented evidence-based arguments for telehealth to supplant triage level 4 and 5 (and some level 3) emergency room visits based on his study and experience at Augusta University. With the opportunity to address problems of overcrowding and increasing wait times, and especially important for small, rural hospitals with limited resources, telehealth for non-life threatening calls can improve access and affordability in addressing these problems. Dr. Heboyan’s compelling data showed the massive wasted ED time and resources on low severity, triage level 4 and 5 issues that can be handled elsewhere, and often, remotely. So now that telehealth infrastructure is becoming more affordable and efficient, why not use it for emergency coverage?
- Build It & They Might Come: The Importance of Marketing Telehealth Services
Kathy Schwarting from Palmetto Care Connection in South Carolina shared key marketing strategies for promoting a telehealth solution to consumers. Marketing is critical for telehealth services, just as it is for other products and services. As Ms. Schwarting explained, for a service or product to be a success, people must know about it, understand it, and see the value of it; otherwise, they will not use it. She outlined four key aspects to consider when developing a marketing campaign: product, price, place, and promotion. She also provided an overview of two misconceptions: the assumption that because the service exists, patients know about it and what it is; and the assumption that “need” equals “demand.” In essence, marketing is understanding what customers need, and giving it to them. However, marketing efforts must begin before defining and developing the program—the first step must be to confirm not only that there is a need for the service, but also that there is a demand. Finally, Ms. Schwarting emphasized the importance of marketing to people, not to organizations; personalize the message to the target customers.
- Teaching Telehealth: Harnessing the Power of a Connected Healthcare Landscape
Representatives from Georgia Southern University’s mental health nurse practitioner program, which has developed one of the first telehealth specific training programs that graduated its first class in December 2016, described the problem: Georgia is the 47th state in the nation in access to mental healthcare. Georgia Southern learned that to create an effective telehealth curriculum: start early, clearly define objectives, develop a foundational knowledge early, and survey any involved stakeholders, including faculty, IT, community and students.
- Realizing the Value of Telehealth with Chronic Conditions
Reminding providers to remember the patient, not just the diagnoses, Bryan Arkwright from Schumacher Clinical Partners described the telehealth opportunity in chronic care management: closing the communication gap, real time monitoring, empowering patients to partner with care teams, and maximizing financial value of a chronic care management program. Comparing key metrics of chronic care management both with and without telehealth, he found that the revenue can add up. And with recent and upcoming legislation and regulatory changes, there is more coming.
- Telehealth: Care Coordination + Patient Engagement = Positive Outcomes
Amanda Martin, RN, and Jeff Parks from Barnes Healthcare Services discussed the benefits to patients of receiving care in the home setting, and outlined ways that telehealth can help maximize these benefits. The telehealth “triple aim” objectives are well-suited to home-based care: optimizing health care utilization to improve health outcomes for patients; reducing the cost of care; and enhancing patient engagement. Benefits of such programs include: better access to care, improved quality, and the ability to educate, empower, and engage patients; filling gaps in the continuum of care; and reducing rates of readmissions.
- General Council Update
Erica Baker from the Medicaid office in the Georgia Department of Community Health described state efforts to encourage and grow telehealth, including the upcoming addition of ambulance originating site reimbursement, and new speech therapy codes effective April 1, 2017. She urged providers to visit mmis.georgia.gov/portal for more information on Georgia Medicaid.
- Implementing Maternal Fetal Telemedicine into an Urban Obstetric Private Practice Setting
Tanya Mack and Dr. Anne Patterson from Women’s Telehealth described their key goals, barriers, and strategies with implementing maternal fetal medicine in urban environments—a different setting than the rural focus of most of the rest of the presentations, but where telehealth services are also needed. Reaffirming comments made earlier in the week, they emphasized the need for a dedicated, trained telehealth coordinator and a backup, i.e., a “telehealth champion” within the organization. Telehealth for maternal fetal medicine does not need to be a specialty, Ms. Mack said, but it is just another tool to improve women’s health that should be utilized.
- Telehealth Law: Getting Past the Perceived Regulatory and Reimbursement Barriers
Attorneys Bill Boling and Mason Reid from Boling & Company answered the questions they most frequently receive: are we allowed to do that, and how do we get paid for it. After describing the state of the law in Georgia and some of the licensure requirements nationwide, Bill Boling emphasized that providers need to challenge regulators and payors—sometimes those discussions lead to more reimbursement and regulatory changes for the better. Private payment should be approached payor-by-payor and state-by-state, but with this kind of outreach, providers can usually find a way to get paid. He also emphasized that compliance should not be an impediment, but that practitioners should be mindful of applicable requirements.
When questioned about liability, the attorneys reminded the audience that (typically) rules that apply in the physical environment will translate to the virtual—e.g., the standard of care for practitioners is still what a reasonable provider would do in that circumstance, and it is not a particularly heightened standard of care, but the special circumstances of telehealth must be considered. In contrast, although the standard of care is the same in-person and virtually, privacy and security of electronic data do present heightened concerns, and practitioners should consider specialized insurance coverage. They also emphasized the importance of consent forms, and suggested that school-based health centers utilize a broad consent form to be executed at the beginning of the year, and then obtain verbal consent for each telehealth event during the year.
- Federally Qualified Health Centers
Sherrie Williams, COO of the conference host Georgia Partnership for Telehealth, moderated a panel with FQHC representatives Jennifer Mitchell (Valley Healthcare) and Carla Belcher (Community Health Care System), who described the challenges to their use of telehealth in Georgia.
- Clinical Integration: Models for Success
Dr. William Kanto from Augusta University shared his observations about challenges for rural hospitals: financial problems, patient base maintenance, physician and clinical professional recruitment, and adequate skilled staff. He also expressed that it is essential to overcome these challenges and keep healthcare options available in rural areas, because patients discharged home from hospitals in their own communities have far better outcomes than those that remain at faraway tertiary facilities before going home. Patients need a local resource.
Telehealth, according to Dr. Kanto, is part of the answer. There are several steps to provide a safe and compliant telehealth encounter, and potentially several remaining questions (e.g., the legal standard for telehealth vs. in-person encounters), but overall, Dr. Kanto was hopeful about the future of rural health in Georgia using telehealth.
- Worksite TeleDermatology; Improving Health Outcomes through Collaboration and Partnership
Skin cancer affects everyone, of any age; it is the most common cancer, and affects 2 million people a year in this country. Dr. Suephy Chen, Vice Chair of Dermatology at Emory University, and Suleima Salgado, the Georgia Department of Public Health Director of Telehealth & Telemedicine, therefore created a pilot program to test teledermatology in Georgia. They found it enthusiastically successful—76% of the participants rated it as excellent and 97% said they would use teledermatology again. Now it’s time to expand.
- Patient Care Experience
Bryan Larrieu, Director of Information Services & Technology User Experience at Children’s Healthcare of Atlanta, described the large hospital system’s technical and IT challenges, but emphasized that to make telehealth successful, the patient care experience must be seamless. He also emphasized that the system must be future-proof; it must be easy to continuously upgrade as technology evolves. But overall, with the “office anywhere” approach utilized by CHOA, access to healthcare has improved and the patient experience has transformed for the better. In this modern world, technology is expected.
For help overcoming the regulatory or licensure challenges in telehealth, to explore options to maximize reimbursement, or to discuss your own questions or feedback on the conference or your telehealth solution, please contact Sean T. Sullivan or Madison M. Pool.