Rural Telehealth: Beyond Video Visits

One of the biggest challenges facing rural America is access to care and the barriers to accessing care are manifold, including transportation, time, and technology.

Obviously one solution is to access care through a video visit. 

But even that basic care delivery modality is not available for many rural residents. Because rural patients may not have access to technology, may not have access to the internet, or may not have the digital literacy to operate a smartphone or computer to connect on a video call.

But there is another challenge, too: ensuring the continuity of care and to provide care management between visits.

When I think about optimizing care delivery in rural America, I’m mostly thinking about optimizing chronic care management. That may be the four typical “lifestyle” diseases of high blood pressure, high cholesterol, type 2 diabetes and obesity. But it can also be other debilitating “chronic” diseases such as cancer or severe mental illness, that require more than just primary care or basic counseling.

While I’m not a clinician, I have learned that to effectively treat chronic conditions it is important for patients to become engaged in their care and to follow the clinician’s care plan which often includes medications as well as “recommendations” to the patient’s lifestyle, including diet, exercise, and sleep.

But to make that kind of change requires more than just the occasional visit - which also oftentimes gets skipped or rescheduled due to other constraints such work, child care, or simply not having the time.

So here are some other solutions for rural health beyond a video visit over the patient’s smartphone.

The Power of Secure Messaging

Over the past decade, sending short messages via text has become the preferred communication methods between friends and family. While some of those communications may be asynchronously (i.e., without an instant response), some may occur in real-time with a few iterations of back and forth.

This mode of communication is ideal for the continuous engagement of the patient in following the care plan and can work in both directions. Members of the care team can periodically check in with the patient to encourage them to follow the plan and to provide an opportunity for the patient to ask any questions.

The feeling of “belonging” is one of our strongest emotions that we strive for, and over the years I’ve had numerous stories about patients that simply appreciated that there was someone who “cared” about them and reached to inquire how they were doing. It can be as simple as a “How are you doing?” or a more specific inquiry such as “Do you have any questions about your medication?” that can go a long way to have the patient participate in their care.

Texting, even when conducted securely and HIPAA-compliant, does not require an expensive data plan and, with informed consent, there may not even be the need for a smartphone that can install an app.

Thus, to engage the rural patient population in effectively managing their condition, maybe we could go back to the basics of checking in on people (just like my family doctor used to call (in person!) after his clinic day to check on me when I was sick).

(For this week’s column I’m going to purposefully side step the whole reimbursement discussion and the notion that on top of a busy clinic day we cannot expect our clinicians to also attend to a full inbox of messages — but I will get back to that in the future).

A Sense of Belonging through RPM

We have been excited about the possibility of getting better clinical insights into the patients important vital signs such as blood pressure for hypertension, weight for congestive heart failure, or glucose levels for diabetes. This ability to more frequently monitor the patient’s well being can create great value.

But the biggest benefit is not just the access to the data to detect a deterioration of the patient’s condition. The biggest benefit goes back to that deep desire to belong, to know that someone cares.

What RPM offers is an opportunity to reach out to the patient and to use the real-time data as an opportunity to do real-life teaching on how certain lifestyle choices (e.g., a high salt meal or a few days with little sleep) more or less immediately lead to changes in their vital signs. 

This presents a great opportunity for a member of the care team (e.g., a monitoring nurse) to reach out to the patient to share that they are concerned and to help the patient get back on track in a very timely manner (i.e., well before the next visit).

But the opportunity to teach just-in-time is not the only benefit. Similar to the notion above, checking in on the patient when they missed a measurement (or when they successfully completed two weeks of perfect measure taking!) is another indication to the patient that someone cares, that they belong. And it often takes just a short phone call to do so.

Community Telehealth Access Points

Another trend — one that we have been working on quite a bit with schools and libraries — is the idea of a public Telehealth Access Point, e.g., in a school, a community center, or a fire station.

This specific way to gain access to a video visit solves the problem of long-distance transportation, connectivity, or digital literacy.

In the Northwest region of the US the Northwest Regional Telehealth Resource Center (NRTRC) has mapped over 100 Telehealth Access Points in a 7 state area.

Community Paramedicine

Another great solution is to take advantage of paramedics that can use their time between transports to check in on patients - e.g., those recently discharged from the ED, the hospital, or a nursing home; or those known to be high utilizers of urgent or emergent care services.

When equipped with the right tools and the right equipment, community paramedics can also connect back to the clinical care team via an ad hoc (or even pre-scheduled) video visit or the transmission of vital signs or of photos/video using exam tools such as a dermascope or otoscope.

Using Technology to Increase the Sense of Belonging

Isolation and loneliness are two critical contributors to “unwellness” and they can be exacerbated in rural areas.

All of the solutions presented above bring patients closer to other humans - whether that’s a short trip into town to use the telehealth access point at the library, a home visit by your local friendly paramedic, or a call from the monitoring nurse reminding you to step on the scale: All are opportunities to help patients to be more engaged in their care.

Which solution beyond video visits are you using to reach your rural population? Let me know.

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Christian Milaster and his team launch, expand, and grow Telehealth Programs for rural health centers, behavioral health agencies, health systems, schools, and libraries. Christian is the Founder and CEO of Ingenium Digital Health Advisors where his team and consortium of experts partner with healthcare leaders to enable the delivery of extraordinary care by accelerating the adoption of digital health innovation.

To explore how we can help your organization solve your challenges, contact Christian by phone or text at 657-464-3648, via email, or video chat.