telehealth and rural practices…the road less traveled kiki c. nocella university of southern...
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Telehealth and Rural Telehealth and Rural Practices…the Road Practices…the Road Less TraveledLess Traveled
Kiki C. NocellaKiki C. NocellaUniversity of Southern CaliforniaUniversity of Southern CaliforniaKeck School of MedicineKeck School of MedicineDepartment of Family MedicineDepartment of Family Medicine
Rural CaliforniaRural California
75% of land mass
11% of population
75% i75% of land mass and
11% of population
live in rural California
Tehachapi Valley Tehachapi Valley Healthcare DistrictHealthcare District
State of the State of the Region….2004Region….2004 Had a telemedicine unit since Had a telemedicine unit since
1998 1998
JPA CollaborativeJPA Collaborative
New TVH built by 2008, seismic New TVH built by 2008, seismic retrofitretrofit
98.7% outward 98.7% outward migration for inpatient migration for inpatient care!care!
Hospital Discharges of Patients living in southeast Kern
47.0%
10.0%
9.5%
7.2%
1.3%TVHD0.7%
0.7%
0.8%1.9%
3.9%
1.8%2.3% 1.2%
9.7%
0.5%0.5%
Support and Success Support and Success for Telehealthfor Telehealth Blue Cross of California/WellpointBlue Cross of California/Wellpoint
– Funded through State to develop Funded through State to develop telehealth network for Healthy Families telehealth network for Healthy Families (SCHIP) and MediCal (Medicaid). (SCHIP) and MediCal (Medicaid).
CTECCTEC– California Telemedicine and eHealth California Telemedicine and eHealth
CenterCenter UC DavisUC Davis
…….So why wasn’t it working in SE Kern?.So why wasn’t it working in SE Kern?
What sites do you think of What sites do you think of when you think of when you think of Telehealth?Telehealth? Rural hospital?Rural hospital?
Rural Health Clinic?Rural Health Clinic?
Academic Medical Center?Academic Medical Center?
Physician Office?????? Physician Office??????
So….what was our So….what was our processprocess Community based planning Community based planning
collaborativecollaborative Networking outside the rural Networking outside the rural
region region Capacity BuildingCapacity Building Lots of data gathering Lots of data gathering Lots of key informant interviewsLots of key informant interviews
– Provider Provider -- Ancillary -- Ancillary – AdminAdmin -- Office staff-- Office staff
How did we get the How did we get the docs talking?docs talking? Trust buildingTrust building
Listened, and listened, and listenedListened, and listened, and listened
Maintained confidentiality to a level that Maintained confidentiality to a level that was virtually painfulwas virtually painful
And the ripple effect began – the docs And the ripple effect began – the docs kept talking – to each other and testing kept talking – to each other and testing the trustthe trust
What the docs said What the docs said (about telehealth)(about telehealth)Only possible after much listening and trust buildingOnly possible after much listening and trust building Show me what is possible in a way I can get my head Show me what is possible in a way I can get my head
around – and I’ll run with it from therearound – and I’ll run with it from there Will it take revenue out of my practice?Will it take revenue out of my practice? Will it impact my relationships with my specialists?Will it impact my relationships with my specialists? My patients better not get billed anything extra My patients better not get billed anything extra
(Translation – I don’t want to hear any complaints)(Translation – I don’t want to hear any complaints) What’s in it for me? (Not said, but always there)What’s in it for me? (Not said, but always there) The hospital is just trying to compete with meThe hospital is just trying to compete with me
OK. Got the docs’ OK. Got the docs’ attention….but that’s not attention….but that’s not all of the challengesall of the challenges
Hospital’s business needs
Community’s
Health
Needs
Physician business needs Health Plan Business
Needs
The “Win-Win” is at the center
So, what was the So, what was the solution?solution? Telehealth only part of the Telehealth only part of the
equationequation System redesign is the approach System redesign is the approach
we’ve embracedwe’ve embraced
Providers (Physicians, PAs, and NPs)
• Basic “talking heads” teleconferencing
• More as utilization dictates
• Via “Integrated Technology Association”
Rural Hospitals and Clinics
•Higher cost equipment
•Telehealth center that integrates with other programs
Academic Medical Centers and other specialists
Telehealth Solution
• Teach them “rural”
• Agree to take all patients
• Specialties that were not in competition
We’re reforming – but We’re reforming – but not around the edges!not around the edges! InfrastructureInfrastructure
– Give, give, give and then get a littleGive, give, give and then get a little– Provider leadership teamProvider leadership team– Population based quality improvementPopulation based quality improvement– Start with the basics…playing nice and Start with the basics…playing nice and
sharingsharing EducationEducation
– Rural residency training Rural residency training – Rural HIT and population health curriculumRural HIT and population health curriculum– E-health alertsE-health alerts– CME/CEUCME/CEU– Some cool pipeline conversationsSome cool pipeline conversations
And reformingAnd reforming
Telehealth – meeting the providers’ Telehealth – meeting the providers’ needsneeds– ““Talking heads” at every provider’s deskTalking heads” at every provider’s desk
Telehealth – meeting the community’s Telehealth – meeting the community’s needsneeds– Diabetic RetinopathyDiabetic Retinopathy– Women’s health issuesWomen’s health issues– Cardiac issuesCardiac issues
And reforming!And reforming!
Synergistic and overlapping Synergistic and overlapping approaches on technologiesapproaches on technologies– PHRPHR– SCDRSCDR
Capacity buildingCapacity building
Policy suggestionsPolicy suggestions
Focus on the physiciansFocus on the physicians Count all costs, not just traditional Count all costs, not just traditional
costscosts Implement a reimbursement Implement a reimbursement
model that does not further model that does not further fractionate an already fractionate an already fractionated systemfractionated system
““Ultimately, the challenge Ultimately, the challenge of health care reform is of health care reform is the challenge of building the challenge of building community”community”
Shortell, 1996Shortell, 1996
AcknowledgementsAcknowledgements Thanks to Michael and Jami for pinch hitting Thanks to Michael and Jami for pinch hitting
with no notice!with no notice! Thanks to AHRQ for giving this community the Thanks to AHRQ for giving this community the
reason to have this, and other, conversationsreason to have this, and other, conversations Office of Statewide Health Planning and Office of Statewide Health Planning and
Development – thanks for the maps!Development – thanks for the maps! Gregg, Lisa, George, Adil, Atif, Julie, Bill – thanks Gregg, Lisa, George, Adil, Atif, Julie, Bill – thanks
for your wisdomfor your wisdom Residents of SE Kern – thanks for being so Residents of SE Kern – thanks for being so
open, willing, and dedicatedopen, willing, and dedicated
Wish I were there Wish I were there