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Title V Technical Assistance Meeting

 Telehealth: Challenges, Emerging Needs and Opportunities for Title V

By Stacy Collins, MSW
Associate Director, Health Systems Transformation
AMCHP

By Paige Bussanich, M.S.
Senior Program Manager, Children & Youth with Special Health Care Needs
AMCHP

Although telehealth provides access to high-quality care at reduced cost and helps to fill gaps in care for populations in the most need, the strategy remains an underutilized resource for maternal and child health populations. This is especially true in rural and urban regions, resulting, for example, in long waiting times for diagnostic and treatment services. Health care patterns across the country point to the need to use telehealth to address these gaps – but we must build capacity for accessing the technology in more communities.

First, let's be sure we agree on what telehealth is. The U.S. Health Resources and Services Administration defines it as the "use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health and health administration"[i].

The use of tele-mental health has grown dramatically in recent years, and clinical trials have demonstrated that its effectiveness is comparable or superior to in-person care.[ii] Across Title V Programs, however, challenges to using telehealth include use and maintenance of the technology and equipment, infrastructure (e.g., Internet bandwidth), start-up costs, and compliance with privacy provisions in the Health Insurance Portability and Accountability Act of 1996. Additionally, further supports are needed to provide access to interpreter services, as well as technical assistance related to billing and reimbursement for telehealth services[iii]. Yet while the launching of telehealth programs can be a daunting task, it can succeed  with appropriate buy-in from the workforce, collaborative leadership, and public health investment.

As testaments to such success, we share below lessons from four large health systems on overcoming challenges to successfully develop, implement, and sustain robust telehealth programs. These are five challenges and practice-based strategies – used by Michigan Medicine, Massachusetts General Hospital, Emory Healthcare, and Jefferson Health – to sustain telehealth programs.[iv]

  • Engaging leaders: Mobilize results to drive decision-making in support of telehealth as a game-changer in strategic growth and program expansion. Program sustainability is strengthened by ensuring telehealth proposals are designed to work within existing systems to promote change.
  • Prioritizing telehealth needs: Use need prioritization in planning to maximize return on health investments for those receiving services.
  • Engaging clinicians and staff members: Identifying champions at all levels of the workforce to leverage support throughout the organization. For example, invite clinicians to share input on how they believe telehealth could improve their care delivery capacities.
  • Enrolling and educating patients: Develop strategies to simplify and streamline processes, ideally mimicking old processes, and provide training content in various accessible formats (e.g., video, print, in-person)
  • Evaluating outcomes: Adopt evaluation frameworks specifically for demonstrating value and return on investment in telehealth focusing on access to care, financial impact and cost, experience, and effectiveness.

With those concepts in mind, let's look at how telehealth should be better supported to address one emerging need, and how telehealth is emerging as a solution to a rural state's longstanding challenge.

Emerging need: Telehealth for treatment of opioid and other substance use disorders in women

Despite the opioid crisis, the use of telehealth to diagnose and treat substance use disorders (tele-SUD) has remained low. This is unfortunate, because tele-SUD offers an opportunity to significantly expand community-based access to care for women with SUD by boosting self-efficacy among primary care physicians (PCPs) to treat addiction.  Using tele-SUD, PCPs can consult with addiction medicine specialists to become proficient in the use of medication-assisted treatment (MAT), now considered the standard of care for pregnant women with opioid use disorder. PCPs can also use telemedicine to link patients to licensed clinical social workers who can provide tele-therapy and other recovery support services. Tele-SUD via Skype or mobile phone apps to support women in drug recovery are other emerging interventions. Through these practices, tele-SUD can overcome barriers to care such as transportation, distance, and stigma.

To address the enormous unmet need for SUD treatment for women of reproductive age, state Title V programs and their partners should explore tele-SUD as a means of expanding access to care for this highly vulnerable population.    

Emerging solution: Putting PCPs at the center

As with most rural states, Nebraska suffers significant provider shortages in nearly all disciplines, including general pediatrics, child and adolescent psychiatry, and mental health.  Telehealth has emerged as an essential tool for the provision of health care services to Nebraska's MCH population. 

Nebraska Title V 's early childhood screening program has benefited from the state's prioritization of telehealth. The state is committed to expanding the competency of the primary care workforce to conduct screening and improve access to this and other fundamental pediatric services. To facilitate this objective, Nebraska Title V participates in Project ECHO (Extension for Community Healthcare Outcomes), a hub-and-spoke telehealth model in which specialists provide training and case consultation to PCPs in rural and underserved communities.  Title V's integrated, systems approach to care is woven into Nebraska's program. Through telehealth consultation, primary care providers become better equipped to provide dyadic screening, identifying the behavioral health needs of both mother and child. 

With its emphasis on maintaining the locus of care at the primary provider level, telehealth consultation in Nebraska has fostered provider skills-building in diagnosis and treatment of maternal mental health and substance use disorders. In addition to Project ECHO consultation, community clinics have begun offering direct-to-consumer tele-mental health and medication tele-monitoring.  The state's child welfare system employs tele-mental health to support family maintenance efforts.  Growth and sustainability of telehealth in all its forms is a central goal of Nebraska's public health department and the Title V program.

[i] U.S. Department of Health and Human Services, Office of the National Coordinator for Health Information Technology (2017). Telemedicine and Telehealth. Washington, DC: U.S. Department of Health and Human Services, accessed Jan. 15, 2019, https://www.healthit.gov/topic/health-it-initiatives/telemedicine-and-telehealth

[ii] Huskamp HA, et al. (2018). How is telemedicine being used in opioid and other substance use disorder treatment? Health Affairs, 37(12), 1940-1947. https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05134

[iii] Health Resources and Services Administration, Maternal and Child Health Bureau. Title V Information Services (Webpage). Available from: https://mchb.tvisdata.hrsa.gov/ 

[iv] Ellimoottil, C., An, L., Moyer, M., Sossong, S., & Hollander, J. E. (2018). Challenges and Opportunities Faced by Large Health Systems Implementing Telehealth. Health Affairs, 37(12), 1955-1959. doi:10.1377/hlthaff.2018.05099