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 CenterCalifornia Telemedicine and eHealth Center

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 with Thanks to Michael and Jami for pinch hitting with

no notice!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 open, Residents of SE Kern – thanks for being so open,

willing, and dedicatedwilling, and dedicated

Wish I were there Wish I were there