What does it take to build a successful telehealth program that harnesses the technology capabilities for digital health while gaining the outcomes the local population truly need? Hospital systems keen on reducing chronic care costs and unnecessary readmissions might want to take a look at what’s going on in Tallahassee, Florida.
Over the past five years, Tallahassee Memorial Hospital (TMH) has become one of the few healthcare organizations that has broken down healthcare delivery silos between acute care delivery and community wellness programs. TMH’s approach began at the hospital and branched out into transitional care, rehabilitation and a community wellness center.
The project is being led by Lauren Faison, TMH’s service line administrator over regional development, population health and telemedicine. Of interest, Faison isn’t an IT professional. She isn’t a clinician, either. But, she does know how to take a bull by the horns. “My role is merging all of the piece of the project,” she tells Healthcare Informatics. “What does the operational piece look like? What information would be most valuable for the clinicians to have at their fingertips? How can we deliver the information they need so they can spend their time providing clinical care instead of searching for data? I help bridge the gap between all these different institutions.”
She says her current job role at TMH could be an emerging one in the industry, as more health organizations seek ways to reach across the organizational barriers and implement digital health as a mainstay for improved outcomes long after a hospital discharge—much like the emergence of the CMIO role. “Telemedicine isn’t just an IT project, and it’s a mistake to think of it that way,” she insists.
The Local Mission
In part, the telehealth initiative stemmed from the facts of the Tallahassee region, which includes sizeable populations of homeless and under-insured patients, Faison noted. “If you look at our demographics in Florida, we're surrounded by very poor, very rural communities with little public transportation and very few health services. Once discharged from the hospital, patients couldn't get the follow-up services they needed. Or, they couldn’t get any specialty services at their local rural hospital. We needed to find a way to increase access to care while also being able to monitor them from their homes. We wanted to be able to talk with them about their medication, hear how they're feeling and watch their blood pressure without making them travel.”
The telehealth program began in earnest in 2012, with the acquisition of telehealth equipment to provide a link for high-specialty services between Level-2 trauma center and outlying areas. Like most successful implementations, it started with a lot of homework. “We spent a lot of time in Georgia where they have wonderful telehealth legislation and seeing how their networks are set up and how their technology works.” The team also spent months assessing available technologies and getting input from IT and the clinical side.
Once the specialty trauma services were set up, Faison developed a program to extend telehealth services to high-risk patients upon discharge, tackling the success rate of the crucial 90-day post-discharge window. Early focus was on patients with chronic heart failure, pneumonia and cardio-pulmonary issues—classic conditions whose outcomes benefit from close monitoring 30 days post-discharge.
While many of TMH’s patients have socioeconomic challenges, nearly all of them had a cell phone, Faison explains. “Sometimes it’s just about a voice call to say, “How are you feeling right now?” And, we can touch base to remind them about appointments and see if they’re taking their medications correctly. When people leave the hospital, they’re given a lot of instructions, but they’re still not feeling well and can be overwhelmed easily, especially when they don’t have a solid support system.” One of the biggest fail points in healthcare deliver, she says, is the follow-up stage.
Digging Deep into Population Health
Successful telehealth programs need to dive deep into the needs of the local community, focusing on the barriers to healthcare access and the reasons why patients are at high risk. “We look at things like patients who visit the hospital three or more times in the past year. Do they report not having a primary care provider? Do they not have insurance? Within our hospital EMR [electronic medical record], we have a button that case managers, nurses and physicians can push to indicate if this person is at high-risk for readmission and whatever their barriers are. If we can't see them physically because they can't get to us, we'll see them virtually through telemedicine.”
Reducing readmissions means delivering quality follow-up services as they’re needed, and that means offering access via telemedicine to much more than a case manager or ask-a-nurse service. “We have a pharmacist, we have a social worker, we have the clinicians, and we have this multidisciplinary team that all meets with the patient to see what their barriers to care may be,” she says. Faison even got the homeless shelters involved, including the community social workers.
Still, it was a challenge to tether in ancillary services, such as rehabilitation centers and wellness check-in centers. Some of the struggle was operational, but a lot of it was technological, Faison remembers. “Embedding technology isn’t hard, especially with all the mobile apps,” she explains. “But how do you get a patient and a physician in front of two separate cameras at the same time to facilitate the consult? What information is documented? How do we facilitate what needs to happen afterward? There are a lot of moving pieces and decisions to be made. You really have to have every person who is part of that process involved in the project planning for it to be successful.”
TMH’s system had even greater meaning once the Centers for Medicare & Medicaid Services (CMS) began penalizing hospitals for excessive preventable hospital readmissions. But even then, the culture change was a challenge, Faison says. “Until there’s that financial penalty or incentive, it's hard to get folks to change their practices. Now they’re paying attention. And then they’ll say, ‘Wait a mind. I just spent thousands of dollars to transport patients all over the place for consults. Why don't I just pay for the consult and get the savings on better patient outcomes?’ I present at fiscal forums and clinical forums, and I work with administrators to show them all how everybody should be increasing the benefits of telehealth.”
“I think you will see more administrator level positions getting involved in how we integrate all of this,” she adds. “You can no longer have IT in one building, data in another building, and clinical practices in another building. You have to have a multidisciplinary team that is focused on looking at how we use all this information, what the infrastructure is needed to access it and what technology is best to move the clinical practice forward. But even today, it’s a huge deal to say, ‘We can’t think of this solely as an IT project.’”
Implementing with a Context
By design, the success of a telehealth project is based on its impact outside the health system walls. Faison is always tweaking and adding to the project, growing its reach and scope, acutely aware of the patients’ socioeconomic barriers at every turn. “We’ve got the big clinical parts covered, but now I want more boots on the ground, out in the community or on the phone,” she says. “We should be helping patients through the system and helping them find answers to their questions, not just passing them off to somebody. I think we're very good in giving people referrals and phone numbers, instead of just answering their questions themselves.”
While digital health initiatives and telehealth capabilities can solve many issues related to healthcare delivery, even important technological innovations can still be stymied by lingering barriers within the healthcare system itself. “I think many healthcare institutions are still very still siloed,” Faison says. “It still can be a very slow and hard road to culture change in many environments. That’s why it’s so important to be able to sit around the table and figure out how to use the information we have and maximize technologies to get the best information into the hands of those who need it the most, which is our clinicians and our patients.”
Pamela Tabar is a healthcare writer based in Medina, Ohio.Read our exclusive Q&A with Faison on the evolving world of digital health and population health management.
Hear more about TMH’s telehealth implementation at the Health IT Summit in St. Petersburg, Florida, July 24-25, 2018.
