Telehealth Expands to Frontier Country

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode, we're talking about telehealth and how Alaska used this approach to support a project to lower hypertension among people living in the most remote parts of America's last frontier.

DR. MARCUS PLESCIA:
This is relevant to everybody working in state or territorial health, public health—everybody's got remote communities that are difficult to reach.

JOHNSON:
Where planes deliver the mail, telehealth fills a need.

JANICE GRAY:
Without telehealth, these individual communities are incredibly isolated and the staff that are in there are incredibly isolated.

JOHNSON:
And delivers results for the Eastern Aleutian Tribes.

SUSAN HIGHLEY BAILEY:
And their aim was to improve by 50%.

They gave themselves six months; within the first three months, they had doubled that. They had already improved, and they were at 18%.

Providing that information to the staff that had been working on this improvement project, you could imagine how excited people got.

JOHNSON:
Welcome to Public Health Review, a new podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we'll discuss the most pressing public health issues facing our states and territories and explore what health departments are doing to improve the condition of our country's most vulnerable populations.

This episode, we're talking about telehealth, a concept familiar in healthcare delivery settings but now emerging as a tool for public health professionals as well.

In Alaska, the state health department earned a competitive grant from ASTHO—with support from CDC—to help fund a project intended to provide long distance training for healthcare workers at eight clinics scattered over an area the size at the state of Colorado. It launched last July and the results have been impressive, to say the least.

We'll hear from several people working on the project in a few minutes. But first, we consider telehealth as a public health tool with Marcus Plescia, the chief medical officer at ASTHO.

PLESCIA:
You know, telehealth has really emerged over the last decade to be much more commonplace than people might think. And, you know, the health side has mostly focused on clinical applications; and so, I think that what we're talking about today—which is a really more public health engagement using telehealth as a modality—that's a little newer and more novel.

But telehealth itself, I'd say, really has quite a bit of momentum now. And, you know, there's some very good examples out there of some ways and places that it's made a huge difference, particularly for communities that are hard to reach and don't have the same kind of access as, you know, communities that are in more mainstream urban environments.

JOHNSON:
Why is this approach new in the public health field? Can you explain that?

PLESCIA:
I think we've just not used it as much. I think that telehealth really got popular in the clinical field because of the access issue and because you have places where, you know, there's either limited access to medical care completely, or—you know, maybe more commonly—you get situations where you've got a generalist, a primary care physician or a nurse practitioner, who's dealing with some pretty complex problems. And what we found, in medicine, is that this kind of telehealth assistance can really make a big difference in taking somebody who's got a pretty general understanding and allowing them to deal with some more complex issues.

And for the patients, for the people that need the care, that makes a huge difference because they are able to be cared for in their home community or home setting, as opposed to having to travel to some, you know, foreign and sometimes kind of scary place.

JOHNSON:
So, we have two sides of this: we have delivering healthcare; and then we have the public health side, which is training, education, building more informed medical communities as they go out into the patient world?

PLESCIA:
Yeah, that's correct. That, I would say, that's really what this.

I mean, this is an interesting project to begin delving into public health's role, or public health's use of telehealth, because there is a strong medical component to it. This is about, you know, trying to help with more effective management of elevated blood high blood pressure in some of these rural communities. Although this is specific to a situation in Alaska, we think this is an important topic for public health in general because every state public health department has rural communities that they have a hard time reaching.

And so, this is beginning to look at how public health can use the modality better, but also tying into the fact that it's a clinical issue. And so, a place where, you know, there has been some use of telehealth modalities, and it's really more of a matter of bringing some of the public health perspective into that.

JOHNSON:
You mentioned that, of course, every state in the country, the territories, everybody's got rural communities.

Is Alaska the only state trying this in a public health application, or are there others?

PLESCIA:
I think this is really emerging as an area of interest for a lot of states.

You know, we're seeing a lot of interest in using telehealth modalities in state public health departments in trying to deal with the problem we're having now with the opioid epidemic.

You know, we've seen some interface of public health being engaged in telehealth around some infectious disease issues: hepatitis C and Project ECHO—which I'm going to talk about it a little bit more later—is a good example of that.

So, it's emerging; but we thought this was a really nice example—I mean, it's a very remote setting, but you know, there are places like this in lots of our other states and territories.

JOHNSON:
Okay, so, let's go ahead and get into the Alaska case study.

The Eastern Aleutian Tribes are well underway. They've been at this for a while, using telehealth to engage and educate the medical practitioners who were in the field, to build relationships with them.

Talk about that program: what it's about, what's working—just give us the history.

PLESCIA:
So, the main gist of this project or program is trying to improve identification and treatment of patients who have high blood pressure and also trying to support clinical practices in that work.

So, let me start with the first part. I mean, we were wanting to work with these clinical facilities, you know, to make clinicians more aware of the importance of high blood pressure, more aware of the various treatments, more aware of, you know, what to do when one of the treatments you're trying aren't working.

You know, it's really just— and we're also trying to teach them a quality improvement mechanism that has them not just looking at their single patient that they're seeing, you know, during that time, but really looking at their practice—looking at all of the patients with high blood pressure in their practice—and monitoring how well they're doing with that population of patients as far as controlling them.

So, that's the first part of what we're doing. And, you know, I think that's an area where there's a lot of experience and momentum, and we've seen a lot of improvements in blood pressure control as a result of that approach. But we're also trying to bring this public health perspective and help clinicians think about the fact that, you know, this patient is there with them for 15–20 minutes dealing with their high blood pressure, and then they're going to go out and be on their own for several weeks before they come back kind of dealing with this issue. And so, how do you connect that patient with supportive mechanisms so that they, you know, so if they have questions, they have people they can talk to; if they are concerned or nervous about their condition or the treatment they've been given them for their condition, you know, there are people that they can engage in their community that they trust who can help them with that.

And that's, you know, we talk about that; we refer to this as self-management. And I think where public health and public health departments really have a big potential role in this idea of how do we really expand those self-management situations, how do we help clinicians understand how important that is to people's everyday health, and how they can reach out and really engage some of those kinds of networks and systems.

JOHNSON:
So, is the telehealth approach—as it relates to the Alaska example—really happening more between the people who can share the knowledge giving it to the people who are delivering the health care? Is that where the telehealth approach comes into play here?

PLESCIA:
Yeah—although I would say, in this case, it's not so much about, you know, teaching them how do you handle a patient with high blood pressure. I mean, that's kind of bread-and-butter primary care. I think that the folks in the Aleutian Tribes and elsewhere, you know, they're pretty capable when it comes to that.

It's more teaching them this quality improvement, quality assurance approach; where, you know, they're looking at their practice population, they're looking at their numbers, they're looking at, you know, how well are we doing overall with treating hypertension, what kind of changes can we make to improve that?

And those changes aren't always about, you know, getting the doctor or the nurse practitioner to prescribe the right medicine. Some of that is about, you know, is there something we should be doing to call our patients after we've made a change and remind them and check in with them. That can be very, very effective as far as helping people make a change in a treatment modality. You know, are other things that we can do to make sure that patients have good access, you know, they are able to get the medicine to get prescribed.

You know, it really varies from place to place what they identify as the challenges or what they identify as those, you know, kind of interventions they can make to try to make their overall approach to control of blood pressure stronger.

And again, this isn't just about how am I doing with this individual patient I'm with, but how am I doing really identifying—or how are we, those in the clinical practice—doing identifying patients in that community who have high blood pressure, you know, getting them to come in, and then helping them get their blood pressure under control.

JOHNSON:
So, telehealth allows those practitioners to stay connected and helps them answer those questions as they try to operate in these very remote areas.

PLESCIA:
Yes, keeping them connected and engaged. And, you know, I don't know that it's been as well-developed with this project, but the other thing that telehealth can do is connect people who are facing similar challenges to each other.

So, you know, you get somebody in the Aleutian Tribes talking to somebody, you know, working in tribes elsewhere and, you know, they just start talking about, "Well, here's what worked for us, and here's what was challenging for us." And, you know, they learn from each other.

And that kind of thing is always—it's always helpful. But it's also very supportive because you realize that other people are—other professionals are—facing the same challenges. And, you know, you're often—you know, it gets people thinking in a more creative way about what they can do.

JOHNSON:
How does this program look, then, to the people who are on both sides of the camera? Is it a regular meeting? Is it training? Is it checking in as needed? Or how does that really look if you put it on paper—what's the syllabus, if you will?

PLESCIA:
I think it varies depending on what the different sites need. You know, I think it's best when it's very interactive, when you're bringing lots of people to the table and exploring different approaches to how to problem-solve on various issues.

I also think that that any— it doesn't— not just telehealth, any kind of intervention like this is good and stronger if there are frequent touch points. So, you've got people really familiar with the technology and, you know, facile at using it to, you know, reach out anytime they have a question. And that's the thing, you know, it can be very real time if it's working and working well.

So, it's not just, we're going to— I mean, you know, often it is, "We're going to link at two o'clock on Tuesdays," and that's what they do. But I think when there's also the opportunity for some ad hoc interaction. I think that tends to make these kinds of modalities much stronger.

JOHNSON:
What are the early results showing you? Is this program working?

PLESCIA:
Yes. The early results are, you know, much more processed results. So, you know, we're starting to see the kinds of changes and practice, the kind of engagements, kind of links, and the community supportive resources that are very, very important long-term to get at what we really want, which is improvement in blood pressure control.

And even that is what we would describe as an intermediate outcome. The most important outcome is improvement in heart disease—you know, the occurrence of heart disease and mortality from heart disease. And so, you know, those are going to be things we don't see for a few years.

But we're seeing the signs that we know from the science that, you know, if you start to make these changes, if you start to engage clinical practices in communities and certain key practices, then you know, that that is going to lead down the line to better control of blood pressure and then, ultimately, better cardiovascular disease outcomes.

JOHNSON:
And as you mentioned, this approach really could applied—and is being applied—across the public health spectrum, right?

PLESCIA:
That's why this is so important to us, and that's why we really thought this was an important podcast to do, because this is relevant to everybody working in state or territorial health—public health.

Everybody's got remote communities that are difficult to reach; and, you know, frankly, even if the community's not that remote, this can be a very, very efficient way to interact. You know, even if it's somebody who's just an hour down the road, you know, if you get this kind of telecommunications going well, you can cut down on, you know, even those travel times—which are short, but still consume time.

So, you know, we think there's a lot of relevance here to everybody. I mean, people think about the Aleutian Tribes and they are in very, very remote, difficult situation. And so, in some ways, maybe it's a bit of an extreme example, but we really think it brings up the points that are so important to why telehealth can be really effective. And, you know, I mean, I guess I would say if you can make it work in a place as remote as this, I would think that most people would be pretty encouraged that they could make it work in their own state or their own territory.

JOHNSON:
With everyone on a mobile phone these days, it seems kind of like a no brainer; but why do you think it's just now coming to the public health arena?

PLESCIA:
You know, to do it right, it does require some more sophisticated technology than, you know, just what we've got on our mobile phones—I mean, we certainly talk back and forth live on that, that's helpful.

But to get the actual video component where people can see each other and where the images are good—I mean, that has taken a little while to come along.

But also, I think we're still exploring, you know, how do we use this kind of an approach to improve a community's health as opposed to, as I've been saying earlier, to focusing on individuals and how is this specific patient doing? And I'm gonna, you know, teleconference in to discuss a case versus teleconferencing to discuss a population or a community.

And, you know, we haven't gotten all that figured out yet. I think that understanding how you work at that level around something like high blood pressure is something that is still emerging for us.

JOHNSON:
Does ASTHO have plans to take this approach to other areas of public health, or is that happening already?

PLESCIA:
Yes, absolutely. I mean, we've used this in some of these other projects that we have going right now. But we're also very interested in expanding this and really looking not just—well, first of all, expanding the capacity of different states and territories to do this of work, and expanding not just necessarily to high blood pressure but the other problems and issues that we face in a public health.

And then, we're also looking at some ways that we can really expand ASTHO's capacity as kind of a hub that can really help with some of the technical assistance or, at times, even with some of the resource needs for states or territories to be able to do more telehealth-type modality.

GRAY:
In one of the clinics that we're working with, they didn't have mail service for a month and a half because the plane that took the mail service in had a broken engine. So, that gives you an idea of how difficult it is to manage medical care and anything like that in the area.

JOHNSON:
That's Janice Gray, a nurse consultant for the Alaska Department of Health and Human Services

GRAY:
Without telehealth, these individual communities are incredibly isolated, and the staff that are in there are incredibly isolated.

JOHNSON:
The telehealth program, according to Gray, has been a game changer for the people of the Eastern Aleutian Tribes.

GRAY:
The communication system that they used in the clinics predated the ASTHO grant. What the ASTHO grant added to that was a learning management system that helped them expand their training capabilities to all of the clinics.

So, they now have the ability to plan and record training modules—that's for the community health workers and the clinic staff—and for the hypertension project that they can put into a library and have those available for staff to be used whenever is convenient for them, in addition to doing group projects or group trainings throughout all of the eight sites.

JOHNSON:
And the results aside, she says the program has been very well received.

GRAY:
Two of our state staff people traveled out to King Cove and Cold Bay to meet with the staff there last October, and they are so engaged and so excited about being part of the project. And I don't know how to word it other than they felt like they weren't forgotten, that they were important, and this showed that they were important enough to focus this work on their very, very remote patients and very remote communities.

JOHNSON:
Working on the ground as the RN case manager for all eight clinics is Susan Highley Bailey.

BAILEY:
I think it's been really beneficial to everybody within the clinic because we've seen improvements with our patients and, of course, that's always the goal we want to strive for—so, actually spending time doing, you know, the ground work of how we were going to do things and how we're going to measure.

And I think it just helped everybody feel as though they were connected to it and that there was a big reason for it. And it was a very rewarding, too. We started in a relatively low level of what are our blood pressure control was like, and we improved significantly—more than 50% improvement on where we had been.

So, and, you know, I think it made everybody feel positive about what they were doing work-wise, but it made them also feel really rewarded to see the benefits it brought our patients.

JOHNSON:
And what about those results?

When the project started at the end of 2016, just 8% of patients with high blood pressure were in control of their condition. Six months later, in June of last year, the number had grown to 17%. This past February, it was at 57%.

The program's success with patients is well documented, but Bailey says the staff is getting a boost from the project, too.

BAILEY:
I feel it's benefited everybody because, as I said, it refocused everyone on looking at blood pressure and how we wanted to address that and how we want to take early intervention. And I think the program was all about that. It really, really just refocused things and was just a real help for staying on task.

TARA FERGUSON-GOULD:
One of the things that has really made it a big success is the ability for providers and staff to access the information and attend the training when they have time. It's not just held at one time during the day—the virtual recorded trainings can be accessed at their leisure. This has allowed for the increased success of staff receiving this training.

JOHNSON:
Everyone agrees the telehealth program has delivered, but what if it went away?

Tara Ferguson-Gould works with tribes on behalf of the Alaska Primary Care Association. She says the clinic teams would suffer.

FERGUSON-GOULD:
One of the most remarkable comments that I've heard from a physician out in one of the rural settings is, "Now, I know who these patients are. I have a list of patients that have uncontrolled hypertension, that have a diagnosis of the hypertension, and now I can do something about their care. I can reach out to them."

So, providers and staff would really be challenged with their time. There would definitely be inefficiencies, if you will, with trying to access data and patient information, and really make decisions based on that data, to be able to focus on improvement. Really, what we want our providers doing is the work that they need to be doing, and not spending time on administrative things that others could be doing for them.

JOHNSON:
The program has gone so well that Janice Gray says plans are underway to expand it to other remote areas in the state.

GRAY:
We are already starting to expand this project to other FQHCs in Alaska. The Eastern Aleutian Tribes has eight clinics underneath it. We have another FQHC in the Yukon-Kuskokwim Health Corporation that has 39 clinics under their umbrella. What we want to do is continue to try to connect these clinics that are so isolated and help them to exchange ideas and just improve the way that they care for patients.

JOHNSON:
Take a look down the road a little bit. 5–10 years from now, how do you see public health using this tool to improve the health of communities all over the United States and the territories?

PLESCIA:
Well, so, we're looking at—ASTHO is looking at—a model that has been in place maybe about five years. It's called Project ECHO. You know, the word echo it, you know, is playing on this idea of sound echoes and the idea of, you know, this whole idea of what we're going to sort of echo our best practices back and forth.

It was developed in New Mexico, and it was developed specifically to help deal with hepatitis C. And the issue that hepatitis C is a much more prevalent condition than I think we realized, and also that there were new and emerging ways to treat hepatitis C that we didn't have in the past. So, the project got going around that.

It was extraordinarily effective, and they really did build a very organized approach—which hits on some of the things that I've mentioned in this interview.

I mean, it's not just about access to expertise. It's about bringing people together, bringing communities together in this kind of telecommunications and modality, and giving them a chance to talk to each other, and problem solve, and present cases. And, you know, I think that's what really sort of can motivate improvement and excellence in practice.

So, we're very interested in this particular model. We're very interested in bringing it to ASTHO and making ASTHO a real hub for states or territories that want to do this. And then, we're also very interested in getting this particular approach and some of the best practices that come out of Project ECHO into states where states themselves can be the hub or the sponsor of these kinds of approaches.

It's not—Project ECHO is not—that there's not a specific novel thing about it. It's really building on what we've been talking about in the center view. But they've done it really well, and they package it in a very organized way. And we're really excited about the opportunity to take that out into the states and territories that we serve and, I think, take this whole approach to a whole new level.

JOHNSON:
And that sounds would make it more accessible to more people—maybe demystify the technology, show them ways to use it, how it can help their communities.

PLESCIA:
Yeah, exactly. And it's also, there is just a certain finesse that's come with the Project ECHO approach. And, you know, I think, once you put that out there and once you really put the structure into place that they've developed, you know, the ease of implementing all this stuff for states that want to go out in their communities, that's just improved exponentially.

JOHNSON:
We've not been at this podcast very long, but I feel like maybe we're breaking some news here.

PLESCIA:
Yeah. I think this is a really exciting modality for public health. And again, as we said from the beginning, this is something that the medical care has a little bit of a track record with, but it's time for us to get into this as well and really look at the way that it can help us with these specific outcomes that we're trying to achieve. And again, those are the outcomes about the overall health of communities as opposed to the specific health of an individual.

JOHNSON:
Any final word about telehealth, hypertension, Eastern Aleutian Tribes, anything we've talked about?

PLESCIA:
Yeah. I mean, I hope that people will hear this podcast and get it, and it'll build up enthusiasm. I mean, I think sometimes, you know, you feel like we throw technology at everything as if we expect that's going to fix it. And, you know, sometimes you can feel a little bit of like, "Well, is it over-promised?"

And, you know, I just feel like our experience would— This particular project in the Aleutian Tribes has been so strong that, you know, it's not over-promised. This is the place that we needed to be moving. This is the place that the public health has got to go if we're going to remain relevant and effective. And so, you know, I hope people will really take that to heart.

This particular invention is the real deal. I mean, this is something that's going to make a difference and we really want to get more uptake of this across other states and territories.

JOHNSON:
That was ASTHO's Marcus Plescia, once again, on the future of telehealth.

For more information about telehealth programs, see the links and the show notes for this podcast episode.

Next time on Public Health Review, we consider the latest research in the field of early childhood brain development and ASTHO's work to develop a set of resources and tools to help public health professionals working in this area.

Public Health Review is a production of the Association of State and Territorial Health Officials.

If you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

For Public Health Review, I'm Robert Johnson. Be well.