Tumbleweeds rolled past in windy West Texas as we travel US Highway 87 from Lubbock to the bustling small town of Lamesa. It is a two-hour round trip to meet with staff of the rural hospital and specialty clinic to check in on their telemedicine program.

Melanie Clevenger and I represent the Telemedicine Division and the TexLa Telehealth Resource Center within the F. Marie Hall Institute for Rural and Community Health at the Texas Tech University Health Sciences Center. The Medical Arts Specialty Clinic is one of the sites we serve in some of the vast rural areas of West Texas.

The news was not good. Multiple roadblocks had stalled their telemedicine program and kept them from services to area patients they had planned as part of their participation in Texas’ 1115 Waiver Project. In February of 2016, 72 telemedicine visits were needed by October to meet Year 5 Project goals. Staff explained that there had been several challenges including connectivity and availability of cardiologists willing to provide the service. Melissa Matlock, 1115 Waiver Coordinator and Communications Director, and Albert Acosta, Director of Radiology, Medical Arts Specialty Clinic and Coordinator for Telemedicine, gave us the details about lack of physician availability and firewall issues trying to connect with a Lubbock clinic.

THE 1115 WAIVER

The Texas Healthcare Transformation and Quality Improvement Program is a Section 1115(a) waiver demonstration that was approved by the Centers for Medicare and Medicaid Services (CMS) on December 12, 2011. The waiver has funded Delivery System Reform Incentive Payment (DSRIP) projects intended to enhance access to care, improve the quality of care, and improve the cost-effectiveness of care. Funding is a combination of federal and local money. The projects are focused on Medicaid and indigent patients. The Texas Health and Human Services Commission (HHSC) Medicaid/CHIP Division was tasked with management and oversight of the Program. The five year project was set to end on September 30, 2016 unless an extension was approved.

Texas developed a regional model that includes a diverse mix of providers. Regional Healthcare Partnerships (RHPs) were formed across the state with one organization within the RHP serving as the “anchor” that coordinates projects

within the region and submits proposals to HHSC. Each RHP includes a variety of participating healthcare entities such as hospitals, community mental health centers, public health agencies, and academic medical centers.

DSRIP projects have been directed toward four activity categories:

  1. Infrastructure Development
  2. Program Innovation and Redesign
  3. Quality Improvement
  4. Population-based Improvements

Infrastructure development involved expanding capacity for primary and specialty care and included specific project guidelines to introduce, expand, or enhance telemedicine/telehealth, and, more specifically, use the technology to improve access to behavioral health services. Program innovation and design projects were intended to improve care models and processes such as Medical Homes and the Chronic Care Management Model. Category 3 quality improvements will assess the effectiveness of the projects in the previous two categories through measurement of outcomes. Category 3 plans were to start no later than year 4 and are currently in progress so the real impact of the program in terms of outcomes is still to come. Population-based Improvements in Category 4 will be based on quality data reported through hospitals.

MEDICAL ARTS HOSPITAL

Medical Arts Hospital planned to implement a telemedicine program in the Specialty Clinic to provide expanded specialty referral services and expanded access for rural residents. Based on a Needs Assessment, the target population was established cardiology patients being seen for routine appointments through telemedicine. The benefits to the hospital system were many. Telemedicine services improve access, decrease time and fuel costs driving significant distances for healthcare, and reduce lost productivity when patients or family members must take time off from work to spend at least half a day getting to and from an appointment for specialty services unavailable in the community. The value of successful implementation to the hospital district based on 1115 Waiver funds was up to $1,869,879. Medical Arts Hospital, like many rural hospitals, struggle with operating on smaller profit margins while providing a valuable service to the community and area. Those supplemental funds were not something they could afford to lose.

Our meeting with Albert Acosta started a whirlwind of coordination to meet the telemedicine encounter number of 72. After learning that the TTUHSC Texas Tech Physicians Center for Cardiovascular Health had some capacity and a physician willing to use telemedicine to see patients in Lamesa, the Telemedicine Division and TexLa Telehealth Resource Center provided technical support and trained staff. Cardiologist Dr. Scott Shurmur agreed to try telemedicine. It was a new experience for Dr. Shurmur but he quickly became comfortable with use of the technology. TTUHSC Telemedicine coordinated clinics with Mr. Acosta and staff. By October, 72 patients in Lamesa had been seen by Dr. Shurmur via telemedicine. Medical Arts Hospital reached their goal… and the celebration was on!

In addition to 1115 Waiver funding, the Medical Arts staff have seen other evidence that the program has been successful.

“It’s something else we can offer to serve our community,” Mr. Acosta told Telemedicine staff. He gave examples of the impact on patients.

One 90 year old woman, who speaks only Spanish and does not drive, would likely not have the means to make the two hour round trip to Lubbock and would not have had the follow-up care. He gave examples of patients that must use the Medicaid transportation services bus to travel to Lubbock for healthcare. It is an all-day affair when everyone must wait until all patients taking the trip are seen at different clinics and different times during the day.

Using an Impact Calculator developed by the South Central Telehealth Resource Center, the 72 patients saved more than 134 hours travel time and approximately $767.00 in fuel. Goals for FY2017, Year 6 of the 1115 Waiver Project, require 141 telemedicine visits and Mr. Acosta hopes to continue and grow the Telemedicine program and include additional services.

How do patients feel about the technology? Patient satisfaction data was collected for the telemedicine clinic and demonstrates:

Satisfaction with the service at the Telemedicine Clinic

95% Agree or Strongly Agree

Would use the Telemedicine Clinic again

94% Agree or Strongly Agree

The Telemedicine Clinic met healthcare needs

95% Agree or Strongly Agree

The Telemedicine Clinic adds to the quality of care available to me in the community

95% Agree or Strongly Agree

TELEMEDICINE FOR RURAL TEXAS

The 1115 Waiver projects have been implemented in many rural and underserved areas in Texas. Lamesa is representative of many areas in the 131,000 square mile area of primarily rural West Texas – the service area for TTUHSC Telemedicine. It is the county seat of Dawson County, designated as rural, a Healthcare Professional Shortage Area (HPSA) for primary care and mental health, and a Medically Underserved Area (MUA). Since the nearest tertiary facilities are 60 miles away, Medical Arts serves as the hub of healthcare to more than 83,000 residents in the area.

Of the 254 counties in Texas, 133 are rural. Forty seven have no hospital and 68 have one hospital. Sixty-four are considered frontier with less than 7 people per square mile. Thirty-two of the frontier counties are border counties. Sixteen percent or 3.2 million Texans live in rural areas. Sixty-eight percent of the 254 counties in Texas are all or in part primary care HPSAs. Eighty percent of Texas counties are HPSA for mental health.

Rural health is different and requires innovation to bridge gaps in care. Rural residents tend to have lower income and are less likely to have healthcare coverage than their metropolitan counterparts. There are significant health disparities. Rural adolescents are more likely to use alcohol and smoke cigarettes. There are higher rates of hypertension and suicide. Death rates after myocardial infarction are higher in rural areas. There are often vast distances to travel to reach needed care.

In this environment, telehealth has played a key role in 1115 Waiver projects to overcome challenges and enhance access to care. Telemedicine maximizes the use of existing health care professionals by allowing them to remotely diagnose, monitor and recommend treatment for patients located in rural areas. According to current HHSC reports, 14 percent of active projects involve telehealth. Telehealth is a tool used to expand primary care and specialty care, provide patient navigation and health promotion, and educate the existing healthcare workforce. Sixty-two percent of the projects involving telehealth concentrated specifically on behavioral health in response to severe mental health care worker shortages in both rural and metropolitan areas of the state.

Through the DSRIP or 1115 Waiver Projects, Texas has increased Medicaid enrollment and made more care available to the Medicaid and uninsured populations, populations that represent high costs to the healthcare system. Medical Arts Hospital in Lamesa is just one of many successful examples using telehealth to integrate primary care and mental health services, increase access to mental health services and specialties in remote and rural areas. Numerous studies have associated telehealth with improved access to care, improved quality of care, while decreasing costs but more data is needed. Outcomes reported from the Texas 1115 projects will add to the body of knowledge of outcomes associated with telehealth. In April, 2016, HHSC has received confirmation from CMS that a 15-month waiver extension has been approved, though a longer extension will continue to be negotiated.

The TexLa Telehealth Resource Center is a federally funded program designed to provide technical assistance and resources to new and existing Telehealth programs throughout Texas and Louisiana. The TexLa TRC strives to continually evaluate Telehealth programs in these two states for effective delivery of Telehealth services, efficiency, sustainability, and patient satisfaction. The project described was supported by grant number G22RH30359 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS.