Funding non-office healthcare models Patricia Baginski, APRN, FNP-C

Telehealth has the potential to provide health and mental health care wherever patients can access it (Bauer, & Moessner, 2012; Simpson, & Reid, 2014). Home visits or other "on-site" services and telehealth can supplement each other providing a comprehensive health care delivery model in any setting.

In all areas of our society there are people who cannot access basic healthcare and mental healthcare due to age, disability, illness, transportation or distance to care.
There are many reasons that people may have difficulty accessing healthcare and this can have an impact on their ability to attain and maintain optimal health. Patients anywwhere, particularly those who are elderly or disabled, can have difficulty getting to their primary care providers. People with phobias may not be able to enter a medical office without extreme anxiety. People attempting to access mental health services (Hoge, et al., 2004), who use wheelchairs, service animals or other assistive aids, may have difficulty with stigma, office access or providers who are not educated in their care. In 2010, Able Health, LLC. (AH) began providing home-based (house-call) healthcare to people with disabilities. The first four patients had severe medical phobias or had physical disabilities that made it extremely difficult to leave the house. All four had intellectual disabilities, but were able to tolerate full physical exams and other procedures when done in the comfort of their homes. Due to the cost of operations, including payments for a collaborating physician, equipment, travel expenses, and problems obtaining payment from insurers, AH had to close. Technology has now progressed to a point where many needed healthcare services can be provided in-home but remotely combining efficiency with convenience (Kessler, Sherman, & Becker, 2016). Evaluation, management, charting and billing can all be done "in the cloud," reducing overhead and travel time, but insurance companies do not want to pay for this either. Lack of ability to get paid is a serious barrier to implementing such a service. Connecticut recently became the 28th state to require insurance companies to cover telehealth services, but not if they are done by telephone only, facsimile, text or email (Lacktman, 2015). Although these restrictions are designed to prevent health offices from charging for things like brief calls, calls with lab results and administrative contacts (scheduling, billing, etc.), a picture sent via secure text or email with a telephone call to discuss or mental health sessions are telehealth. Particularly in the age of smart phones, excluding "telephone only"could be confusing. Exclusion should have been based on the reason for the contact, not the mode of contact.
Primary stakeholders include: patients, families, caregivers or groups served. Patients may be people with disabilities, reliance on others for care, transportation issues, busy lives or who otherwise find it difficult to access healthcare. Secondary stakeholders are employers (patients' and caregivers') and schools through decreased absenteeism and increased health which improves productivity and attention. Additional stakeholders are the healthcare providers who would either implement telehealth or house-call programs in their offices or refer patients to a specialty agency providing such services, hospital emergency rooms which could see a reduction in visits. Society as a whole could see a decrease in the cost of services, particularly if no specialty equipment were required for the visit to be considered "telehealth."
Require insurance companies to provide coverage for non-office healthcare delivery models such as house calls and all forms of telehealth. House calls fell out of vogue when managed care increased the need for efficiency (Kao, Conant, Soriano, & McCormick, 2009). A care provider who is driving is not providing care or billing. However, health care providers who make house calls increase the value and efficiency of their service, when combined with telehealth. The Veterans Administration (VA) and military (Mishkind, Boyd, Kramer, Ayers, & Miller, 2013) have already started providing services via telehealth. In the VA, house calls are not as viable an option because of the geographic areas served, but sometimes a provider does need to get "hands on" to truly assess a problem. A hybrid system of telehealth and house-calls with office visits when possible could be a very effective and efficient model. The next step would be to have Medicare and Medicaid begin covering costs for house calls and telehealth. If the Affordable Care Act does have limited provisions for telehealth. If it remains intact, it would be possible to include broader telehealth coverage as a requirement for certified plans. Finally, private insurers, once the benefits of telehealth are obvious, would be more likely to provide coverage for these alternatives.
Resources needed include sufficient evidence to present to insurance companies and governmental agencies of the safety, efficacy, cost-effectiveness and patient/provider acceptance of alternative methods of healthcare delivery (Darkins, 2012; Levy, & Strachan, 2013; Poultney, Maeder, & Basilakis, 2015; Verbosky, Beckey, & Lutfi, 2016; Wantland, Portillo, Holzemer, Slaughter, & McGhee, 2004). Governmental, insurance, healthcare industry and patient willingness to try the alternative methods. In order to implement a telehealth program easy-to-use, low cost or readily available technology capable of providing sufficient data for the intended purpose will also be needed. For some mental health or basic health services, this could be as simple as a telephone connection. For more complex medical issues, it would include web-enabled diagnostic equipment such as stethoscopes, smart-phones or other devices capable of transmitting video, vital signs and other data. Time is the rare resource needed to get all of this together.

In order to implement a viable telehealth program an agency that provides on-site laboratory drawing and other diagnostic tests would need to be identified. Several exist in the community, but appropriate relationships would need to be established for provision of services beyond nursing homes and other congregate living arrangements.

As a DNP prepared APRN, I will be able to: 1) use an increased knowledge of telehealth delivery gained from my DNP focus project to demonstrate the benefits of this delivery system to insurance companies and governmental agencies, 2) use increased networks of professional contacts to advocate for change, 3) use an increased understanding of implementing successful policy change to guide my actions. I will begin by strengthening my network of informed contacts including contacting the American Telehealth Association for guidance and information on previously successful campaigns and lists of any local insurance companies nationwide that provide for broader telehealth reimbursement.
References

Bauer, S., & Moessner, M. (2012). Technology-enhanced monitoring in psychotherapy and e-mental health. Journal of Mental Health, 21(4), 355-363.

Darkins, A. (2012). Patient safety considerations in developing large telehealth networks. Clinical Risk, 18(3), 90-94.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cotting, D. I., & Koffman, R. L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13-22.

Kao, H., Conant, R., Soriano, T., & McCormick, W. (2009). The past, present, and future of house calls. Clinics in geriatric medicine, 25(1), 19-34.

Kessler, E. A., Sherman, A. K., & Becker, M. L. (2016). Decreasing patient cost and travel time through pediatric rheumatology telemedicine visits. Pediatric Rheumatology, 14(1), 54. Lactman, N.M. (2015). Health plans in Connecticut must cover telehealth services. Healthcare Law Today, online journal. Accessed November 21, 2016 at https://www.healthcarelawtoday.com/2015/07/06/health-plans-in-connecticut-must-cover-telehealth-services/

Levy, S., & Strachan, N. (2013). Child and adolescent mental health service providers’ perceptions of using telehealth: Shařon Levy and Neil Strachan gauge the enthusiasm of staff for using a technology-enabled service in rural Scotland. Mental Health Practice, 17(1), 28-32.

Mishkind, M. C., Boyd, A., Kramer, G. M., Ayers, T., & Miller, P. A. (2013). Evaluating the Benefits of a Live, Simulation-Based Telebehavioral Health Training for a Deploying Army Reserve Unit. Military medicine, 178(12), 1322-1327.

Poultney, N., Maeder, A., & Basilakis, J. (2015). Evaluation Study of Australian Telehealth Projects. In Conferences in Research and Practice in Information Technology (CRPIT) (Vol. 164, pp. 63-68).

Simpson, S., & Reid, C. (2014). Telepsychology in Australia: 2020 vision. Australian Journal of Rural Health, 22(6), 306-309.

Verbosky, N., Beckey, C., & Lutfi, N. (2016). Implementation and Evaluation of Diabetes Management via Clinical Video Telehealth. Diabetes care, 39(1), e1-e2.

Wantland, D. J., Portillo, C. J., Holzemer, W. L., Slaughter, R., & McGhee, E. M. (2004). The effectiveness of Web-based vs. non-Web-based interventions: a meta-analysis of behavioral change outcomes. Journal of Medical Internet Research, 6(4), e40.

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