Bonnie Britton, R.N., had a 53-year-old patient with cardiovascular disease who needed serious attention. The man could not read or write, lived in poverty in rural northeast North Carolina, and received only Medicaid assistance.
"His primary care provider said he had one foot in the grave and the other on a banana peel," recalled the chief nursing officer at Roanoke Chowan Community Health Center in Murfreesboro, NC. "If he doesn't do something soon, he will die."
In April 2007, the Patient Provider Community Telehealth Network, created by Roanoke Chowan, placed a telehealth monitor in the patient's home. Since then, he has had his vital signs checked daily, received healthcare counseling and advice, and come to understand how his diet and lifestyle will influence his health. Less than a year later, he is walking 2 miles a day.
This patient's case is just one story on how the telehealth network Britton helped create has produced positive results among a rural northeast North Carolina population that faced many challenges.
Patient demographics
Roanoke Chowan serves four counties. Thirteen primary care providers cover a regional population of about 16,000 people. Of that population, 21% are uninsured, only 41% have graduated high school, 70% are African-American, the annual per capita income is $21,000, and 26% of the children live in poverty. Many poor parents and grandparents must pay their children $30 to $40 to take them to the doctor's office.
The region also leads the state in cardiovascular disease cases and diabetes morbidity and mortality. "Our mission is to provide care to anyone, anytime; indigent patients, we don't turn anyone away," said Britton during her presentation at the 2008 Health Information and Management Systems Society (HIMSS) meeting in Orlando, FL.
Given the demographics and health histories of the region, Roanoke Chowan chose cardiovascular disease, diabetes, hypertension, and childhood obesity as its primary causes. Childhood obesity is a target because North Carolina has been ranked second in the state for the number of obese youths.
Britton and other healthcare providers met in February 2006 with North Carolina Lt. Gov. Beverly Perdue to present the center's conceptual telemedicine plan. Perdue also chairs the North Carolina Health and Wellness Trust Fund, which strives to decrease health disparities in the state.
Roanoke Chowan's grant was approved by the trust, and funds were awarded in July. The center thus created the Patient Provider Community Telehealth Network and began its trek "to reduce health disparities, to increase access to care, to overcome the barriers to care that our patients experience, to contain healthcare expenditures, and to create a community-based network," Britton said.
Telehealth technology
The network works, in part, because it uses low bandwidth telemedicine technology, rather than broadband telemedicine that would be used between hospitals for large data files. The lower-tech telehealth system can work over a standard telephone line, which connects a patient at home, a community center, or a school. A nurse or primary care physician is on the receiving end of the information at Roanoke Chowan or another location.
"In our program, the provider identifies the patients and fills out a one-page plan of care," Britton said. "They set the parameters based on that patient, the protocols, and where the monitoring should be done."
The primary care provider determines whether a patient should be monitored at home or via public kiosks in the community. Roanoke Chowan has placed kiosks at three senior centers, a middle school, and a fitness center to help patients monitor vital signs and give healthcare staff at those facilities more information.
Before starting their regimen, patients swipe their card into the kiosk and are asked patient-specific questions, and their vital signs are taken, according to Britton. "The nurse will contact the primary care providers. We are all on electronic medical records, so the provider can go to the computer and see all the patient's data to see if any adjustments are needed in medication," she said.
No matter where the telehealth monitoring occurs, the goal is to help patients understand how their lifestyle affects their health.
Making strides
In its first 18 months of its telehealth initiative, Roanoke Chowan screened 166 seniors for cardiovascular disease, diabetes, and hypertension. Of that total, 101 people were eligible for the telehealth program; currently, 78 are enrolled and actively participating in monitoring and improving their conditions.
At the middle school, 106 students were screened over a seven-month period. Last summer, Roanoke Chowan initiated a childhood obesity program. Twenty students initially were enrolled, but only eight finished the course. Seven of the eight students decreased their body mass index and four lost weight. All eight at least lowered or maintained their blood pressure readings. The eight students "barely could walk a mile" when the program began, Britton said. By the time it ended, all eight could run a mile.
Forty patients are enrolled in Roanoke Chowan's in-home program. All patients have decreased respective blood pressure readings and blood sugar levels. The cardiovascular patients have either lowered or maintained their weight.
Program achievements
The results have had ripple effects on the area's healthcare facilities. In the six months prior to placing telehealth monitors in homes, the 40 patients went to the hospital 38 times for a total of 216 hospital bed days. In the first six to nine months of the telehealth program, hospitalizations decreased to 14, with total bed days down to 54. In the nine to 12 months after installation and telehealth monitoring ended, hospitalizations continued to decline to 11 and total bed days also dropped to 42 days.
In addition, hospital charges for the 40 patients in the six months prior to telehealth totaled $1.2 million. The total decreased to $229,000 six to nine months after the program began, and declined to $146,000 nine to 12 months after inception.
"Nine to 12 months out, patients truly have made that correlation between what they do, how they act, and how they eat to maintain their health," Britton said.
The positive results also were seen in the 53-year-old patient with cardiovascular disease, who now is walking 2 miles a day. He had one hospitalization and 11 emergency room visits in the six months prior to daily monitoring. During the first six months of his enrollment, he had no hospitalizations and only one ER visit. That incident occurred one week after the monitor was installed.
Telehealth expansion
Roanoke Chowan and 12 other community healthcare centers in the area are collaborating to create the North Carolina Community Health Center Telehealth Network. Each center will use Roanoke Chowan's protocols, templates, policies, and procedures to start a study on heart failure patients only for Medicaid.
The research project plans to collect data from 600 patients by monitoring them for six months. The results will be sent to Medicaid to express the need for reimbursement of telehealth services. "We hope to have this program up and running in the next six to eight months," Britton said. "We are looking at potential funds for the program and other support to get it accomplished."
Britton estimated that some 25,000 patients use telehealth in the U.S. "The next logical place for telehealth to expand across the country, in my opinion, is community health centers," she said. "They already are funded partially by the federal government, and it is another way to provide care for the indigent and uninsured."
By Wayne Forrest
AuntMinnie.com staff writer
March 31, 2008
Related Reading
Remote island gets telemedicine capability, November 14, 2007
Philips, others launch national telehealth home-care study, April 25, 2007
Alaska telehealth project improves efficiency, access to care, February 27, 2007
U.S. initiatives promote health information technology, November 26, 2004
Digital telemammography trial underway at Navajo Nation, June 8, 2001
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