Implementation of Telehealth Services in Rural Schools: A Qualitative Assessment.

BACKGROUND: In rural areas with health professional workforce shortages, telehealth offers an opportunity to address service gaps and meet the health needs of students. Few studies have examined telehealth implementation in rural schools. This study explores facilitators and barriers to the implementation of telehealth programs in rural schools and identifies strategies for successful implementation to inform future school-based telehealth initiatives. METHODS: We conducted semi-structured qualitative interviews with 50 key informants involved in the implementation of telehealth programs funded through the School-Based Telehealth Network Grant Program. Researchers completed a thematic analysis of interview transcripts. RESULTS: The most commonly cited barriers were technology, reimbursement for services, and facilitating acceptance of the telehealth among school staff, clinicians, parents, and students. Key informants identified strategies for facilitating program implementation, including technology training and support, marketing efforts, and integration into existing school processes. CONCLUSIONS: School-based telehealth can augment clinical capacity in areas with clinician shortages. Entities interested in such an approach to care must engage with their school community to ensure successful implementation. For rural, school-based telehealth to gain greater adoption and be sustained, these services must be reimbursable by Medicaid and private insurers.

Telehealth Use in a Rural State: A Mixed-Methods Study Using Maine's All-Payer Claims Database.

PURPOSE: This study assesses trends in telehealth use in Maine-a rural state with comprehensive telehealth policies-across payers, services, and rurality, and identifies barriers and facilitators to the adoption and use of telehealth services. METHODS: Using a mixed-methods approach, researchers analyzed data from Maine's All Payer Claims Database (2008-2016) and key informant interviews with health care organization leaders to examine telehealth use and explore factors impacting telehealth adoption and implementation. FINDINGS: Despite a 14-fold increase in the use of telehealth over the 9-year study period, use remains low-0.28% of individuals used telehealth services in 2016 compared with 0.02% in 2008. Services provided via telehealth varied by rurality; speech language pathology (SLP) was the most common type of service among rural residents, while psychiatric services were most common among urban residents. Medicaid was the primary payer for over 70% of telehealth claims in both rural and urban areas of the state, driving the increase of telehealth claims over time. Issues challenging organizations seeking to deploy telehealth included provider resistance, staff turnover, provider shortages, and lack of broadband. Key informants identified inadequate and inconsistent reimbursement as barriers to comprehensive, systematic billing for telehealth services, resulting in underrepresentation of telehealth services in claims data. CONCLUSIONS: Claims covered by Medicaid account for much of the observed expansion of telehealth use in Maine. Telehealth appears to be improving access to behavioral health and SLP services. Provider shortages, broadband, and Medicare and commercial coverage policies limit the use of telehealth services in rural areas.

Using Public Cost Information During Low Back Pain Visits: A Qualitative Study.

Background: Patients desire information about health care costs because they are increasingly responsible for these costs. Public Web sites that offer cost information could inform provider-patient discussions of costs at the point of care. Objective: To evaluate tools to facilitate the use of publicly available cost information during clinical visits for low back pain (LBP). Design: Qualitative study using individual and group interviews and surveys. Setting: 6 rural primary care practices in 2 health systems in Maine. Participants: Practice staff (n = 50) and adult patients with LBP (n = 72). Intervention: Participating health systems and practices were offered financial incentives, a series of trainings, and technical assistance to pilot tools for discussing costs of LBP care using CompareMaine.org, Maine's cost and quality transparency Web site. Measurements: Integration of tools into workflow, awareness and value to providers, and patient experience were identified through 11 group interviews with practice staff (n = 25) and health system leaders (n = 11), provider (n = 25), and patient (n = 47) surveys; patient interviews (n = 5); and administrative data. Results: The intervention increased provider and consumer awareness of CompareMaine.org, but minimally changed use in clinical discussions as a result of fewer-than-expected patients with LBP, limited system support, workflow barriers, and providers' reluctance to adopt the tools because of perceptions of limited value for their patients. In contrast, patients valued cost conversations and found the tools useful, and over one half reported intending to use CompareMaine.org during future care decisions. Limitations: Generalizability was limited by the small number of practices and participants. Lower-than-anticipated participation precluded examination of the effect of the tool on the frequency of cost-of-care conversations. Conclusion: This multicomponent intervention to introduce publicly reported cost information into LBP clinical discussions had low provider uptake. Whereas cost conversations and CompareMaine.org were perceived as useful by participating patients with LBP, providers were uncomfortable discussing cost variation at the point of care. Successful use of public cost information during clinical visits will require normalizing use to a broader group of patients and greater provider outreach and health system engagement. Primary Funding Source: Robert Wood Johnson Foundation.