One Health, based in Hardin, Montana, is a family of Federally Qualified Health Centers that provides integrated primary care to rural and frontier communities in Montana and Wyoming.

It has 12 clinics spanning from the Canadian border to the Montana/North Dakota border to northern Wyoming. The service area (though not continuous) covers a region roughly equivalent to the states of New York, New Jersey and Vermont – combined.

The Rural Health Information Hub breaks down various definitions of frontier designations, but a common one is six or fewer people per square mile. All but one of One Health's clinic locations serve communities that meet the frontier definition.

THE PROBLEM

"As a testament to the efficacy of telehealth and its benefits to rural and frontier communities, Montana is home to two of the oldest telehealth networks in the country – Billings Clinic's Eastern Montana Telemedicine Network and Benefis Health System's REACH network," Sarah Compton, telehealth program manager at One Health, said.

"Due to billing regulations, FQHCs have historically been excluded from being able to bill for distant site services and have only been eligible to bill for the originating site fee," she continued. "This historical reimbursement structure has been beneficial from a coordinated-care perspective, but until COVID, the financial feasibility of telehealth for FQHCs has been challenging."

Montana Medicaid has been favorable toward telehealth even before COVID, allowing FQHCs not only to be eligible distant site providers, but also allowing for direct-to-patient visits. This shift in policy enabled One Health to pursue a sustainable telehealth model that provided much-needed access to the patient populations who regularly encounter barriers to accessing care.

"We used the Lean Six Sigma framework to optimize our telehealth workflows."

Sarah Compton, One Health

"In 2019, One Health met representatives from vendor TytoCare at the ATA conference and was impressed by their solution," Compton recalled. "Since then, TytoCare has been One Health's telehealth partner, providing the software and hardware solutions for our organization."

PROPOSAL

The first use case that One Health implemented in 2016 was a clinic-to-clinic system to help the organization leverage staffing resources across the health system. This enabled providers with open slots in their schedules to be filled at other locations where demand for in-person visits was higher.

"We built our telehealth carts by mounting iPads on a pole with wheels, and pairing a TytoPro kit with the stethoscope, otoscope and tongue depressor peripheral attachments to be used at the distant site provider's discretion," Compton explained.

"When COVID hit, we thankfully already had a telehealth platform in place," she added. "As our needs quickly shifted, we designed and launched our direct-to-patient workflow. The video-only use cases of behavioral health and substance use disorder patients immediately benefited from our D2P telehealth workflow."

Medical use cases proved more complex and One Health experienced some challenges with equipment rollout, communication and utilization. There also were some technology and health literacy challenges with pairing the devices on a home WiFi signal. One Health also underestimated the amount of education needed for patients and training needed for staff and providers.

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MEETING THE CHALLENGE

One Health categorizes three different visit types for telehealth and has corresponding workflows to ensure appropriate documentation. The three visit types/workflows are clinic-to-clinic, direct-to-patient and facilitated. Facilitated visits occur when a One Health staff member is not facilitating the visit at the originating site.

"In the past few years, we've begun to expand our thinking about how and when and where we can use telehealth," Compton said. "Our school-based health clinics rely heavily on telehealth as a program model. In 2021, we participated in a tele-dentistry learning collaborative hosted by NNOHA and effectively triaged, treated and educated dental patients virtually.

"We continue to have conversations about how we can better leverage our staff at different sites through telehealth to provide social determinants/drivers of health assistance to patients through our community health advocates, how we can use telehealth to enhance our home visits for our prenatal and perinatal visits, and how we can leverage our pharmacists to assist with medication management and adherence," she continued.

The telehealth technology runs parallel with One Health's electronic health record; the health system is exploring options for integration as it moves forward with remote patient monitoring to ensure that appropriate data is able to be transferred into patient charts.

RESULTS

"One Health experienced a similar spike in telehealth utilization that has been shown across the healthcare sector during the initial months of COVID," Compton reported. "For 2022, we have settled into 7% of our clinic encounters being done virtually across our system, with the highest utilization continuing to be around behavioral health and substance use disorder treatment and counseling.

"Recently, we used the Lean Six Sigma framework to optimize our telehealth workflows," she added. "After the initial rollout of the D2P workflow, each clinic location's process looked a little bit different based on staffing resources and comfort with technology. This inconsistency led to different expectations and experiences for patients and providers."

Providers generally were initiating their own telehealth encounters, which meant they were also the ones who were dealing with any technical issues that arose on the patient end.

"We tapped into our centralized intake team and put more structure within the platform to ensure that our D2P visits were registered with our intake staff who were specifically trained in telehealth and could provide technical assistance before transferring the visit to the provider," Compton said. "We have built the internal structure of our platform to ensure that patients aren't bypassing the intake step of the patient journey.

"Our data analytics team utilizes the Power BI dashboard, so we are able to see and track our telehealth usage based on clinic, department and provider," she continued. "We are in the process of updating our dashboards to be even more robust to integrate our third-party customer satisfaction data for virtual visits, reports from TytoCare, in addition to our EHR data."

USING FCC AWARD FUNDS

One Health was awarded $930,000 from the FCC telehealth grant program for remote patient monitoring equipment, mobile devices, cellular data plans and monitoring platform services to provide remote care and monitoring to patients.

"We are very excited to be using our FCC funds for a remote patient monitoring program," Compton noted. "We are starting with hypertension patients but look forward to exploring other chronic conditions, as well.

"As an FQHC, our ROI for RPM is not directly tied to readmission reduction," she continued. "We plan on helping to sustain this program by billing for the chronic care management codes, and also by helping our patients manage their condition and overall health."

It also will allow staffing resources to be used more effectively by being able to focus on the individual needs of higher-priority patients and focusing on their individualized goals and targets.

"The TytoCare solution will also enable our RPM enrollees to use the platform for more than just RPM and will be able to access any of our other services that we provide virtually," she concluded.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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