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Anatomy of a Successful Telehealth Program

June 5, 2018
by Pamela Tabar
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So you’ve got a new telehealth program on deck. What’s the best way to make sure it doesn’t fail?

What does it take to build a successful telehealth program that harnesses the technology capabilities for digital health while gaining the outcomes the local population truly need? Hospital systems keen on reducing chronic care costs and unnecessary readmissions might want to take a look at what’s going on in Tallahassee, Florida.

Over the past five years, Tallahassee Memorial Hospital (TMH) has become one of the few healthcare organizations that has broken down healthcare delivery silos between acute care delivery and community wellness programs. TMH’s approach began at the hospital and branched out into transitional care, rehabilitation and a community wellness center.

The project is being led by Lauren Faison, TMH’s service line administrator over regional development, population health and telemedicine. Of interest, Faison isn’t an IT professional. She isn’t a clinician, either. But, she does know how to take a bull by the horns. “My role is merging all of the piece of the project,” she tells Healthcare Informatics. “What does the operational piece look like? What information would be most valuable for the clinicians to have at their fingertips? How can we deliver the information they need so they can spend their time providing clinical care instead of searching for data? I help bridge the gap between all these different institutions.”

She says her current job role at TMH could be an emerging one in the industry, as more health organizations seek ways to reach across the organizational barriers and implement digital health as a mainstay for improved outcomes long after a hospital discharge—much like the emergence of the CMIO role. “Telemedicine isn’t just an IT project, and it’s a mistake to think of it that way,” she insists.

The Local Mission

In part, the telehealth initiative stemmed from the facts of the Tallahassee region, which includes sizeable populations of homeless and under-insured patients, Faison noted. “If you look at our demographics in Florida, we're surrounded by very poor, very rural communities with little public transportation and very few health services. Once discharged from the hospital, patients couldn't get the follow-up services they needed. Or, they couldn’t get any specialty services at their local rural hospital. We needed to find a way to increase access to care while also being able to monitor them from their homes. We wanted to be able to talk with them about their medication, hear how they're feeling and watch their blood pressure without making them travel.”

The telehealth program began in earnest in 2012, with the acquisition of telehealth equipment to provide a link for high-specialty services between Level-2 trauma center and outlying areas. Like most successful implementations, it started with a lot of homework. “We spent a lot of time in Georgia where they have wonderful telehealth legislation and seeing how their networks are set up and how their technology works.” The team also spent months assessing available technologies and getting input from IT and the clinical side.

Once the specialty trauma services were set up, Faison developed a program to extend telehealth services to high-risk patients upon discharge, tackling the success rate of the crucial 90-day post-discharge window. Early focus was on patients with chronic heart failure, pneumonia and cardio-pulmonary issues—classic conditions whose outcomes benefit from close monitoring 30 days post-discharge.

While many of TMH’s patients have socioeconomic challenges, nearly all of them had a cell phone, Faison explains. “Sometimes it’s just about a voice call to say, “How are you feeling right now?” And, we can touch base to remind them about appointments and see if they’re taking their medications correctly. When people leave the hospital, they’re given a lot of instructions, but they’re still not feeling well and can be overwhelmed easily, especially when they don’t have a solid support system.” One of the biggest fail points in healthcare deliver, she says, is the follow-up stage.

Digging Deep into Population Health

Successful telehealth programs need to dive deep into the needs of the local community, focusing on the barriers to healthcare access and the reasons why patients are at high risk. “We look at things like patients who visit the hospital three or more times in the past year. Do they report not having a primary care provider? Do they not have insurance? Within our hospital EMR [electronic medical record], we have a button that case managers, nurses and physicians can push to indicate if this person is at high-risk for readmission and whatever their barriers are. If we can't see them physically because they can't get to us, we'll see them virtually through telemedicine.”

Reducing readmissions means delivering quality follow-up services as they’re needed, and that means offering access via telemedicine to much more than a case manager or ask-a-nurse service. “We have a pharmacist, we have a social worker, we have the clinicians, and we have this multidisciplinary team that all meets with the patient to see what their barriers to care may be,” she says. Faison even got the homeless shelters involved, including the community social workers.

Still, it was a challenge to tether in ancillary services, such as rehabilitation centers and wellness check-in centers. Some of the struggle was operational, but a lot of it was technological, Faison remembers. “Embedding technology isn’t hard, especially with all the mobile apps,” she explains. “But how do you get a patient and a physician in front of two separate cameras at the same time to facilitate the consult? What information is documented? How do we facilitate what needs to happen afterward? There are a lot of moving pieces and decisions to be made. You really have to have every person who is part of that process involved in the project planning for it to be successful.”

TMH’s system had even greater meaning once the Centers for Medicare & Medicaid Services (CMS) began penalizing hospitals for excessive preventable hospital readmissions. But even then, the culture change was a challenge, Faison says. “Until there’s that financial penalty or incentive, it's hard to get folks to change their practices. Now they’re paying attention. And then they’ll say, ‘Wait a mind. I just spent thousands of dollars to transport patients all over the place for consults. Why don't I just pay for the consult and get the savings on better patient outcomes?’ I present at fiscal forums and clinical forums, and I work with administrators to show them all how everybody should be increasing the benefits of telehealth.”

“I think you will see more administrator level positions getting involved in how we integrate all of this,” she adds. “You can no longer have IT in one building, data in another building, and clinical practices in another building. You have to have a multidisciplinary team that is focused on looking at how we use all this information, what the infrastructure is needed to access it and what technology is best to move the clinical practice forward. But even today, it’s a huge deal to say, ‘We can’t think of this solely as an IT project.’”

Implementing with a Context

By design, the success of a telehealth project is based on its impact outside the health system walls. Faison is always tweaking and adding to the project, growing its reach and scope, acutely aware of the patients’ socioeconomic barriers at every turn. “We’ve got the big clinical parts covered, but now I want more boots on the ground, out in the community or on the phone,” she says. “We should be helping patients through the system and helping them find answers to their questions, not just passing them off to somebody. I think we're very good in giving people referrals and phone numbers, instead of just answering their questions themselves.”

While digital health initiatives and telehealth capabilities can solve many issues related to healthcare delivery, even important technological innovations can still be stymied by lingering barriers within the healthcare system itself. “I think many healthcare institutions are still very still siloed,” Faison says. “It still can be a very slow and hard road to culture change in many environments. That’s why it’s so important to be able to sit around the table and figure out how to use the information we have and maximize technologies to get the best information into the hands of those who need it the most, which is our clinicians and our patients.”

Pamela Tabar is a healthcare writer based in Medina, Ohio.

Read our exclusive Q&A with Faison on the evolving world of digital health and population health management.

Hear more about TMH’s telehealth implementation at the Health IT Summit in St. Petersburg, Florida, July 24-25, 2018.


2018 Seattle Health IT Summit

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Partnership to Fine-Tune Care Model for High-Needs Patients

August 21, 2018
by David Raths, Contributing Editor
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Goal is to spread the proven Advanced Preventive Care model

The Peterson Center on Healthcare has entered into a partnership with the Camden Coalition of Healthcare Providers and Health Quality Partners (HQP) to improve care and lower costs for high-need patients.

The new project, made possible through a $605,000 grant from the Peterson Center, will work to accelerate adoption of the Advanced Preventive Care (APC) model, which the partners say has been shown to decrease mortality (by 22 percent), reduce hospitalizations (by 25 percent), and lower healthcare costs among chronically ill, older adults (by 10 percent).

The APC model prevents avoidable complications among chronically ill, older adults by filling the gap between office-based primary care and later stage interventions. Skilled nurses closely assess, monitor and engage participants and their families to proactively mitigate health risks and preventable complications. While several health systems have implemented the model, more work is needed to help other health systems adopt complex models such as APC.

 “Improving care and lowering costs for high-need patients should be among our highest priorities in healthcare,” said Jay Want, M.D., executive director of the Peterson Center., in a prepared statement.  “By spreading the proven Advanced Preventive Care model, this exciting partnership has great potential to help the growing population of high-need patients nationwide who require well-coordinated care, but too often are not getting it.”

Through the project, the Camden Coalition’s National Center for Complex Health and Social Needs and HQP will engage a multidisciplinary group of experts (from disciplines including healthcare, implementation science, user-centered design, and evaluation) to design more efficient implementation methodologies and infrastructures for health systems to incorporate APC into their patient care. The Camden Coalition and HQP will also develop an evaluation framework to test the newly designed systems for replication and share key learnings with the field that may help to further scale similar efforts.


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Connecting Medical Care and Social Service Needs: Chicago Health Leaders Take Charge

August 21, 2018
by Rajiv Leventhal, Managing Editor
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A new project will investigate the most effective means for connecting medical care and social service needs

In the new and constantly evolving healthcare landscape, patient care organization leaders are now coming to a near universal acceptance that paying more attention to social determinants of health data has become vital to improving care and lowering costs. Indeed, across the country, there are countless projects that are examining, in various ways, how health outcomes are influenced by factors such as social circumstances, behavioral patterns and environmental exposures.

On example of this is in Chicago, where a group of healthcare leaders have been working on creating a seamless and purposeful link for sharing health and other information between social services agencies and patient-centered medical homes (PCMHs) to improve the health of those most at-risk and address social determinants of health.

The Medical Home Network (MHN) is an organization that manages a Medicaid ACO (accountable care organization), comprised of nine federally qualified health centers (FQHCs) and three hospital systems serving approximately 80,000 Chicago area Medicaid beneficiaries. Earlier this year, MHN and the National Committee for Quality Assurance (NCQA) launched a joint research project to study the effects of connections between Medicaid patient-centered medical homes and community-based organizations (CBOs) that provide social services. For this project, a CBO is defined as any social service provider organization that serves an individual but is not responsible for providing “whole person care” in the same way that a PCMH or a hospital is held responsible, officials noted.

One of the driving factors for the research grant—managed by the Systems for Action National Program Office with support from the Robert Wood Johnson Foundation—according to officials, is that addressing social risk factors has been challenging for medical homes as most do not have adequate mechanisms for referring patients to services. Additionally, most CBOs do not have electronic health records (EHRs) and cannot easily communicate with medical home EHRs. Issues of protected health information and privacy have also blocked progress in this area, according to NCQA and MHN executives.

As such, through this research, the organizations set out to investigate the impact of connecting medical homes and CBOs using a web-based system. More specifically, NCQA, MHN and Cook County Health & Hospitals System (CCHHS) are partnering in this effort with medical homes and CBOs in Cook County, Illinois. As many as 200 medical homes and 25 hospitals will link to a variety of CBOs using a web-based communication and care management platform, known as MHNConnect.

“We want to see how connecting medical and social service care teams can help people with social risks,” Sarah Hudson Scholle, vice president of research and analysis, NCQA, said at the time of the project launch. “For example, if the medical care team and social service agencies coordinate to help people with immediate problems (substance abuse, food, housing, jobs), will that help them manage their health needs better or keep them out of the hospital?”

Cheryl Lulias, president and executive director of the Medical Home Network, notes that the need for this connectivity is an outgrowth of MHN’s core premise of creating a community care record across all venues, while being able to communicate and collaborate between the agencies caring for its patients, and the care teams at the primary care practices who are managing the population throughout the continuum. So the question became, Lulias, says, “How do we connect and communicate, and enable communication in a meaningful way?”

Prior to this project, MHN had built foundational connectivity, and was exchanging real-time alerts and a longitudinal record between 27 hospitals and about 200 medical homes in Chicago. “We connected the acute system, but that wasn’t enough,” says Lulias. “Then we moved to start to connect the sub-acute [system], the behavioral health [facilities] and the community agencies. There are a lot of great systems on the market that do referrals to social service agencies from the medical home primary care practice, but we want to enable conversations and share relevant information on the patient to enable seamless transitions and ongoing communication between care teams serving the patients, as well as provide a more coordinated expedience,” she says.

As an organization, MHN is no stranger to researching how social determinants of health affect patient outcomes. A prior study done by researchers at MHN, and others, found that many risk factors outside of the traditional medical model may be associated with higher utilization and costs. That research, published last year in the Journal of Community Medicine and Public Health Care, found that some addressable factors are associated with greater medical and pharmacy spending, such as needing help getting food, clothing or housing, reporting fair or poor health status, and experiencing transportation challenges. The six most common addressable factors were all associated with higher hospital readmissions; most of them were linked significantly to greater subsequent inpatient stays and ED visits, according to the study’s results.

“We’ve proved that these social issues are critical to predicting the rising risk patients and predicting prospective cost and utilization,” Lulias asserts. “We now know that someone with transportation issues is X percent more likely to have a readmission or to go the ER within three months.” As such, the next step of MHN’s work, she adds, is to analyze how connecting medical homes and CBOs affect the use of hospital and ED services, and affect health outcomes of at-risk populations.

This project is currently in phase one, in which 12 behavioral health agencies and a home health agency in Cook County have access to the Community Care Connect tool—which is a module within MHNConnect—to simply search for patients and better coordinate care for those that are seeking services at their facility, says Sana Syal, project manager, Medical Home Network.

“What we are building out now, and finalizing the requirements for, is opening the messaging center to share that information and coordinate care between care managers at primary care settings and a case manager on the other end, which is likely a behavioral health or home health agency,” Syal explains. She notes that while there are plenty of good resources that provide social service directories for care managers to be able to refer patients, oftentimes, those referrals happen on paper or by phone, which in turn creates a gap in truly knowing what happened to that patient. “Did the patient have a good experience when I referred him or her to the food pantry, for instance? We can track those referrals and close the loop so that we are coordinating care in the best way,” she says.

Syal adds that referrals “have been happening since there were patients,” but the interest in what has happened at that service or that agency, and knowing how to track that, has long been a gap in care. “And the [providers] wouldn’t know unless the patient comes back and tells them. Maybe the patient says that he or she wasn’t eligible for what the [provider] referred him or her to, or the patient was turned away, or the wait time was three months. We are looking to fill that gap by connecting these different entities together,” she says.

What’s more, in addition to doing quantitative analysis, by comparing pre- and post-implementation of the web-based platform, MHN and NCQA will also be conducting interviews of patients and their providers, offers Keri Christensen, director for research innovation at NCQA, and formerly at the Medical Home Network. This will involve interviewing a patient, a community-based organization staff member, and a medical home staff member, she says. “The patient will be at the center of the interview and we’ll also be interviewing the two care providers from the two different organizations that are caring for him or her. We want to understand how the connectivity has assisted in their workflows and how they have seen things change over time—both for the specific patient we are talking about and for the organization as a whole,” says Christensen.

Going forward, both MHN and NCQA leaders believe that this project will further prove the value in this new paradigm of connectivity to enable better coordination and better health. “It’s a simple concept, but not one replicated in many places today,” Lulias attests. “And it’s all part of the need for better coordination to drive better care. I hope that this connectivity becomes a ‘need,’ as opposed to a ‘nice to have’ when it comes to population health, and connecting the social with the medical,” she says.

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San Diego Connects the Dots to Create Social Snapshot of Clients

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Community Information Exchange shares client-level data and participating organizations use a common risk rating tool
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This week my colleague Mark Hagland is covering the Strategic Health Information Exchange Collaborative (SHIEC) Conference in Atlanta. At last year’s SHIEC conference, Mark covered a panel session featuring executives of 2-1-1 San Diego. In that talk, William York executive vice president, said the key to its work is “connecting the dots to create a social snapshot of a client’s situation, and matching that with a database of social service providers and referrals.”

I was reminded of Mark’s story from last year because last week I saw another fascinating presentation on 2-1-1 San Diego’s Community Information Exchange in a webinar co-hosted by the Center for Health Care Strategies and Nonprofit Finance Fund.

Lots of health systems are starting to work on a better understanding of social determinants of health and better connections with social service agencies. I think the effort in San Diego is really a leading model. Its Community Information Exchange (CIE) platform shares client-level data and has participating organizations use a common risk rating tool. The CIE also facilitates community case planning, and care team communications to better address the social determinants of health.

Camey Christenson, senior vice president at 2-1-1 San Diego, said that when people hear the phrase community information exchange, they focus on the technology platform, “but the important piece of the CIE is that it is not just a technology platform, but rather a collective movement of what we are trying to accomplish in our region.”  

She said the 2-1-1 organization was motivated to create the CIE by seeing regional system failures. “We receive 1,500 calls a day. We saw every day how the system of getting people resources was not working and was putting the onus on clients in crisis. Putting prescription pads in doctor’s offices telling them to call 2-1-1 wasn’t sufficient,” she said. “We needed to move to a proactive model to have helpers working more closely together to use data to break down data silos between sectors, especially including health and social services.”

The 45 network partners are connected by the technology platform, the bidirectional referrals and a shared language using a risk rating scale. “We have leveraged our role in the community as a resource hub, worked with our partners to build trust, and created a network of diverse, cross-sector partners who were willing to take the leap and redefine what a client is – that it extends just beyond their four walls,” Christenson said. They had to change their business processes —accepting and confirming referrals, and sharing client-level data, and having that shared language. “We had to make sure we understand and agree on definitions of social determinants of health and how we measure them, and that is why we created a risk rating scale using 14 different domains of a social determinants of health framework. That creates a shared language about where the client is in terms of risk for each domain, and shows changes over time with a longitudinal client record.”

Several organizations are contributing client-level data into the CIE, and clients are consenting to the use of their data for ongoing care coordination across sectors. “This is changing our field to move to more proactive, person-centered work, which is starting to have an impact on community health,” she said.

The 2-1-1 San Diego team worked closely with San Diego Health Connect, the regional HIE, to learn about data sharing and what agreements and authorizations are required. “It was a learning curve for us,” Christenson said. They also worked to leverage technology in different sectors. For instance, they focused on understanding the systems that county governments use and how to connect to them. Housing providers use a system called the Housing Management Information System (HMIS). “We directly connected that HMIS system to the CIE, which was really useful information for healthcare providers,” she said. “We also leverage our existing 2-1-1 database so we could create closed-loop electronic bidirectional referrals using our database.”

The 2-1-1 organization is working with local universities to study whether the interventions are having an impact on outcomes such as reduced hospital readmissions.  It is governed by a board of directors and has an advisory committee with work groups made up of nonprofit CEOs, and executives from health plans and local universities.

There are many examples of groups working together on systems that link social services agencies and health systems. In fact, later this week I am going to interview people working on a community health record in Alameda County, Calif. But it sounds like this effort in San Diego has already tackled a lot of the technology and governance challenges, and is really starting to reap some of the benefits.





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