Dorothy Skowrunski / Sarah Stottsberry

Team 1

Morgan County Telehealth

Needs Assessment Draft– Due April 13th

An evaluation of the Morgan County health care requirements is the most critical step in telehealth planning. The information gathered and decisions made in this step will affect the entire project.

We must answer the question “Why does Morgan County need Telehealth?”

This analysis will address the needs of the patients as well as health care providers in Morgan County and provide an achievable recommendation.

Rural Health Care Statistics

Rural Americans face a unique combination of factors that create disparities in health care not found in urban areas. Economic factors, cultural and social differences, educational shortcomings, lack of recognition by legislators and the sheer isolation of living in remote rural areas all conspire to impede rural Americans in their struggle to lead a normal, healthy life.

(See Appendix A -Table 1 for complete list of facts.)

Current Health Care in MorganCounty

Morgan County is a federally designated Health Professional Shortage Area (HPSA).

It currently has:

  • 1 - Full service pharmacy that provides durable medical equipment covered by insurances and Medicare/Medicaid. Registered pharmacists are on staff
  • 1 - Morgan County Health Department offers a variety of health related services including health screening, immunizations, and medical referrals
  • 2 – Physicians
  • 2 - Licensed Nursing Homes
  • 1 – Licensed Residential Care Facility

Morgan County also has many health careservice providers within their surrounding area.
(See Appendix B - Table 2 for a complete list of regional providers.)
The following chart shows the distance in miles and minutes of locations providing services toMorgan County. The closest is 36 minutes /26 miles away and the farthest is 144 minutes / 129 miles away. MedFlight helicopter service is also available in Morgan County.

Patient Needs

Morgan County does not have local access to primary care services, secondary care and specialist physicians. Travel into a city for medical care takes time and may be impossible during inclement weather. The terrain of Morgan County increases the travel time. The roads are hilly, curvy and in many areas, poorly maintained. When a patient travels a long distance for care, they must incur the expense of travel and often they must be away from their employment, which results in lost wages and/or decreased productivity. Many times patients that do not have a medical facility in their community do not travel for needed care. As a result, their condition can worsen causing hospitalization and increased cost and burden on the family. Morgan County patients with chronic diseases such as diabetes and congestive heart disease are in need of almost continuous care. Medical services and education/training need to be available in Morgan County and possibly in their homes in order to keep their disease under control and maintain their health. As the baby boomer population continues to age, there will become a greater need for a strong telehealth program in rural areas. Much of Morgan County’s population (40%) is in the baby boomer category. Many older adults have health issues that go untreated and others have a need for preventive services. The percentage of people without health insurance also continues to increase. A telehealth solution would help ease the total cost of health care. The percentage of adults in Morgan County with employer-based insurance is only 52.4% and children with employer-based insurance is only 42.6%.

There is also an economic impact on Morgan County when a patient travels outside the community. Dollars spent on medical care and other trip-associated expenses stay in the city that provides the care and not in Morgan County or near the patient’s home.

Health Care Provider Needs

Many heath care providers do not have the time to obtain continuing education/training, especially if they live in rural or remote communities. Participation in distance learning can reduce clinician isolation and increase satisfaction. This is an important strategy for the retention of providers and other clinicians in rural health care organizations. Morgan County’s clinicians who participate in telehealth networks are able to increase skills and confidence in treating conditions traditionally outside the scope of primary care. This would also benefit Morgan County residents and their health care organizations. As we consider telehealth applications so will we need to consider the education/training needs associated with the application. Health care providers are the key personnel in designing, implementing, training and executing anytelehealth project.While Morgan County may not attract healthcare providers to live in the area, distance learning presents opportunities for Telehealth through the following applications:

  • Online University Instruction: An Internet connection can provide the resources needed to participate in online degrees and continuing education.
  • Video Conferencing: Offers a visual and audio context for distance learning that is comparable to conventional classroom instruction.[i]

Health Care Organization/Administration Needs

Having an advisory group for patients and providers is essential throughout the process of the development of a telehealth program. Morgan County will need to create or become part of an organization that is financially viable in order to provide services to patients.

Morgan County Telehealth Care Survey Results

The survey gathered telehealth opinions from a diverse group of individuals living in a rural community similar to Morgan County. Participants answered a variety of closed ended questions as well as given the opportunity to make comments. The primary purpose of the study was to obtain feedback from individuals regarding healthcare issues that affected their lives.

Some interesting results of the survey are:

  • No one knew what telehealth was before participating in the study. They needed a brief explanation before completing the survey.
  • The belief was it was neither a problem driving a distance for healthcare or healthcare education/training nor would the cost of gas be a problem.
  • The vast majority of participants would support and take advantage of a telehealth/telemedicine initiative, are comfortable with the idea and believe it would provide a quality experience. (See Appendix C - Table 3 for the complete survey result.)

Applications

While there are many Telehealth applications available today, our survey results indicate that while Morgan County is rural area, the need to travel a long distance for critical care was not a challenge. Most individuals feel that when faced with a serious condition, especially related to the area of pediatric care, expenses related to travel and specialty care was not a concern. However, situations that warrant constant monitoring and care were ones that they felt most applicable to Telehealth. Therefore, we have focused our analysis on Chronic Disease Maintenance, Mental Health, Prenatal Care, and Pre/Post Surgery Consultation. (See Appendix D – Table 4 for Application Matrix)

Chronic Disease Maintenance

According to the Columbus Dispatch, chronic disease maintenance is costing Ohio nearly $57 billion a year.[ii] Morgan County, with over 40% of its population over the age of 45, is not alone in its need to minimize the costs of chronic disease maintenance. However, as we have already shown, it presents significant challenges given its remote location to specialized services and the population’sinability to access care. Telehealth applications could be a way for Morgan County to gain better control in this area.

Since access to local clinics is sparse, we feel an in-home disease maintenance application would be valuable to the population of Morgan County. Chronic Disease maintenance is highly adaptable to home Telehealth practices since chronic disease can present challenges including the need for repeated hospitalizations and frequent monitoring of the following statistics:

  • Vital Statistics
/
  • Diet

  • Specialized Tests
/
  • Medication Changes

There are many home Telehealth devices that can monitor statistics related to the following conditions. These devices typically require only a normal phone line connection, and offer a wealth of monitors including blood glucose, weight, blood pressure, fluid status, pulse oximeters, peak flow meters, and spirometers.

  • Congestive Heart Failure(CHF)
/
  • Diabetes

  • Chronic Obstructive Pulmonary Disease(COPD)
/
  • Hypertension

  • Asthma
/
  • Obesity

These devices not only offer the appropriate tests and tools needed to monitor the conditions, they also offer easy to use interfaces and friendly reminders to the patient. In no time at all, it makes disease maintenance feel like a normal part of everyday life, and ultimately is preventing further damage and the need for hospitalizations in the future.

Mental Health

The National Institute of Mental Health estimates that 1 out of every 4 adults, 18 years of age and older, will be diagnosed with a mental disorder during a given year.[iii] This amounts to a total of 57 million people a year. This is a staggering statistic and one that rural areas like Morgan County find very challenging. Given that population density is low, the actual numbers affected by mental disease will be slim in comparison to suburban or metropolitan areas. Therefore, providers rarely look at places like Morgan County as desirable service areas, and ultimately the population is left to travel to find these services. Often times, the patient ignores the problem and does not seek treatment.

Telehealth Options for Mental Health

In reviewing examples of Telehealth technologies that we could employ for use in treating mental conditions, we paid close attention to the need for privacy in rural areas. Obtaining mental health services in a metropolitan area is very different from that of a rural area where it is likely that the inhabitants are acquaintances. Not only will home Telehealth help to provide expert resources for mental health conditions, but it clearly can offer a level of privacy that is not available with traditional psychological and psychiatric care given that the patient does not have to leave his/her home.

TelePsychology

There are many forms of help that provide care to remote areas including:

Application / Purpose
Internet Access to Psychological Information / Self awareness and need to request other services
Single Session Psychotically Advice via Email / Used for minor situations or could be something that consumer is “trying out”
Ongoing Personal Counseling and Therapy / Used for significant challenges that requires time to resolve.
Real-Time Counseling / Through use of Chat, Web Telephony, or Videoconference offers a more personal approach.

Applied & Preventive Psychology 8:231-245 (1999). Cambridge University Press. Printed in the USA 1999 AAAPP 0962-1849/99

TelePsychiatry

This is a term used to describe the psychiatric, diagnosis, consultation, and treatment of mental disorders via real-time, interactive videoconference.[iv] While psychological disorders require counseling, telepsychiatry incorporates the use of telemedicine since psychiatric disorders are often times treated with medication. Similar to Telephychology, the following applications are likely to be beneficial to the population of a rural area.

Application / Purpose
Internet Access to Psychiatric Information / Self awareness of condition, and knowledge of drugs used to treat conditions
Initial and On-Going Consultation through Videoconferencing. / In-home consultation by way of webcam, or other video conferencing hardware.
Remote Monitoring of Medication Levels / Remote monitoring device could be used in home.

Prenatal Care

High Risk pregnancies present significant challenges to women who live in rural areas. While the initial diagnosis is made by a certified OB/GYN doctor, the ongoing maintenance of the condition makes it a likely candidate for a telehealth application in Morgan County. With 34% of its population in childbearing age range of 18 years – 44 Years, there are many opportunities for telehealth. High Risk pregnancies occur for many reasons including the following.

OB History Risk Factors /
  • Previous Still Birth
  • Previous Premature
  • Previous Caesarian Section

Medical History Risk Factor /
  • Abnormal PAP Test
  • Chronic Hypertension
  • Thyroid Disease

Physical Factors /
  • Maternal Age over 35 Years
  • Uterine Malformations

While we suggest ongoing in-person monitoring of the high-risk pregnancy, for persons that would likely forgo the monitoring due to the inability to access or pay for care, remote in-home Telehealth monitoring of high-risk pregnancies would provide great benefits. Simple monitoring of the fetal heart rate can be extremely beneficial at preventing stillbirth and pre-term delivery.[v] There are several applications that are available on the market that provide a monitoring belt that can be used to check the fetal heart rate at various times during the day. The results are sent electronically to the attending physician. Some believe in-home monitoring actually offers better prevention than in-clinic consultations simply because the belt can be used during late times of the day, which usually would not be possible with a normal office visit.

Pre/Post Surgery Consultation

With 2 hospitals within a 50 mile radius of Morgan County, it is unlikely that there will be a need for Telesurgery applications. However, pre-operative treatment and surgery planning, and postoperative care offer many opportunities for the use of Telehealth in Morgan County. Researches indicate that improper pre-operative care is a leading cause of death due to surgery. [vi]

Preoperative Applications

  • TeleRadiology: Electronic Transmission of radiological images like x-rays, CTt’s, and MRI’s that help to identify surgical needs.[vii]
  • Access to Instructions via Email or Internet
  • Friendly Reminders via Email or Telephone

Post Operative Applications

  • Post Operative Follow-up: Consultations via Email or Videoconference
  • TeleRehabilitation: While Physical and Respiratory Therapy may begin in the hospital, continual rehabilitation may be possible through remote access to information including text and video instructions, along with video conferencing allowing for the provider to verify results and/or the ability to monitor instructions after monitoring.
  • In-clinic monitoring: in cooperation with Morgan Counties long-term care facilities. Possible applications include remote conferencing, or email communication regarding rehabilitation instructions and results.

Conclusion

Morgan County, situated in the hills of Southeastern Ohio, is clearly challenged in offering healthcare services to its population. Unfortunately, this population is plagued by distance, disparities, and a wealth of healthcare concerns similar to those of populations in metropolitan areas. While Morgan County is considered a remote area, it does have access to critical care within a 50-mile radius. Given this knowledge, inhabitants are not necessarily concerned with occasional situations warranting critical care, but feel that applications offering support for conditions requiring constant monitoring are ones that are most applicable to a Telehealth initiative. We have, through our analysis, offered insight into some of the possible applications for Morgan County. We look forward to investigating these further by studying the technology and support required to make them possible, in an effort to provide the best plan for Morgan County.

Appendix A- Table 1

What is different about rural health care?

  • Only about ten percent of physicians practice in rural America despite the fact that nearly one-fourth of the population lives in these areas. **

Rural residents are less likely to have employer-provided health care coverage or prescription drug coverage, and the rural poor are less likely to be covered by Medicaid benefits than their urban counterparts are.

  • Although only one-third of all motor vehicle accidents occur in rural areas, two-thirds of the deaths attributed to these accidents occur on rural roads.**

Rural residents are nearly twice as likely to die from unintentional injuries other than motor vehicle accidents, as are urban residents. Rural residents are also at a significantly higher risk of death by gunshot than urban residents are.

  • Rural residents tend to be poorer.

On the average, per capita income is $7,417 lower than in urban areas, and rural Americans are more likely to live below the poverty level. The disparity in incomes is even greater for minorities living in rural areas. Nearly 24% of rural children live in poverty.

  • People who live in rural America rely more heavily on the federal Food Stamp Program,

According to The Carsey Institute at the University of New Hampshire. The Institute's analysis found that while 22 percent of Americans lived in rural areas in 2001, a full 31 percent of the nation's food stamp beneficiaries lived there. In all, 4.6 million rural residents received food stamp benefits in 2001, the analysis found.

There are 2,157 Health Professional Shortage Areas (HPSA’s) in rural and frontier areas of all states and US territories compared to 910 in urban areas.**

  • Abuse of alcohol and use of smokeless tobacco is a significant problem among rural youth.

The rate of DUI arrests is significantly greater in non-urban counties. Forty percent of rural 12th graders reported using alcohol while driving compared to 25% of their urban counterparts. Rural eighth graders are twice as likely to smoke cigarettes (26.1% versus 12.7% in large metro areas.) **

Anywhere from 57 to 90 percent of first responders in rural areas are volunteers.**

  • There are 60 dentists per 100,000 population in urban areas versus 40 per 100,000 in rural areas**

Cerebrovascular disease was reportedly 1.45 higher in non-Metropolitan Statistical Areas (MSAs) than in MSAs.**

  • Hypertension was also higher in rural than urban areas (101.3 per 1,000 individuals in MSAs and 128.8 per 1,000 individuals in non-MSAs.)**

Twenty percent of nonmetropolitan counties lack mental health services versus five percent of metropolitan counties. In 1999, 87 percent of the 1,669 Mental Health Professional Shortage Areas in the United States were in non-metropolitan counties and home to over 30 million people **