Posted March 6, 2011: The Use of Telemedicine by Community Pharmacists to Improve Chronic Disease Management in Rural Appalachia
Brief Background and Description of Proposed Project
The Healthy Appalachia Institute reports that Southwest Virginia residents have the highest burden of chronic diseases within Virginia. According to a study commissioned in 2007 by the Southwest Virginia Graduate Medical Education Consortium (GMEC), the rates of chronic diseases such as diabetes, hypertension, depression and asthma in Southwest Virginia are twice the statewide rates. Additionally, Buchanan County currently has the highest diabetes rate in the state of Virginia. A major barrier to medical care in Southwest Virginia is lack of access to care as most of the areas of Southwest Virginia are designated as medically underserved. Economic conditions also pose a major barrier to the quality of health care, as residents often lack the financial resources to afford the cost of medications and medical care. Therefore, Southwest Virginia residents with chronic disease conditions who do not have access to medical care or those unable to afford the cost of medical care will be the target of intervention for this project. The aim is to improve health care and health outcomes by utilizing telemedicine and community pharmacists. Pharmacists will be a part of multidisciplinary team to deliver Medication Therapy Management (MTM) and chronic disease management to residents of rural Appalachia. Chronic diseases such as diabetes, hypertension, asthma, depression and drug abuse will be included in our interventions, but those suffering from diabetes will be targeted first since diabetes has multiple co-morbid conditions. A partnership is forged between Appalachian College of Pharmacy, The Johnston Memorial Diabetes Care Center, the Virginia Diabetes Council and community pharmacists will support and implement this telemedicine diabetes care project in rural and underserved communities of Southwest Virginia.
Description of services to be provided:
A multidisciplinary team made of diabetes specialists from community pharmacists, academic pharmacists and diabetes center providers will provide diabetes management, MTM and chronic disease management to patients in our community. These services will be offered both face to face and via telemedicine platform. Team members who have the training, certifications and licensure requirement will be allowed to provide diabetes management to patients in person or via telemedicine.
Patients from the community who have type II diabetes and deemed to have poor diabetes control ( i.e A1C , >9%) will be referred to diabetes team member. Patient encounters will be conducted across all practice sites in Southwest Virginia (the diabetes center or the community pharmacy or academic pharmacy).
Once patients have been identified and referred to the program, the patient's first visit or encounter will be with a provider from the diabetes center, the diabetes center provider will then refer the patients to the pharmacist for future visits. Diabetes center provider will schedule the patient for a visit every 6 months (It is anticipated that each patient will have 5 visits per year with the pharmacist team members and 3 visits per year with the medical provider at the diabetes center.)
Each patient will meet with the pharmacist or medical team member for a 15-30 minute visit either in person or via telemedicine eight (8) times per year. The services will be provided free of charge to the patients as an incentive to participate. The program will establish a mechanism to pay team providers either from grant funding or through insurance billing. Each pharmacist and provider will be reimbursed $30 per patient visit or encounter from grant money for non billable services.
Each team member will enter patient encounters into the Virginia Diabetes Council electronic Diabetes Registry and Management System (eDRMS) to document episodes of care and to monitor diabetes outcomes.
CareSpark platform will be used to facilitate data exchange across sites.
Service Area:
Our service area will span radius of 70 miles from the diabetes center, the service will be provided from 4 sites. All the four (4) participating provider practices sites are located in the rural Appalachia region. They consist of 1 diabetes center, 1 academic based outreach pharmacy and 2 community retail pharmacies
The academic outreach pharmacy is located at Oakwood, Virginia near the campus of the Appalachian College of Pharmacy, the diabetes center is located 70 miles away in Abingdon, Virginia and 2 community pharmacy locations from Rite Aid one is located at Marion, Virginia and the second is located in Bristol, Virginia.
Current Resources:
Personnel: 3 pharmacists, 1 MD and 16 pharmacy students form the core providers for the project, Additional staff , educators and nurse practitioners from the diabetes center and the community will be recruited as needed by the program.
Facilities: Diabetes center well staffed and equipped with the latest technology in diabetes care, a newly opened outreach campus based pharmacy and 2 community Rite Aid pharmacies will support this project
Point of Care testing: A1cNow for A1c, blood pressure monitors, scales, etc.
Telemedicine: Currently there are 2 telemedicine equipments in place, one at the diabetes center and the other at the campus based pharmacy.
Technology: We have EMR (OpenEMR and OpenVista) and diabetes management (eDRMS)
Project Timeline:
March, 2011: Finalize project proposal and obtain letters of support from partner organizations and stakeholders
April 1, 2011: Test existing telemedicine equipment and test software connectivity and compatibility
May 1, 2011: Recruit and train community pharmacists and health care providers
July 1, 2011: Enroll patients in diabetes management and MTM program
August 1, 2011: Purchase and install telemedicine equipment
December 311, 2011: Analyze data, monitor outcomes and identify gaps and recommend improvement
July 31, 2012: Submit annual report and based on success, recommend expanding the program
Specific Objectives of the Project:
Increase awareness of the chronic disease conditions and provide health literacy training for patients, students, pharmacists and medical providers regarding prevention and management of chronic diseases. Approximately 10 pharmacists and faculty, 200 pharmacy and medical students and 10 medical providers will be involved in providing the care. Preventative medicine programs such as screening for diabetes, cancer, osteoporosis and smoke cessation programs will be provided free of charge and will be tracked and documented in eDRMS
Improve medication use and health outcomes for Southwest Virginia residents by providing Medication Therapy Management (MTM) by pharmacists and multidisciplinary team of health care providers utilizing a chronic disease care model such as electronic Diabetes Registry, (eDRMS - a comprehensive diabetes management and outcome reporting system marketed by Virginia Diabetes Council).
Utilize health information technology to improve medication use and safety, to document pharmacy services, to document outcomes and to improve communication among patients and providers.
Improve access to medical care by providing telemedicine and online visits with the local and remote network of medical provider via secure and HIPPA compliant Telemedicine and Electronic Medical Record (EMR).
Increase access to care and increase health care provider networks in an underserved area by increasing pharmacist and medical preceptors for student practice experiences. This will be specifically done by developing advanced pharmacy experiences (APPE) and by providing professional development opportunities for health care professionals through collaborative and co-management agreements between the clinic providers and remote providers.
Build capacity as medical provider will have an option to call on the community pharmacist to manage their patients with chronic disease conditions, thus freeing up more time for primary care providers to see more patients with acute conditions which ultimately will lead to extending care and increasing access to care in the rural area.
Expected Deliverables and Outcome
Improving overall health outcomes by managing chronic disease conditions is the
expectation. Diabetes is chosen as an initial target condition since it is a complex disease with co-morbid conditions.
Target outcomes are to:
Improve diabetes clinical outcomes such as Hemoglobin A1c, as measured by the number of patient with A1c < 9%, LDL as measured by number of patients with a LDL <100 mg/dL, HDL, blood glucose concentrations, BMI and blood pressure values as measured by number of patients with Blood pressure < 130/80 mmHg;
Improve diabetes medical outcomes as measured the an increase in percentage of patients who get a yearly eye exam, foot exam, influenza vaccination and pneumonia vaccination
Improve behavioral and educational outcomes such as smoke cessation and lifestyle modifications; and
Maintain sustainability of the project
Sustainability
Sustainability of the project will be monitored as an outcome. In the first year, grant money will provide 100% funding for the cost of professional services. During the second year, only 50% of these professional services will be funded by grant money as the project will start billing payers and employers for these services. The project will be self sustainable by the third year.
Barriers
Barriers include lack of funds, economic situation, literacy level, rural area, transportation, and lack of traditional providers.
Project Leadership:
Elshamly Abdelfattah, PharmD, Associate Professor of Pharmacy Practice at ACP will train community pharmacists and medical providers on chronic diseases and will be the community champion for the project.
Dr. Andrew Rhinehart, MD, FACP, CDE, Director, Johnston Memorial Diabetes Care Center will serve as Medical Advisor for the provider network.
Pharmacy network: A network of pharmacists and other health care providers will be recruited and trained on chronic disease and Medication Therapy Management (MTM) utilizing Virginia Diabetes Council eDRMS, as this platform will allow us to document and measure the improvement in outcomes of diabetes
Partner Organizations:
Academic partner and lead organization: APPALACHIAN COLLEGE OF PHARMACY (ACP): ACP is a higher education institution with the mission and vision of improving the life of residents of rural Appalachia by improving education and health care. ACP is uniquely positioned to create a new model of health care delivery, to provide a safety net and to expand access to care for the residents of Southwest Virginia. ACP has at its disposal a network of 200 pharmacists alumni and more than 200 pharmacy students who will be enrolled in the pharmacy network as the project expands and builds a successful model for improving healthcare. This network of well trained pharmacists will collaborate with medical providers to improve chronic disease management through medication therapy management, counseling and prevention services for those within Southwest Virginia.
Appalachian College of Pharmacy will be the lead partner and will contribute a clinic pharmacy site. The site is a newly opened clinic and pharmacy located near the campus of Appalachian College of Pharmacy in the underserved area of Southwest Virginia. The clinic and pharmacy will be staffed by clinical pharmacist faculty and students from the College of Pharmacy. The pharmacy will provide Medication Assistance Program (MAP), medication therapy management and chronic disease management (MTM-CDM) to residents of Southwest Virginia either face to face or via telemedicine. The clinic is staffed by a naturopathic physician to facilitate the provision of medical care and preventative services.
Johnston Memorial Diabetes Care Center: Under the directorship of Dr. Andrew Rhinehart, the Diabetes Care Center provides diabetes care to residents of Southwest Virginia and upper east Tennessee. The center is fully staffed by physicians, diabetes educators, dietitians and CDEs. Also the center will be staffed by a clinical pharmacist contingent upon funding
Community Pharmacy Partner: Community pharmacists from Rite Aid with locations in Southwest Virginia will provide the diabetes management that will be the initial core of community pharmacy network. Each location is staffed by clinical pharmacist to provide patient education as well as medication therapy management (MTM). In addition, each pharmacy location with telemedicine equipment will serve as an access point for patients to receive telemedicine diabetes care.
Virginia Diabetes Council: Virginia Diabetes Council (VDC) will make its electronic diabetes registry and management system (eDRMS) available for the team members to use to document and monitor outcomes. VDC will provide project team members with report card showing their progress and comparing their performance in achieving diabetes outcome. Also they will monitor program compliance with its objectives.
BUDGET: Anticipated total number of 125 patients will be enrolled in this project, each patient will be seen 8 times per year which will generate a total of 1000 encounters or visits per year. The cost per visit or encounter is $30.00
Budget Item
Amount
Provision of care, 1000 encounters @ $30 each
$30,000
Telemedicine Equipment
$25,000
Initial set-up of telemedicine sites
$25,000
Network Training
$10,000
VDC – Diabetes Registry software
$10,000
Direct Project Costs
$100,000
Indirect costs @ 25%
$25,000
Total Project Costs
$125,000
In-kind funding:
Appalachian College of Pharmacy
$25,000
American Pharmacists Association Foundation (pending grant application)
$25,000
Funding requested from VHCF:
$75,000
Northern Virginia AHEC, Dallice Joyner, Executive Director
Click here for more information about the Northern Virginia AHEC.
(Video taken with permission of D. Joyner.)
Michael O. Royster, MD, MPH
Director of the Office of Minority Health and Health Equity, at the Virginia Rural Health Association 2010 Annual Conference. Click here to access the Office of Minority Health and Health Equity Web site. (Photo and video below taken with permission of Dr. Royster.)
The Veterans Clinic at Cumberland Mountain Community Services
(Telemental Session at the Veterans Clinic at Cumberland Mountain, Virginia. Photo provided courtesy of J. Blankenship.)
The Veterans Clinic at Cumberland Mountain Community Services facilitates mental health services for rural area eligible veterans. Mental health services are provided on an out-patient basis using the technology of videoconference via the Polycom Video Conference System. These Veterans would otherwise have to travel two to three hours one-way to receive services from the Department of Veterans Affairs. Veterans can travel to a closer site at the main office at Cumberland Mountain Community Services where a nurse facilitates the telecommunication link to Salem, Virginia. This clinic links the veteran to a VA psychiatrist for a consultation evaluation, medication management and provides referrals based upon identified needs.
The Polycom Video Conference System in Southwest Virginia: The two state facilities in Southwest Virginia, the Southwest Virginia Mental Health Institute (SWVMHI) and the Southwestern Virginia Training Center (SWVTC), use the Polycom Video Conference System to communicate with the Community Service Boards (CSB’s) for discharge planning, treatment team meetings, family sessions, consumer interviews and, as part of commitment law process, for hearings and re-commitments.
(A young dermatology patient in the Tappahannock telehealth clinic accompanied by his mother and grandmother, with Terry Webb of Riverside Medical Group.)
(Photo provided courtesy of E. McRee Bowles)
The Northern Neck Middle Peninsula Telehealth Consortium established a telemedicine outpatient clinic in May 2008 on the campus of Riverside Tappahannock Hospital for patients of the region’s rural primary care providers. A year later, NNMPTC arranged an outpatient setting with Rappahannock General Hospital in Kilmarnock, with equipment previously used only in the ER-ICU. Now patients in two sections of the 10-county region -- 45 miles apart -- have regular access to remote specialists at UVa and VCU Health Systems. Teledermatology consults are usually scheduled once a month. Nursing staff from either Riverside or Rappahannock General use live videoconferencing and digital examination cameras to transmit patient encounters to Dr. Kenneth Greer of the University of Virginia Health System. Dr. Greer’s diagnosis and medical orders are communicated to the local referring physician, who provides follow-up care. Through June 2010, 73 dermatology patients have received teledermatology care at these two clinics.
For a video about the Northern Neck Middle Peninsula Telehealth Consortium click here.
Harrionsburg Community Health Center
(Photo at Harrisonburg Community Health Center of Dr. Chris Chisholm (on screen) providing a live video consult courtesy of the Daily News Record, Harrisonburg, VA)
High Risk Obstetrics
Dr. Chris Chisholm of the UVA Department of OB/GYN is providing high-risk obstetrics to the following sites: 1. Harrisonburg Community Health Center (funded by Governor's Productivity investment Fund); 2. Waynesboro Health Department; 3. Augusta-Staunton Health Department; and 4. Culpeper County Health Department. (The last three are funded by HRSA Rural Telehealth Network Grant Program)..
Sentara Telehealth Home Care
(Photo Provided Courtesy of S.T. Brent, Sentara)
Sentara Home Care Services utilizes telehealth technology in all of its eight home care branches, located in Covington, Charlottesville, Richmond, Williamsburg, Hampton, Suffolk, Hampton Roads (including Norfolk, Portsmouth, Chesapeake and Virginia Beach) and Elizabeth City, NC. Sentara employs close to 300 units, monitoring patients with chronic diseases such as CHF, COPD, and Diabetes.
Currently, the entire Sentara Healthcare system (including physician practices, rehab and skilled nursing facilities, and other outpatient facilities) is looking at incorporating telehealth on all its disease management patients. The main focus this year (2010) is on patients with CHF.
Saltville Medical Center Digital Retinal Camera
(Photo Provided Courtesy of H. Chapman, SVCHS)
Above is a photograph of Sally Pennings, FNP, at the Saltville Medical Center, Saltville, VA performing a digital retinal camera eye exam. The images are then forwarded to the University of Virginia Medical Center for reading and interpretation. The Saltville Medical Clinic is one of the centers within the Southwest Virginia Community Health Systems, Inc. (SVCHS), a group of non-profit community health centers. For more information about click on: SVCHS.
