Impact of School Telehealth on Impact of School Telehealth on Access to Medical Care, Clinical Access to Medical Care, Clinical

Outcomes, and Cost Savings Outcomes, and Cost Savings Among Children in Rural ArkansasAmong Children in Rural Arkansas

Ann B. Bynum, EdDAnn B. Bynum, EdDCathy A. Irwin, PhD, RNCathy A. Irwin, PhD, RN

Bryan L. Burke, Jr., MD, FAAPBryan L. Burke, Jr., MD, FAAPMatthew V. Hadley, DNP, RN, ANP, PNP-BCMatthew V. Hadley, DNP, RN, ANP, PNP-BC

Ralph Vogel, RN, PhD, CPNPRalph Vogel, RN, PhD, CPNPPatrick Evans, MEd, RRT, RNPatrick Evans, MEd, RRT, RN

Denise Ragland, PharmD, CDEDenise Ragland, PharmD, CDETina Johnson, LPNTina Johnson, LPN

Telehealth for Kids in Delta Telehealth for Kids in Delta Schools (Telehealth KIDS)Schools (Telehealth KIDS)

• Project Goal: Demonstrate how telehealth can Project Goal: Demonstrate how telehealth can improve access to quality health care services in one improve access to quality health care services in one of the most underserved regions of the U.S., of the most underserved regions of the U.S., Arkansas Delta Arkansas Delta

• Catalyze improvements in clinical outcomes, quality of Catalyze improvements in clinical outcomes, quality of care, and cost effectivenesscare, and cost effectiveness

• Conducted by the University of Arkansas for Medical Conducted by the University of Arkansas for Medical Sciences (UAMS), Center for Distance HealthSciences (UAMS), Center for Distance Health

• Funded by the Office for the Advancement of Funded by the Office for the Advancement of Telehealth, HRSA, DHHS Telehealth, HRSA, DHHS

Telehealth KIDS ProjectTelehealth KIDS Project 2-Year Project: August, 2007-August, 20092-Year Project: August, 2007-August, 2009 Asthma Telemonitoring: 2007-2009 Asthma Telemonitoring: 2007-2009 Diabetes Telemonitoring: 2008-2009Diabetes Telemonitoring: 2008-2009 Telehealth consults: 2 Elementary Schools, 1 Middle Telehealth consults: 2 Elementary Schools, 1 Middle

School,1 High School, Marianna, ARSchool,1 High School, Marianna, AR Daily peak flow, FEV1, pulse oximetry, blood glucose, blood Daily peak flow, FEV1, pulse oximetry, blood glucose, blood

pressure, heart rate, asthma and diabetes symptomspressure, heart rate, asthma and diabetes symptoms Medical management: Asthma, diabetes, acute pediatric Medical management: Asthma, diabetes, acute pediatric

conditions conditions Collaborated with local PCPCollaborated with local PCP Self-management education:Asthma, diabetesSelf-management education:Asthma, diabetes

Marianna, ArkansasMarianna, Arkansas

Initiating the Asthma and Diabetes Initiating the Asthma and Diabetes Telemonitoring ProjectTelemonitoring Project

Project Personnel, TrainingProject Personnel, Training Develop evaluation forms and database to Develop evaluation forms and database to

assess outcomes, telehealth consultsassess outcomes, telehealth consults Telemonitoring, interactive video equipment at Telemonitoring, interactive video equipment at

the schoolsthe schools Educate school staff, teachers, parents Educate school staff, teachers, parents

community health professionalscommunity health professionals Protocols for telehealth consultsProtocols for telehealth consults Approval for data collection: IRB, schools, Approval for data collection: IRB, schools,

healthcare facilities, hospitalshealthcare facilities, hospitals Recruiting and referral of studentsRecruiting and referral of students

Purpose of the Study

Assessed access to medical care, Assessed access to medical care, changes in clinical outcomes, and changes in clinical outcomes, and cost savings among children cost savings among children participating in telehealth medical, participating in telehealth medical, asthma and diabetes telemonitoring asthma and diabetes telemonitoring consults in the school Telehealth consults in the school Telehealth KIDS project in the rural Arkansas KIDS project in the rural Arkansas DeltaDelta

Significance of the StudySignificance of the Study• Model for delivery of health services for Model for delivery of health services for

children in rural, underserved areas of children in rural, underserved areas of ArkansasArkansas

• Potential method for reaching a large number Potential method for reaching a large number of children to improve access to medical care of children to improve access to medical care and health educationand health education

• Improved medical management, patient adherence, and clinical outcomes; prevent hospital admissions and school absences

• School telehealth fits into health care reform

Project OutcomesProject Outcomes

Access to Medical Care Access to Medical Care • Pediatric services from pediatrician in local Pediatric services from pediatrician in local

communitycommunity• Clinical and health education services Clinical and health education services • Other health resources received in local Other health resources received in local

community health facilitiescommunity health facilities• Referrals to Pediatric Nurse Practitioner (PNP) Referrals to Pediatric Nurse Practitioner (PNP)

during telehealth consults during telehealth consults • Referrals to additional health resources for Referrals to additional health resources for

children and families during telehealth consults children and families during telehealth consults

Project OutcomesProject Outcomes School absenteeism School absenteeism Emergency room (ER) and hospital admissions for asthma Emergency room (ER) and hospital admissions for asthma Cost savings from reduced ER and hospital visits for Cost savings from reduced ER and hospital visits for

asthmaasthma Metered-dose inhaler (MDI) techniqueMetered-dose inhaler (MDI) technique Asthma-symptom daysAsthma-symptom days Forced expiratory flow (FEF) 25-75 % predictedForced expiratory flow (FEF) 25-75 % predicted Blood glucoseBlood glucose Hemoglobin A1cHemoglobin A1c Adherence to daily glucose monitoringAdherence to daily glucose monitoring

Design and Methods One-group pretest; 3-, 6-, and 12-month follow-One-group pretest; 3-, 6-, and 12-month follow-

up design; N = 56 children and adolescentsup design; N = 56 children and adolescents Baseline Sample: N = 40 with asthma, N = 6 Baseline Sample: N = 40 with asthma, N = 6

with diabeteswith diabetes Elementary, Middle, and High Schools, Elementary, Middle, and High Schools,

Marianna, ARMarianna, AR Participated in the UAMS Center for Distance Participated in the UAMS Center for Distance

Health, Telehealth KIDS Project during 2007-Health, Telehealth KIDS Project during 2007-20092009

Data Collection: August, 2007-August, 2009Data Collection: August, 2007-August, 2009

Spirometry TestingSpirometry Testing

Assessment of Assessment of MDI TechniqueMDI Technique

Asthma and Diabetes Asthma and Diabetes Telemonitoring Consults and Telemonitoring Consults and

EquipmentEquipment

Interactive Video EquipmentInteractive Video Equipment

InstrumentsInstruments Asthma Assessment FormAsthma Assessment Form Asthma Severity Assessment FormAsthma Severity Assessment Form MDI Technique ChecklistMDI Technique Checklist Diabetes Assessment Reporting FormDiabetes Assessment Reporting Form Project Evaluation, Subject Visit FormProject Evaluation, Subject Visit Form Encounter FormEncounter Form Assessment Reporting FormAssessment Reporting Form Student Master RecordStudent Master Record

Data AnalysisData Analysis

Statistical Package for Social Statistical Package for Social Sciences (SPSS), Version 17Sciences (SPSS), Version 17

Longitudinal Data AnalysisLongitudinal Data Analysis McNemar TestMcNemar Test Wilcoxon Signed Ranks TestWilcoxon Signed Ranks Test Paired Samples T-TestPaired Samples T-Test

Characteristics of the Sample for the Characteristics of the Sample for the Telehealth KIDS ProjectTelehealth KIDS Project

VariableVariable N N % %Total NTotal N 5656Total Telehealth Consults Total Telehealth Consults 3,135 3,135GenderGender FemaleFemale 2828 50%50% MaleMale 2828 50%50%

EthnicityEthnicity African-AmericanAfrican-American 4949 88%88% WhiteWhite 6 6 11%11% Hispanic/MexicanHispanic/Mexican 1 1 1% 1%

SchoolSchool Elementary (grades K-2, 5-8 y.o.)Elementary (grades K-2, 5-8 y.o.) 3737 66%66% Elementary (grades 3-5, 9-11 y.o.)Elementary (grades 3-5, 9-11 y.o.) 1111 20%20% Middle school (grades 6-8, 12-14 y.o.)Middle school (grades 6-8, 12-14 y.o.) 6 6 10%10% High school (grades 9-12, 15-18 y.o.) High school (grades 9-12, 15-18 y.o.) 2 2 4% 4%

Results: Characteristics of the Sample Results: Characteristics of the Sample for the Asthma Projectfor the Asthma Project

N = 2,583 Telehealth consults for asthma telemonitoring, MDI N = 2,583 Telehealth consults for asthma telemonitoring, MDI assessments/education, spirometry testing, asthma educationassessments/education, spirometry testing, asthma education

Baseline Sample: N = 40 children/adolescentsBaseline Sample: N = 40 children/adolescents Male, n = 26 (65%); Female, n = 14 (35%)Male, n = 26 (65%); Female, n = 14 (35%) African-American, n = 37 (93%)African-American, n = 37 (93%) White, n = 2 (5%)White, n = 2 (5%) Hispanic/Mexican, n = 1 (2%)Hispanic/Mexican, n = 1 (2%) Elementary School (grades K-2), n = 18 (45%)Elementary School (grades K-2), n = 18 (45%) Elementary School (grades 3-5), n = 16 (40%)Elementary School (grades 3-5), n = 16 (40%) Middle School (grades 6-8), n = 6 (15%)Middle School (grades 6-8), n = 6 (15%)

Results: Characteristics of the Sample Results: Characteristics of the Sample for the Diabetes Projectfor the Diabetes Project

N = 546 Telehealth consults for diabetes telemonitoring and educationN = 546 Telehealth consults for diabetes telemonitoring and education Baseline Sample: N = 6 children, adolescentsBaseline Sample: N = 6 children, adolescents Female, n = 6 (100%)Female, n = 6 (100%) African-American, n = 6 (100%)African-American, n = 6 (100%) Elementary School (grades 3-5), n = 1 (17%) Elementary School (grades 3-5), n = 1 (17%) Middle School (grades 6-8), n = 5 (83%)Middle School (grades 6-8), n = 5 (83%) Insulin treatment, n = 5 (83%) Insulin treatment, n = 5 (83%) Oral diabetic medications, n = 1 (17%)Oral diabetic medications, n = 1 (17%) Overweight, n = 6 (100%)Overweight, n = 6 (100%) Children with Asthma, n = 2 (33%)Children with Asthma, n = 2 (33%)

Results: Access to Medical Care, Baseline and 12-Month Follow-up

89

21

46

79

0102030405060708090

Percentage

Nopediatricservices

received incommunity

No clinicalservices

received incommunity

No healtheducation

received incommunity

No otherhealth

resourcesreceived incommunity

Figure 1. Access to Medical Care for Children in the Telehealth KIDS Project: Baseline and 12-Month Follow-up

Access to Medical Care for Children in Access to Medical Care for Children in the Telehealth KIDS Projectthe Telehealth KIDS Project

Access to Medical Care Baseline 12-mo FU Access to Medical Care Baseline 12-mo FU n %n % n % n % P P ValueValue

Received pediatric services Received pediatric services from a pediatrician in local from a pediatrician in local communitycommunity 2 7% 2 7% 0 0 0% 0% .50 .50

Received clinical services inReceived clinical services inlocal communitylocal community 9 32% 2 9 32% 2 7% 7% .07 .07

Received health education Received health education in local communityin local community 4 14% 7 4 14% 7 25% 25% .55 .55

Received other health resources Received other health resources in local community in local community 5 18% 5 18% 1 1 4% 4% .22 .22

Access to Medical CareAccess to Medical Care

• During 9/07-8/08: Referrals to PNP during 2,625 (84%) During 9/07-8/08: Referrals to PNP during 2,625 (84%) telehealth consultstelehealth consults

• At 12-month follow-up: Referrals to PNP during 875 (28%) At 12-month follow-up: Referrals to PNP during 875 (28%) consults consults

• During 9/07-8/08: Referrals to additional health resources for During 9/07-8/08: Referrals to additional health resources for children and families during 1,939 (62%) telehealth consultschildren and families during 1,939 (62%) telehealth consults

• At 12-month follow-up, referrals to additional health resources At 12-month follow-up, referrals to additional health resources during 1,309 (42%) consultsduring 1,309 (42%) consults

• Health resources: Asthma and diabetes education, lung Health resources: Asthma and diabetes education, lung function testing, inhaler technique assessment and educationfunction testing, inhaler technique assessment and education

Results: ER and Hospital Results: ER and Hospital AdmissionsAdmissions

No significant decrease in ER admissions (N = 15), No significant decrease in ER admissions (N = 15), over time from baseline (over time from baseline (MM = 0.20) to 12-month follow-up = 0.20) to 12-month follow-up ((MM = 0.20, = 0.20, pp = 1.00) = 1.00)

Decreased hospital admissions (N = 15), over time from Decreased hospital admissions (N = 15), over time from baseline (baseline (MM = 0.20) to 12-month follow-up ( = 0.20) to 12-month follow-up (MM = 0.00) = 0.00)

No significant decrease in hospital admissions over time No significant decrease in hospital admissions over time ((pp = .25) = .25)

Mean decline of 0.20 hospital admissions per student Mean decline of 0.20 hospital admissions per student from baseline at 12-month follow-up from baseline at 12-month follow-up

100% decline in hospital admissions at 12-month follow-100% decline in hospital admissions at 12-month follow-up for the 3 children who had hospital admissions at up for the 3 children who had hospital admissions at baselinebaseline

Results: Cost SavingsResults: Cost Savings From reduced hospital admissions, the average cost From reduced hospital admissions, the average cost

savings per participating child (N = 15) was $168.40 savings per participating child (N = 15) was $168.40 at 12-month follow-up (0.20 X $842.00 = $168.40)at 12-month follow-up (0.20 X $842.00 = $168.40)

Total cost savings (N = 15) in Medicaid Total cost savings (N = 15) in Medicaid reimbursement costs was $2,526.00 (15 X $168.40 = reimbursement costs was $2,526.00 (15 X $168.40 = $2,526.00)$2,526.00)

At 12-month follow-up, the average cost savings for At 12-month follow-up, the average cost savings for each of the 3 children who had hospital admissions at each of the 3 children who had hospital admissions at baseline was $842.00baseline was $842.00. .

Results: School AbsencesResults: School Absences Children with asthma participating in baseline and 12-Children with asthma participating in baseline and 12-

month follow-up (N = 15) month follow-up (N = 15) Showed a trend of having fewer school absences, over Showed a trend of having fewer school absences, over

time from baseline (time from baseline (MM = 4.33) to 12-month follow-up ( = 4.33) to 12-month follow-up (MM = 2.87)= 2.87)

No significant reduction in school absences over time No significant reduction in school absences over time (Z = -0.67, (Z = -0.67, pp = .50). = .50).

Six children demonstrated a trend of having decreased Six children demonstrated a trend of having decreased school absences from baseline to the 12-month follow-school absences from baseline to the 12-month follow-up.up.

Children with asthma reduced their school absences by 34% at 12-month follow-up.

Results: Asthma-Symptom Days Results: Asthma-Symptom Days Children with asthma showed a trend of having fewer asthma-Children with asthma showed a trend of having fewer asthma-

symptom days at daytime from baseline(BL) (N = 39, symptom days at daytime from baseline(BL) (N = 39, M M = = 3.26 ) to 12-month follow-up (FU) (N = 15, 3.26 ) to 12-month follow-up (FU) (N = 15, MM = 1.33, slope est. = 1.33, slope est. = -0.02, = -0.02, pp = .73)—No significant reduction in asthma-symptom = .73)—No significant reduction in asthma-symptom daysdays

While exercising—Fewer asthma-symptom days from BL (While exercising—Fewer asthma-symptom days from BL (M M = = 2.56) to 20-month FU (N = 7, 2.56) to 20-month FU (N = 7, M M = 0.86, slope est. = -= 0.86, slope est. = -0.07, 0.07, pp = .16) No significant reduction in asthma-symptom days = .16) No significant reduction in asthma-symptom days

Showed a trend of having more asthma-symptom days at night Showed a trend of having more asthma-symptom days at night from BL (from BL (MM = 2.08) to 20-month FU ( = 2.08) to 20-month FU (MM = 2.86, slope est. = = 2.86, slope est. = 0.06, 0.06, p p = .31)—No significant increase in asthma-= .31)—No significant increase in asthma-symptom dayssymptom days

Results: FEF 25-75 % Predicted, Results: FEF 25-75 % Predicted, MDI TechniqueMDI Technique

Children with asthma: Significant reduction in FEF 25-75 % predicted Children with asthma: Significant reduction in FEF 25-75 % predicted from BL (N = 39, from BL (N = 39, MM = 0.74 ) to 12-mo FU (N = 10, = 0.74 ) to 12-mo FU (N = 10, MM = 0.55, slope = 0.55, slope est. = -0.02, p < .01)—No improvementest. = -0.02, p < .01)—No improvement

Significant improvement in MDI technique from BL (N = 40) to 15-month Significant improvement in MDI technique from BL (N = 40) to 15-month FU (N = 8)FU (N = 8)::

For mean total scores (BL For mean total scores (BL MM = 3.75, FU = 3.75, FU MM = 5.88, slope est. = = 5.88, slope est. = 0.17, p < .01)0.17, p < .01)

For 3 steps for MDI technique: For 3 steps for MDI technique: Shakes inhaler (slope est. = 0.03, p = .05, approached Shakes inhaler (slope est. = 0.03, p = .05, approached

significance)significance) Exhales normally (slope est. = 0.04, p < .01)Exhales normally (slope est. = 0.04, p < .01) Holds med. in lungs 10 secs. before exhaling (slope est. = 0.04, p Holds med. in lungs 10 secs. before exhaling (slope est. = 0.04, p

< .01)< .01)

Results: Blood Glucose, Results: Blood Glucose, Hemoglobin A1c, Adherence to Hemoglobin A1c, Adherence to

Daily Glucose MonitoringDaily Glucose Monitoring Children with diabetes (N = 6): Decreased blood glucose Children with diabetes (N = 6): Decreased blood glucose

from BL (from BL (MM = 285.17 mg/dL) to 6-month FU ( = 285.17 mg/dL) to 6-month FU (MM = = 209.83 mg/dL, 209.83 mg/dL, pp = .18)—No significant reduction in blood = .18)—No significant reduction in blood glucoseglucose

Increased hemoglobin A1c from BL (Increased hemoglobin A1c from BL (MM = 8.67%) = 8.67%) to 3-month FU (N = 6, to 3-month FU (N = 6, M M = 9.35%, = 9.35%, pp = .37) and = .37) and 6-month FU (N = 5, 6-month FU (N = 5, MM = 10.00%, = 10.00%, pp = .21)—No significant = .21)—No significant increase in hemoglobin A1c, No improvement increase in hemoglobin A1c, No improvement

Improved adherence to daily glucose monitoring from BL Improved adherence to daily glucose monitoring from BL (n = 3, 50%) to 6-mo FU (n = 6, 100%)—increased by (n = 3, 50%) to 6-mo FU (n = 6, 100%)—increased by 50% at 6-mo FU50% at 6-mo FU

Conclusions and Implications School Telehealth improved access to medical care for School Telehealth improved access to medical care for

children in the rural, Arkansas Delta. children in the rural, Arkansas Delta. Demonstrated positive clinical outcomes and cost savings Demonstrated positive clinical outcomes and cost savings

in Medicaid reimbursement costsin Medicaid reimbursement costs Effective strategies: Daily asthma, diabetes monitoring; Effective strategies: Daily asthma, diabetes monitoring;

improved medical management, adherence; collaboration improved medical management, adherence; collaboration with PCP; asthma, diabetes education; 2-yr. program with PCP; asthma, diabetes education; 2-yr. program interventions; follow-up evaluation of outcomes; School interventions; follow-up evaluation of outcomes; School Telehealth Nurse, interdisciplinary healthcare teamTelehealth Nurse, interdisciplinary healthcare team

Future research:Future research: Experimental research designs with Experimental research designs with larger samples, minority ethnic groups in rural larger samples, minority ethnic groups in rural communities—assess clinical, health behavior outcomes; communities—assess clinical, health behavior outcomes; access to medical care, and cost savingsaccess to medical care, and cost savings