Telehealth played a critical role helping people deal with the COVID-19 pandemic. It allows patients to safely contact their providers to deal with their non-urgent but still important conditions like diabetes, high blood pressure, and pregnancy. 

The technology proved to have limits, though. Many were highlighted in rural parts of the country. Undeterred, healthcare groups, businesses, and community leaders in those areas found workarounds to these limits. Three of them – third space, mobile health clinic, and rural home hospital – are covered here. 

Issue: Lack of Broadband Access or Dealing with Digital Deserts

People living in rural areas have already been struggling with medical care (or lack of) before the pandemic. You can read more about that in the posts, Battling the Unique Challenges Faced by Rural Hospitals, and How Can Rural Telehealth Keep Up with the Telehealth Boom?

  • Per the CDC, death by suicide had “the highest rates and greatest rate increase in rural counties.”
  • Obesity rates were around 10 percent higher in rural areas compared to urban areas.
  • 100 percent higher rates of workplace injuries, drowning, firearm wounds, car crashes, fires, and electrocutions.
  • Rural areas eclipsed urban areas in the rate of drug overdose.

While both posts discuss how telehealth can help deal with these issues, they acknowledge  telehealth’s shortcomings, namely lack of broadband access for many dwellings. In a 2019 study released by Purdue University, 21.3 million people in the US do not have access to high-speed internet like DSL, with nearly 5 million having no access to an Internet Service Provider (ISP) at all. In these “digital deserts,” two-thirds were living in rural areas. Many of telehealth’s strengths like telemedicine and remote patient monitoring are either spotty at best or simply impossible in such places. While various governments from the city level and up are pushing for more broadband access in rural areas, the process is glacially slow, facing roadblocks ranging from few willing local carriers to tangles of local, state, and federal laws.

Solution: Third Space

Unsurprisingly, rural communities are not waiting for a response. One solution is what Jim Henry, senior VP and healthcare director at CallisonRTKL, an architecture and design company, calls the creation of “third space.” These are safe, private, and broadband-configured places where a rural resident can telecommute with their healthcare provider using a panel PC, for example. Churches, community centers, the local convenience stores, or even gas stations could be used as third space. “It’s unconventional,” Henry admits, but “the point it’s not what the place was, it’s the idea of finding ways to meet the needs of your patients.”  

The Libraries Health Connect Program by the state of Maine could be considered such a third space. Launching next month, it provides telehealth services to patients through 10 public libraries, many of which are located in rural areas across the Pine Tree state. 

The program provides:

  • A private room.
  • A laptop equipped with a camera and mouse. 
  • Appropriate lighting. 
  • Headset.
  • Any other relevant technology for telehealth.

Patients can use the telehealth service for: 

  • Wellness visits. 
  • Prescriptions.
  • Follow-up appointments. 
  • Consultations with specialists.  
  • Nutritional counseling. 
  • Mental health counseling.
  • Other non-urgent conditions.

There are no fees for the above services.

Marijke Visser, the library development section supervisor for the Maine State Library, says about the program: “If you are in a small community you may need to drive a long distance to see a specialist…fundamentally libraries are responsive to the needs of their communities, so the libraries seeing that the people were struggling with the pandemic and with receiving quality health care…we wanted to step up and mitigate those challenges.” 

Main State Librarian Jamie Ritter agrees. “Maine’s libraries are committed to ensuring their communities have access to equitable services. This means offering programs that you might not associate with your library, like telehealth. We strongly believe that where you live should not dictate the quality of your healthcare. These libraries are leading the way for establishing libraries as another way Mainers can connect with a healthcare provider.”

Solution: Mobile Health Clinics

If rural patients can’t access telehealth at home and there is no third space available, how about bringing it to them? That’s one way to view the abilities of a mobile health clinic, or MHC. Extensively discussed in the post, How Medical Tablets Enhance Care at Mobile Clinics, these specially-modified vehicles travel to underserved sectors in the US like rural areas to provide healthcare services. The International Journal for Equity in Health, in its 2020 study on MHC, estimates 5.2 to 7.0 million people on average visited the 1500 to 2000 mobile clinics in the US between 2007 through 2017. An estimated 36 percent of those visits were from those dwelling in rural areas. 

MHCs provide a wide variety of services from preventive health screenings, dental care, to even bringing X-Rays to rural areas. Obviously, they cannot offer all the services of a true healthcare clinic no matter the size of the vehicle. This is especially true of medical specialists. This is where telehealth comes in. 

The New Mexico Mobile Screening Program for Miners is an MHC which monitors the health of miners in the state of New Mexico. While on-site staffing includes either a physician assistant (PA) or nurse practitioner (NP), medical assistants, and various technicians, it does not include specialist physicians like a pulmonologist. Instead, they reside at the University of New Mexico Health Sciences Center. Miners deemed high-risk for conditions such as asthma and chronic obstructive pulmonary disease (COPD) are then scheduled to speak with one through the on-board telemedicine system. The on-site staff also speak directly with the specialists for consultation. 

The famous Health Wagon, considered the oldest MHC in the US, performs similar duties for the residents of rural southwest Virginia and select adjacent states. In 2016, one of the NP onboard performed the first bladder cancer screening of a patient via telemedicine with the University of Virginia. Besides its use of remote connectivity, the event was also newsworthy because such procedures are usually performed by fully-trained physicians. 

“These people not only can’t find these services [in Appalachia}, they can’t afford them,” says Dr. Teresa Tyson, president and CEO of The Health Wagon. “For us, it’s all about removing those barriers. When you’ve done that, then you’re going to get some good results.”

Solution: Rural Home Hospital

Hospital at Home (HaH) is a Point of Care (POC) service providing hospital-level care to patients at their residence. It is covered at length in the post, How Hospital at Home Saves Lives While Reducing Costs. In summary, patients are monitored remotely via devices like heart monitors, while clinicians make periodic virtual visits. Support medical staff like registered nurses check on the patient twice daily.

Large amounts of bandwidth is consumed in HaH from the monitors and sensors sending patient data 24/7, medical tablets for patient use, to the televideo appointment with clinicians. Hospitals with HaH programs typically pre-screen the patient’s residence to make sure it has enough broadband access for all the equipment. Unsurprisingly, most programs are located in urban areas which typically have solid broadband access.

So it was a surprise when Ariadne Labs, which is a joint center for health systems innovation at Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, announced it was developing Rural Home Hospital (RHH), a POC for rural patients. The reasoning was sound, though. Many of the advantages of urban HaH apply even more so to rural patients. There are far fewer hospitals available in rural areas, for example. This makes freeing up hospital beds more critical. Many rural residents tend to be older, suffer more medical conditions, and have less personal financial resources than their urban counterparts. Recovering at home is far less expensive than a typical hospital stay.

Two rural-based healthcare systems are conducting three-year trial tests of RHH: Illinois-based  Blessing Health System and Appalachian Regional Healthcare, which is located in Kentucky. To deal with the bandwidth issues for their patients, they have come up with solutions from installing a new connection at their home, to setting up a small satellite receptor in case the internet signal proved too weak.

Closing Comments

Telehealth has many advantages which were on display during much of the COVID-19 pandemic. Its limits were also shown especially in rural areas with their lack of fast internet connections. Organizations in the area from libraries to healthcare rallied to come up with solutions like use of third space to creating rural home hospitals

Contact an expert at Cybernet if you’re interested in learning about three such programs and if they fit the needs of your rural healthcare group. 

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