Photo by Bradyn Shock on Unsplash
When I first heard of telehealth services coming to our rural hospital, no one was a bigger skeptic than I was.
Perhaps the main reason was the way I was educated as a nurse and how I learned to practice as an APRN. Honestly, I am “old school” in every way possible. My first thought was, “This is not good practice; how could it be? Won’t there be shortcuts? How about the lack of a physical exam? How can you properly physically evaluate someone over telehealth? How can you take safe care of patients and avoid missing something that’s potentially life-threatening if you can’t touch them? How could someone a thousand miles away help me way up in the mountains of the Eastern Panhandle? What could they know about the community here and their needs?”
These were just a few of the questions and concerns I had regarding telehealth coming to our rural community access hospital. When we assess our patients, we not only to listen to their heart and lungs, look into their eyes, hear their voice, feel the temperature of their skin, but we connect. We are building trust and ensuring support with looking, listening, and feeling.
The APRN in me wanted to know more about the evidence backing these services; reviewing the literature gave me hope and helped me better understand the benefits to having an extra set of “eyes” on my patients.
Filling a gap in care, saving lives.
Rural counties have fewer health care workers and specialists, critical care units, emergency facilities, and transportation options for patients to get to appointments. A recent study about videoconferencing to connect specialists in stroke centers with providers in smaller hospitals found that these “telestroke” services helped get lifesaving treatments like clot-busters to these smaller hospitals within the 60-minute national average more often.
Consider the fact that the number of potentially excess deaths (deaths among persons under age 80 in excess of the number that would be expected) differs among and within public health regions and US states. In light of this, a statistic that really hit home with me is that a substantially higher proportion of trauma patients in rural vs. urban areas die within 24 hours: 89.6% vs 64%. As you can imagine, trauma and critical patients who come to many rural EDs are transferred out if there is a bed at another facility and if they can survive the one-hour (or longer) ambulance transport.
In the rural hospital I served in, there were few in-house specialists. The nearest specialists were an hour away in each direction. There was no neurologist, no pulmonologist, hematologist/oncologist, trauma surgeon, psychiatric or mental health providers, infectious disease specialists, nephrologist, urologist, or gastroenterologist. We had a cardiologist who came once a week for office visits but did not see consults in the hospital. Many times, I had to be a little of each of those specialists in order to care for the patients who had been admitted.
In addition, we had no ICU, only an ED and medical–surgical unit. When the COVID-19 pandemic hit and we were housing ICU patients, telehealth was my saving grace. Due to the lack of hospital beds at other facilities, we had no choice but to admit these patients to offload the overwhelmed ED. At any time, day or night, I could call a specialist (pulmonology or intensivist) to help with managing these critically ill patients from afar. These providers helped us save countless lives.
A return to the time pressures of family practice.
After the pandemic, I decided to leave hospital medicine and go back to family practice. I was quickly reminded why I left family medicine all those years prior. Productivity. The lack of time with patients and the sense of feeling rushed during the day added to burnout. With EMRs and documentation requirements, too many hours were spent on the computer instead of with patients.
Providers like APRNs are required by their employers to see a specified number of patients per hour. Some APRNs are lucky to get 30 minutes per patient, but the norm for follow-up is usually 10 minutes. In rural areas, our demographics generally demand more time to fully educate and prepare patients to care for themselves and their chronic illnesses. Add in financial constraints, illiteracy, lack of resources and consultants, and you have a recipe for frequent hospital readmissions, medication/nutrition/exercise noncompliance, and increased morbidity and mortality.
Telehealth and primary care: a good fit.
In response to these pressures, I decided to open my own telehealth practice and see patients on my own terms. (I practice in Virginia, which allows APRNs full practice authority, and West Virginia, which is partial but allowed me to apply for full practice authority with my years of experience.) This meant I could take all the time I needed with patients, educate them, encourage them, and support them. Since I have patients who work six of seven days a week, most of my appointments fall on Sundays. Ninety percent of the US population has cell phones, so talking with them is not an issue if they do not have video conference availability. With the price of gas and food so high, many patients prefer this method of communication; they feel supported and are more likely to not miss appointments.
I have found two things to be true with having my own practice: I have all the time I need with my patients and they love it, and I have zero “no-shows” on practice days.
After two years of having video telehealth intensivist backup during the worldwide pandemic, I quickly changed my opinion on physical touch being a necessity during all patient evaluations. No one would argue that physical examination isn’t valuable. But it’s not always essential. Many of the patients in my current practice come for specific services such as medical weight loss, hormone replacement therapy, and chronic disease management and counseling. Some are also followed by in-person primary care providers, some I see once in person before beginning telehealth visits, and others are asked to take their blood pressure at home because of the medications they are taking. Each patient’s needs are different.
As a health care team or individual, we can make the connection whether in person, phone, or video. The space in between is not always as relevant as we may believe.
Martha Vesterlund, DNP, APRN, ANP-C, FNP-C, is an assistant professor at Shenandoah University Eleanor Wade Custer School of Nursing in Virginia and a family nurse practitioner at Compassionate Care Telehealth Services.
Diana, It’s quite a process, but you start c your town government to see if they have any contracts for cable TV, cell service, or (likely not) fiber service pending or outstanding. See if there are other towns or governmental units in your area that could partner c yours. See which state regulatory body will be dealing c these issues (or does already). Make sure you have somebody on your side who is a tech expert and can smell malfeasance, self-dealing, or smoke-blowing a mile away that can help with diversity/equity access polling in the area, and somebody who’s an expert on grant-writing and the associated hoop-jumping. Happy to chat if you would like to give me a call, but I don’t know how to get my email or phone # to you. Try this lightly encoded attempt: (double-u mylastname thedigitone at Em Ay Cee dot com)
You’re absolutely right. Broadband access is supposed to get better in myvrural community because of the Inflation Reduction Act. It is a necessity.
If you have any insights into innovative ways to improve access to broadband or transportation, is love to hear about them.
I’m working on an town advisory board concerned with broadband access in our small town. We look at underserved areas and other factors with a goal of getting grants, better contracts, and educating the Town Select Board and citizens about tech capabilities and access, which presently are spotty and outdated. Everybody understands about businesses, schools, EMS, and libraries. To my mind, another big concern here is telehealth for citizens— visits c providers by the home bound or just unable to travel, applying for benefits, working c insurance and governmental entities like Mcare, Mcaid, and SS. It’s good for remote providers to have access to remote experts. Now do what you can to have your patient population have access to what has become a basic utility, as necessary for wellbeing as electricity, water, and telephony.
Hi Diana,
I am so glad you enjoyed it.
There are so many obstacles, practice restrictions and insurance/ CME requirements that are sometimes asking for the unnecessary. Many times APRNs are under a collaborative physician who instructs/orders things done their way, which is another reason I went out on my own.
Safety and following evidenced based practice should be first, always, following guideline therapy, making sure we are treating what we believe is the correct diagnosis, and proper follow up and care (via phone, text or email) to ensure the patient was treated as predicted, and correctly.
Martha, thank you for this post. You described my rural community perfectly, including the transportation challenges. But I live in mountains where even cell service can be iffy. Still, I was dumbstruck when my primary care provider–an NP–insisted that I come in for a visit to renew a medication or get treatment for a repeat UTI (I suggested that I pick up a lab slip for a urine c&s and she treat me without seeing me since she didn’t have an opening to see me for 3 days; but her office said she had to see me).
We desperately need more primary care providers AND we need to change our thinking about our models of care. An RN could have handled my issues and talked with the NP as needed. (Registered Nurses: Partners in Transforming Primary Care https://macyfoundation.org/assets/reports/publications/macy_monograph_nurses_2016_webpdf.pdf) Instead, systems such as United Health Grouo’s Optum are getting rid of all of their RNs.
Thank you for helping others to think differently about how to improve access to primary cate.