SPM-1: The degree to which Title V programs utilize telehealth to improve access to services, education, and training for families and providers.

Introduction

Expanded use of telehealth technology was identified as a priority in the 2015 Title V 5-year needs assessment. The objective set was by July 2020, 100% of Title V programs use telehealth to provide services, education, and/or training. With the reduction in personnel resources, increases in travel costs, availability of the internet, HIPAA compliant software, and affordable devices, telehealth can be one of the tools to increase access to services, education, and training for families and providers while reducing costs and travel time especially for neighbor island and rural communities.

The National Survey of Children with Special Health Needs show that Hawaii children with special health care needs (CSHCN) have more difficulty accessing specialist care (5.9%) compared with non-CSHCN (1.1%).  (Data source: NSCH 2016/17).  The State of 2015 Hawaii Community Health Needs Assessment noted that fewer services are available in rural parts of Oahu and Neighbor Islands.  Also, many specialized services are not available on each island, requiring costly air transportation to receive needed care.  Use of telehealth in Hawaii for provision of genetics and behavioral health services have families and providers reporting high satisfaction with use of the technology and services provided.

There has been an increase in statewide efforts toward the use of telehealth by programs within the Department of Health (DOH), statewide hospitals, the University of Hawaii, state legislators, and our Congressional representation.  These efforts are supported by the HRSA funded Pacific Basin Telehealth Resource Center based in the University of Hawaii that works to help stakeholders collaborate on telehealth activities.

Hawaii’s Congressional Senator Brian Schatz and his aides continue to communicate with the State Telehealth Collaborative and support the use of telehealth in Hawaii. In 2014 the Legislature passed Act 159 for face-to-face and telehealth reimbursement parity.  In July 2016, the legislature and Governor Ige enacted Act 226 which expanded the existing telehealth law that was passed in 2014.  Act 226 requires the State’s Medicaid managed care and fee-for-service programs to cover any service provided through telehealth that would be covered if the service were provided through in-person consultation between a patient and a healthcare provider.  The law also requires payment parity which means that a service that can be provided by telehealth that is equivalent to a face-to-face service must be reimbursed at the same rate as the face-to-face service.  Act 226 also made Hawaii one of the first states to remove geographic restrictions or requirements for telehealth coverage and restrictions on originating site requirements for telehealth coverage or reimbursement.

Within the DOH, the Director has made increasing the use of telehealth as one of the top priorities in the new strategic plan for the Department. To support telehealth activities, the Department was successful in obtaining funding from the 2018 state legislature to fund a position for a telehealth coordinator and some funding for pilot studies.  Within the Family Health Services Division (FHSD) there is ongoing support for efforts to implement or increase telehealth activities for genetics, newborn screening, early intervention, and home visiting activities.  As part of these efforts, workforce training about telehealth is being developed.

Other FHSD telehealth activities include the Office of Primary Care and Rural Health’s support of Project ECHO Hawaii (echohawaii.org), a national innovative model that utilizes videoconferencing to build primary care workforce capacity while improving patient access to specialty health care in rural communities. Project ECHO was recognized by the state Medicaid program as a priority innovation initiative to build health workforce capacity and included as part of the Hawaii’s 1115 waiver to the Centers for Medicare and Medicaid Services.

FHSD is also partnering with the DOH Developmental Disabilities Division to support a pilot teledentistry program at three early childhood locations in Kona on Hawaii Island. The project was expanded to Maui to serve early childhood programs (Head Start, Early Head Start, WIC, preschool) as well as a senior living facility.

There are 4 strategies for this measure: Infrastructure development, workforce development, service provision, and Education/Training. The strategies were developed by the FHSD staff, led by the CSHNB Genomics Section supervisor who serves as the FHSD lead for this priority.

FHSD funds telehealth activities through several federal grants from both HRSA and the Centers for Disease Control. Although Title V does not fund telehealth activities directly, key management and support staff funded by Title V facilitate the telehealth expansion activities described in this narrative.

Strategies to address this objective and NPM are discussed below.

Strategy 1: Telehealth infrastructure development

The Governor and the Director of Health continue to have telehealth as one of their top priorities for the state.  The use of telehealth continued to increase including programs within the DOH, statewide hospitals, community organizations, and the University of Hawaii.  These efforts are supported by the HRSA funded Pacific Basin Telehealth Resource Center based in the University of Hawaii that works to help stakeholders collaborate on telehealth activities.

Senator Brian Schatz and his aides continue to communicate with the DOH, University of Hawaii, and hospital representatives to discuss ways to increase the use of telehealth in Hawaii.

Third party payers and providers in the state are making progress on developing policies to implement Act 226 (2016) that removed the originating site restrictions, so telehealth can be done to a person’s home or work.

FHSD worked with the University of Hawaii to plan a statewide telehealth meeting which took place October 2017.  State program staff, hospitals, healthcare providers attended the conference which covered current practices and policies and discussed needs for future support to expand telehealth in the state.  FHSD staff presented about our telehealth activities and facilitated the break-out sessions to determine the needs of the community.

Strategy 2: Service Provision

Within FHSD, telehealth use is increasing for meetings, training, and education for staff and external partners.  FHSD support continues its efforts to implement or increase telehealth clinical and service provision for genetics, newborn screening, early intervention, and home visiting activities.  The Office of Primary Care and Rural Health continues to support Project ECHO Hawaii (echohawaii.org ), which is an innovative model that utilizes videoconferencing to build primary care workforce capacity while improving patient access to specialty health care in rural communities. FHSD continues with the DOH Developmental Disabilities Division to support pilot teledentistry projects on the neighbor islands at early childhood and senior living settings.  The Early Intervention Section continues its telehealth work group to plan, implement, and evaluate using telehealth to provide early intervention services to families and training to staff and providers.

The neighbor island FHSD staff use the videoconferencing equipment that was installed in 2017 to facilitate telehealth visits for their neighbor island families and participate in meetings and trainings.  Genetics and neurology visits were completed using the technology.  The FHSD staff are now working with neighbor island organizations, including the Native Hawaiian Health Center clinics, to plan and implement telehealth services at community sites outside the District Health Offices.  Initial discussions seem to lead to a partnership between the Department of Health and the Veteran’s Administration to support a pilot program of telehealth kiosks in community locations such as libraries.  This would eliminate the concern about wireless internet reception in the more remote areas on the neighbor islands since the kiosks would be hard wired to the internet.

Strategy 3: Workforce development

The telehealth training curriculum was implemented for FHSD staff.  The training consists of nine on-line training modules and a one day in-person session.  The HRSA funded Pacific Basin Telehealth Resource Center is worked with the Genomics Section to develop the in-person training to accompany the on-line telehealth training.  The training course was stalled as we worked on developing new policies for coverage and reimbursement with the state third party payers.  However, the Genetics program does provide short trainings for new users as needed so that they can use the telehealth systems for meetings and training.  We will be resuming the training course in the summer of 2019.

Strategy 4: Education/Training

FHSD is also using videoconferencing on a daily basis for meetings and training.  We have changed the vocabulary of the program staff and they routinely request to “Zoom” each other.  We also have been able to schedule statewide training more easily since the trainings are now done using Zoom videoconferencing.  The childhood lead prevention and maternal mortality programs have used the videoconferencing for their trainings.

State Performance Measure (SPM)

The FFY 2018 indicator for the SPM (The degree to which Title V programs utilize telehealth to improve access to services and education for families and providers) is 12 out of 72. A copy of the completed data collection form can be found in the supporting documents. The Data Collection Form lists 24 strategy components organized by the three areas in telehealth activities:

• Infrastructure development
• Training/education development
• Service development

Each item is scored from 0-3 (0=not met; 1=partially met; 2=mostly met; 3=completely met), with a maximum total of 72.  Scoring is completed by FHSD staff. The data collection form is attached as a supporting document.

Factors Contributing to Success

The major factor contributing to success towards expanding telehealth in Title V programs continues to be support from the Governor, legislature, DOH administration, Division/Program leadership, program staff, and outside agencies such as the University of Hawaii and the HRSA funded Pacific Basin Telehealth Resource Center.  The legislature approved funding during the 2017 legislative session for a State Telehealth Coordinator position with the DOH and development of a State Telehealth Plan.  The DOH also consolidated the individual Zoom videoconferencing licenses into one HIPAA compliant corporate license to allow more efficient expansion for telehealth for our public health programs.

The prioritization of telehealth is pushing this Title V activity forward as a great example of what can be done in this area.  The Title V activity also coincides with the telegenetics activities being developed and implemented as part of the HRSA funded Western States Regional Genetics Network which is administered within the Title V agency in Hawaii.  This allows cross utilization of knowledge and resources.

Another factor contributing to supporting telehealth is the benefits for improving access for families and providers to services and education while containing costs.  With more access to broadband internet and applications that work well on devices like smartphones, we can reach more families and providers more often without the cost and time for travel.

Challenges

The main challenge facing more rapid adoption of telehealth for the Title V programs is the limitation of staff time and competing priorities.  As with other health departments, programs are experiencing staff retirements and departures with more difficulty filling positions with the many opportunities in the private sector.  Since current staff continue to cover shortages, this can be a barrier to implement new opportunities in telehealth.  However, the ability to reduce travel time and costs to attend meetings, trainings, and provide support and services to families makes it an attractive option for staff to make time to learn new skills.

Another key challenge is the families that would most benefit from telehealth are located in rural or neighbor island areas with limited wireless internet.  While programs can bring the equipment and hotspots to provide the telehealth services to rural families telehealth resources may be hampered by poor or no reception.