Telehealth Impact in Frontier Critical Access Hospitals: Mixed Methods Evaluation.

BACKGROUND: Frontier areas are sparsely populated counties in states where 65% of the counties have 6 or fewer residents per square mile. Residents access primary care at critical access hospitals (CAHs) located in these rural communities but must travel great distances for specialty care. Telehealth could address access challenges; however, there are barriers to broader use, including reimbursement and the need for practical implementation support. The Centers for Medicare & Medicaid Services implemented the Frontier Community Health Integration Project (FCHIP) Demonstration to assess the impact of telehealth payment change and technical assistance to adopt and sustainably use telehealth for CAHs treating Medicare fee-for-service patients in frontier regions. OBJECTIVE: We evaluated the impact of the FCHIP Demonstration telehealth payment change and technical assistance on telehealth adoption and ongoing use using a mixed methods approach. METHODS: We conducted a mixed methods evaluation of the 8 CAHs in Montana, Nevada, and North Dakota that participated in the FCHIP program. Key informant interviews and FCHIP program document review were conducted and analyzed using thematic analysis to understand how CAHs implemented their telehealth programs and the facilitators of program adoption and maintenance. Medicare fee-for-service claims were analyzed from August 2013 to July 2019 relative to a group of CAHs that did not participate in the demonstration project to understand the frequency of telehealth use for Medicare fee-for-service beneficiaries receiving care at the participating CAHs before and during the Demonstration program. RESULTS: CAH staff noted several key factors for establishing and sustaining a telehealth program: clinical and administrative staff champions, infrastructure changes, training on telehealth processes, and establishing strong relationships with specialists at distant facilities to deliver telehealth services to patients of CAH. There was a modest increase in telehealth services billed to Medicare during the FCHIP Demonstration that were limited to a handful of CAHs. CONCLUSIONS: The frontier setting is characterized by a low population; and thus, the volumes of telehealth services provided in both the CAHs and comparison sites are low. Overall, CAHs reported that patient satisfaction was high and expressed the desire for more virtual services. Telehealth service selection was informed by perceived community needs and specialist availability. CAHs made infrastructure changes to support telehealth and expressed the desire for more virtual services. Implementation support services helped CAHs integrate telehealth into clinical and operational workflows. There was some increase in telehealth services billed to Medicare, but the volume billed was low and not enough to substantially improve hospital revenue. Future work to inform policy and practice could include standardized, formal community need assessments and assistance finding distant providers to meet those needs and further technical assistance around billing, service selection, and ongoing use to support sustainability.

Factors Influencing Telehealth Implementation and Use in Frontier Critical Access Hospitals: Qualitative Study.

BACKGROUND: Telehealth has potential to help individuals in rural areas overcome geographical barriers and to improve access to care. The factors that influence the implementation and use of telehealth in critical access hospitals are in need of exploration. OBJECTIVE: The aim of this study is to understand the factors that influenced telehealth uptake and use in a set of frontier critical access hospitals in the United States. METHODS: This work was conducted as part of a larger evaluation of a Centers for Medicare & Medicaid Services-funded demonstration program to expand cost-based reimbursement for services for Medicare beneficiaries for frontier critical access hospitals. Our sample was 8 critical access hospitals in Montana, Nevada, and North Dakota that implemented the telehealth aspect of that demonstration. We reviewed applications and progress reports for the demonstration program and conducted in-person site visits. We used a semistructured discussion guide to facilitate conversations with clinical, administrative, and information technology staff. Using NVivo software (QSR International), we coded the notes from the interviews and then analyzed the themes. RESULTS: Several factors influenced the implementation and use of telehealth in critical access hospitals, including making changes to workflow and infrastructure as well as practitioner acceptance and availability. Participants also cited technical assistance and support for implementation as supportive factors. CONCLUSIONS: Frontier critical access hospitals may adopt telehealth to overcome challenges such as distance from specialty practitioners and workforce challenges. Telehealth can be used for provider-to-patient and provider-to-provider interactions to improve access to care, remove barriers, and improve quality. However, the ability of telehealth to improve outcomes is limited by factors such as workflow and infrastructure changes, practitioner acceptance and availability, and financing.

Supporting multi-state collaboration on privacy and security to foster health IT and health information exchange.

As part of the HHS funded contract, Health Information Security and Privacy Collaboration, 41 states and territories have proposed collaborative projects to address cross-state privacy and security challenges related to health IT and health information exchange. Multi-state collaboration on privacy and security issues remains complicated, and resources to support collaboration around these topics are essential to the success of such collaboration. The resources outlined here offer an example of how to support multi-stakeholder, multi-state projects.

Staphylococcus aureus virulence genes identified by bursa aurealis mutagenesis and nematode killing.

Staphylococcus aureus is the leading cause of wound and hospital-acquired infections worldwide. The emergence of S. aureus strains with resistance to multiple antibiotics requires the identification of bacterial virulence genes and the development of novel therapeutic strategies. Herein, bursa aurealis, a mariner-based transposon, was used for random mutagenesis and for the isolation of 10,325 S. aureus variants with defined insertion sites. By screening for loss-of-function mutants in a Caenorhabditis elegans killing assay, 71 S. aureus virulence genes were identified. Some of these genes are also required for S. aureus abscess formation in a murine infection model.