1. Impact of School Telehealth on Access to Medical Care, Clinical Outcomes, and Cost Savings Among Children in Rural Arkansas Ann B. Bynum, EdD Cathy A. Irwin, PhD, RN Bryan L. Burke, Jr., MD, FAAP Matthew V. Hadley, DNP, RN, ANP, PNP-BC Ralph Vogel, RN, PhD, CPNP Patrick Evans, MEd, RRT, RN Denise Ragland, PharmD, CDE Tina Johnson, LPN

2. Telehealth for Kids in Delta Schools (Telehealth KIDS) Project Goal: Demonstrate how telehealth can improve access to quality health care services in one of the most underserved regions of the U.S., Arkansas DeltaProject Goal: Demonstrate how telehealth can improve access to quality health care services in one of the most underserved regions of the U.S., Arkansas Delta Catalyze improvements in clinical outcomes, quality of care, and cost effectivenessCatalyze improvements in clinical outcomes, quality of care, and cost effectiveness Conducted by the University of Arkansas for Medical Sciences (UAMS), Center for Distance HealthConducted by the University of Arkansas for Medical Sciences (UAMS), Center for Distance Health Funded by the Office for the Advancement of Telehealth, HRSA, DHHSFunded by the Office for the Advancement of Telehealth, HRSA, DHHS

3. Telehealth KIDS Project  2-Year Project: August, 2007-August, 2009  Asthma Telemonitoring: 2007-2009  Diabetes Telemonitoring: 2008-2009  Telehealth consults: 2 Elementary Schools, 1 Middle School,1 High School, Marianna, AR  Daily peak flow, FEV1, pulse oximetry, blood glucose, blood pressure, heart rate, asthma and diabetes symptoms  Medical management: Asthma, diabetes, acute pediatric conditions  Collaborated with local PCP  Self-management education:Asthma, diabetes

4. Marianna, Arkansas

5. Initiating the Asthma and Diabetes Telemonitoring Project  Project Personnel, Training  Develop evaluation forms and database to assess outcomes, telehealth consults  Telemonitoring, interactive video equipment at the schools  Educate school staff, teachers, parents community health professionals  Protocols for telehealth consults  Approval for data collection: IRB, schools, healthcare facilities, hospitals  Recruiting and referral of students

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

7. Significance of the Study Model for delivery of health services for children in rural, underserved areas of ArkansasModel for delivery of health services for children in rural, underserved areas of Arkansas Potential method for reaching a large number of children to improve access to medical care and health educationPotential method for reaching a large number of children to improve access to medical care and health education Improved medical management, patient adherence, and clinical outcomes; prevent hospital admissions and school absences School telehealth fits into health care reform

8. Project Outcomes Access to Medical Care Pediatric services from pediatrician in local communityPediatric services from pediatrician in local community Clinical and health education servicesClinical and health education services Other health resources received in local community health facilitiesOther health resources received in local community health facilities Referrals to Pediatric Nurse Practitioner (PNP) during telehealth consultsReferrals to Pediatric Nurse Practitioner (PNP) during telehealth consults Referrals to additional health resources for children and families during telehealth consultsReferrals to additional health resources for children and families during telehealth consults

9. Project Outcomes  School absenteeism  Emergency room (ER) and hospital admissions for asthma  Cost savings from reduced ER and hospital visits for asthma  Metered-dose inhaler (MDI) technique  Asthma-symptom days  Forced expiratory flow (FEF) 25-75 % predicted  Blood glucose  Hemoglobin A1c  Adherence to daily glucose monitoring

10. Design and Methods  One-group pretest; 3-, 6-, and 12-month follow-up design; N = 56 children and adolescents  Baseline Sample: N = 40 with asthma, N = 6 with diabetes  Elementary, Middle, and High Schools, Marianna, AR  Participated in the UAMS Center for Distance Health, Telehealth KIDS Project during 2007-2009  Data Collection: August, 2007-August, 2009

11. Spirometry Testing

12. Assessment of MDI Technique

13. Asthma and Diabetes Telemonitoring Consults and Equipment

15. Interactive Video Equipment

16. Instruments  Asthma Assessment Form  Asthma Severity Assessment Form  MDI Technique Checklist  Diabetes Assessment Reporting Form  Project Evaluation, Subject Visit Form  Encounter Form  Assessment Reporting Form  Student Master Record

17. Data Analysis  Statistical Package for Social Sciences (SPSS), Version 17  Longitudinal Data Analysis  McNemar Test  Wilcoxon Signed Ranks Test  Paired Samples T-Test

18. Characteristics of the Sample for the Telehealth KIDS Project Variable N % Total N 56 Total Telehealth Consults 3,135 Gender Female2850% Female2850% Male2850% Male2850%Ethnicity African-American4988% African-American4988% White 611% White 611% Hispanic/Mexican 1 1% Hispanic/Mexican 1 1%School Elementary (grades K-2, 5-8 y.o.)3766% Elementary (grades K-2, 5-8 y.o.)3766% Elementary (grades 3-5, 9-11 y.o.)1120% Elementary (grades 3-5, 9-11 y.o.)1120% Middle school (grades 6-8, 12-14 y.o.) 610% Middle school (grades 6-8, 12-14 y.o.) 610% High school (grades 9-12, 15-18 y.o.) 2 4% High school (grades 9-12, 15-18 y.o.) 2 4%

19. Results: Characteristics of the Sample for the Asthma Project  N = 2,583 Telehealth consults for asthma telemonitoring, MDI assessments/education, spirometry testing, asthma education  Baseline Sample: N = 40 children/adolescents  Male, n = 26 (65%); Female, n = 14 (35%)  African-American, n = 37 (93%)  White, n = 2 (5%)  Hispanic/Mexican, n = 1 (2%)  Elementary School (grades K-2), n = 18 (45%)  Elementary School (grades 3-5), n = 16 (40%)  Middle School (grades 6-8), n = 6 (15%)

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

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

22. Access to Medical Care for Children in the Telehealth KIDS Project Access to Medical Care Baseline 12-mo FU n % n %P Value n % n %P Value Received pediatric services from a pediatrician in local community 2 7% 0 0%.50 Received clinical services in local community 9 32% 2 7%.07 Received health education in local community 4 14% 7 25%.55 Received other health resources in local community 5 18% 1 4%.22

23. Access to Medical Care During 9/07-8/08: Referrals to PNP during 2,625 (84%) telehealth consultsDuring 9/07-8/08: Referrals to PNP during 2,625 (84%) telehealth consults At 12-month follow-up: Referrals to PNP during 875 (28%) consultsAt 12-month follow-up: Referrals to PNP during 875 (28%) consults During 9/07-8/08: Referrals to additional health resources for children and families during 1,939 (62%) telehealth consultsDuring 9/07-8/08: Referrals to additional health resources for children and families during 1,939 (62%) telehealth consults At 12-month follow-up, referrals to additional health resources during 1,309 (42%) consultsAt 12-month follow-up, referrals to additional health resources during 1,309 (42%) consults Health resources: Asthma and diabetes education, lung function testing, inhaler technique assessment and educationHealth resources: Asthma and diabetes education, lung function testing, inhaler technique assessment and education

24. Results: ER and Hospital Admissions  No significant decrease in ER admissions (N = 15), over time from baseline (M = 0.20) to 12-month follow-up (M = 0.20, p = 1.00)  Decreased hospital admissions (N = 15), over time from baseline (M = 0.20) to 12-month follow-up (M = 0.00)  No significant decrease in hospital admissions over time (p =.25)  Mean decline of 0.20 hospital admissions per student from baseline at 12-month follow-up  100% decline in hospital admissions at 12- month follow-up for the 3 children who had hospital admissions at baseline

25. Results: Cost Savings  From reduced hospital admissions, the average cost savings per participating child (N = 15) was $168.40 at 12-month follow-up (0.20 X $842.00 = $168.40)  Total cost savings (N = 15) in Medicaid reimbursement costs was $2,526.00 (15 X $168.40 = $2,526.00)  At 12-month follow-up, the average cost savings for each of the 3 children who had hospital admissions at baseline was $842.00.

26. Results: School Absences  Children with asthma participating in baseline and 12-month follow-up (N = 15)  Showed a trend of having fewer school absences, over time from baseline (M = 4.33) to 12-month follow-up (M = 2.87)  No significant reduction in school absences over time (Z = -0.67, p =.50).  Six children demonstrated a trend of having decreased school absences from baseline to the 12-month follow-up.  Children with asthma reduced their school absences by 34% at 12-month follow-up.

27. Results: Asthma-Symptom Days  Children with asthma showed a trend of having fewer asthma-symptom days at daytime from baseline(BL) (N = 39, M = 3.26 ) to 12-month follow-up (FU) (N = 15, M = 1.33, slope est. = -0.02, p =.73)—No significant reduction in asthma-symptom days  While exercising—Fewer asthma-symptom days from BL (M = 2.56) to 20-month FU (N = 7, M = 0.86, slope est. = -0.07, p =.16) No significant reduction in asthma-symptom days  Showed a trend of having more asthma- symptom days at night from BL (M = 2.08) to 20-month FU (M = 2.86, slope est. = 0.06, p =.31)—No significant increase in asthma- symptom days

28. Results: FEF 25-75 % Predicted, MDI Technique  Children with asthma: Significant reduction in FEF 25-75 % predicted from BL (N = 39, M = 0.74 ) to 12-mo FU (N = 10, M = 0.55, slope est. = -0.02, p <.01)—No improvement  Significant improvement in MDI technique from BL (N = 40) to 15-month FU (N = 8) :  For mean total scores (BL M = 3.75, FU M = 5.88, slope est. = 0.17, p <.01)  For 3 steps for MDI technique:  Shakes inhaler (slope est. = 0.03, p =.05, approached significance)  Exhales normally (slope est. = 0.04, p <.01)  Holds med. in lungs 10 secs. before exhaling (slope est. = 0.04, p <.01)

29. Results: Blood Glucose, Hemoglobin A1c, Adherence to Daily Glucose Monitoring  Children with diabetes (N = 6): Decreased blood glucose from BL (M = 285.17 mg/dL) to 6-month FU (M = 209.83 mg/dL, p =.18)—No significant reduction in blood glucose  Increased hemoglobin A1c from BL (M = 8.67%) to 3-month FU (N = 6, M = 9.35%, p =.37) and 6-month FU (N = 5, M = 10.00%, p =.21)—No significant increase in hemoglobin A1c, No improvement  Improved adherence to daily glucose monitoring from BL (n = 3, 50%) to 6-mo FU (n = 6, 100%)—increased by 50% at 6-mo FU

30. Conclusions and Implications  School Telehealth improved access to medical care for children in the rural, Arkansas Delta.  Demonstrated positive clinical outcomes and cost savings in Medicaid reimbursement costs  Effective strategies: Daily asthma, diabetes monitoring; improved medical management, adherence; collaboration with PCP; asthma, diabetes education; 2-yr. program interventions; follow-up evaluation of outcomes; School Telehealth Nurse, interdisciplinary healthcare team  Future research: Experimental research designs with larger samples, minority ethnic groups in rural communities—assess clinical, health behavior outcomes; access to medical care, and cost savings