Telehealth and Allergy Services in Rural and Regional Locations That Lack Specialty Services
2022; Elsevier BV; Volume: 10; Issue: 10 Linguagem: Inglês
10.1016/j.jaip.2022.06.025
ISSN2213-2201
AutoresKirk H. Waibel, Tamara T. Perry,
Tópico(s)Healthcare Systems and Technology
ResumoSecondary to the coronavirus disease 2019 pandemic, telehealth quickly peaked as the dominant health care modality and its use still remains high. Although allergists and health care systems adapted quickly to adopt telehealth, its increased use has both highlighted its benefits for patients and allergists and demonstrated known concerns with delivering allergy specialty care to rural and regional patient populations. With increased concentration of both patients and allergists in urban areas, the ability to provide allergy specialty care to the rural and remote population continues to remain a challenge despite the advantages leveraged through telehealth. Herein, we review aspects specific to the rural patient population, tele-allergy outcomes with these patient cohorts, and efforts, both past and present, taken at different levels within the allergy community to promote our specialty through specific telehealth modalities to address and engage the rural and regional patient. Secondary to the coronavirus disease 2019 pandemic, telehealth quickly peaked as the dominant health care modality and its use still remains high. Although allergists and health care systems adapted quickly to adopt telehealth, its increased use has both highlighted its benefits for patients and allergists and demonstrated known concerns with delivering allergy specialty care to rural and regional patient populations. With increased concentration of both patients and allergists in urban areas, the ability to provide allergy specialty care to the rural and remote population continues to remain a challenge despite the advantages leveraged through telehealth. Herein, we review aspects specific to the rural patient population, tele-allergy outcomes with these patient cohorts, and efforts, both past and present, taken at different levels within the allergy community to promote our specialty through specific telehealth modalities to address and engage the rural and regional patient. Despite comprising the vast majority of the land area in the United States, rural areas contain only 1 in 6 individuals, or approximately 60 million people.1Taylor L. Waller M. Portnoy J.M. Telemedicine and allergy services to rural communities.J Allergy Clin Immunol. 2019; 7: 2554-2559Abstract Full Text Full Text PDF Scopus (20) Google Scholar Multiple studies have observed that individuals who live in these rural areas face unique barriers to health care. These include geographic and transportation barriers, reduced access to specialists, reduced insurance coverage, reduced knowledge of telemedicine opportunities, and reduced connectivity with reduced broadband internet access among other factors.2Valet R.S. Perry T.T. Hartert T.V. Rural health disparities in asthma care and outcomes.J Allergy Clin Immunol. 2009; 123: 1220-1225Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 3Apter A.J. Casillas A.M. Eliminating health disparities: what have we done and what do we do next?.J Allergy Clin Immunol. 2009; 123: 1237-1239Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 4Marcin J.P. Shaikh L. Steinhorn R.H. Addressing health disparities in rural communities using telehealth.Pediatr Res. 2016; 79: 169-172Crossref PubMed Scopus (158) Google Scholar These factors contribute to worse health outcomes for this population, with some coining this the “rural mortality penalty.”5James W. All rural places are not created equal: revisiting the rural mortality penalty in the United States.Am J Public Health. 2014; 104: 2122-2129Crossref PubMed Scopus (74) Google Scholar With the continued interest in delivering allergy specialty care to this underserved and vulnerable population as well as efforts to identify and address health care inequities and disparities, multiple federal, organizational, state, and local initiatives are ongoing with a clear emphasis to leverage telehealth to achieve these goals.6Davis C.M. Apter A.J. Casillas A. Foggs M.B. Louisias M. Morris E.C. et al.Health disparities in allergic and immunologic conditions in racial and ethnic underserved populations: a Work Group Report of the AAAAI Committee on the Underserved.J Allergy Clin Immunol. 2021; 147: 1579-1593Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar,7Rural Telehealth and Healthcare System Readiness Measurement Framework – final report.https://www.qualityforum.org/Publications/2021/11/Rural_Telehealth_and_Healthcare_System_Readiness_Measurement_Framework_-_Final_Report.aspxDate: November 2021Date accessed: May 1, 2022Google Scholar In the United States, the National Quality Forum (NQF) is a consensus-based health care organization relied on by the federal government to provide evidence-based recommendations to improve health care. Many of these NQF performance measures have been reviewed by the American Academy of Asthma, Allergy & Immunology/American College of Asthma, Allergy, and Immunology Joint Task Force of Quality Performance Measures and incorporated by allergists. Regarding measures and outcomes for rural telehealth, the NQF published its latest update in November 2021 but lacks significant and specific aspects that pertain to the allergist/immunologist.7Rural Telehealth and Healthcare System Readiness Measurement Framework – final report.https://www.qualityforum.org/Publications/2021/11/Rural_Telehealth_and_Healthcare_System_Readiness_Measurement_Framework_-_Final_Report.aspxDate: November 2021Date accessed: May 1, 2022Google Scholar Telehealth’s strengths, weakness, opportunities, and threats have evolved over the past 10 to 20 years; however, the coronavirus disease 2019 (COVID-19) pandemic resulted in telehealth quickly becoming the dominant health care modality compared with the standard “brick and mortar” clinical encounter. Before 2020, telehealth accounted for only 1% of health care claims, but it reached a peak of almost 80% of claims in April 2020, decreased to approximately 30% to 40% in late 2020, and has fluctuated since then based on COVID-19 incidence and local and state health restrictions.8Drees J. Led by COVID-19 surge, virtual visits will surpass 1B in 2020: report.https://beckershospitalreview.com/telehealth/led by covid-19 surge-virtual-visits-will-surpass-1b-in-2020.report.htmlDate accessed: May 1, 2022Google Scholar,9Demeke H.B. Merali S. Marks S. Pao L.Z. Romero L. Sandhu P. et al.Trends in use of telehealth among health centers during the COVID-19 pandemic – Unites States, June 26-November 6, 2020.MMWR Morb Mortal Wkly Rep. 2021; 70: 240-244Crossref PubMed Scopus (60) Google Scholar However, a Morbidity and Mortality Weekly Report of the percentage of weekly telehealth visits from June to November 2020 demonstrated significantly fewer visits in the South and rural areas compared with those in urban areas.9Demeke H.B. Merali S. Marks S. Pao L.Z. Romero L. Sandhu P. et al.Trends in use of telehealth among health centers during the COVID-19 pandemic – Unites States, June 26-November 6, 2020.MMWR Morb Mortal Wkly Rep. 2021; 70: 240-244Crossref PubMed Scopus (60) Google Scholar The shift to telehealth was vital to provide clinical care due to significant limitations for in-person visits caused by the pandemic and to support specialty care delivery to the rural and remote patient population who, even before the pandemic, had significant barriers obtaining specialty care.7Rural Telehealth and Healthcare System Readiness Measurement Framework – final report.https://www.qualityforum.org/Publications/2021/11/Rural_Telehealth_and_Healthcare_System_Readiness_Measurement_Framework_-_Final_Report.aspxDate: November 2021Date accessed: May 1, 2022Google Scholar This article will review the key components of tele-allergy services to the rural and regional patient, which include the allergy workforce, the rural patient population, the originating site where the patient is located, the distant site where the allergist is located, and aspects of regional tele-allergy efforts to the rural or remote patient. Leveraging telemedicine for allergy/immunology is more important than ever as the US population is predicted to grow by 10% over the next 20 years while the allergist workforce is predicted to have a shortfall of nearly 500 allergists by 2025.10Malick A. Meadows J.A. Allergy and immunology physician workforce. Where do we stand today?.Ann Allergy Asthma Immunol. 2021; 127: 522-523Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Second, the geographic disparity of urban- versus rural-based allergists is significant. A 2019-2020 American Board of Medical Specialties report listed 5705 allergists in the United States, with a range of 2 in Wyoming to 716 in California; most allergists practice in urban or suburban locations.11American Board of Medical SpecialtiesABMS Board Certification report 2019-2020.https://www.abms.org/wp-content/uploads/2020/11/ABMS-Board-Certification-Report-2019-2020.pdfDate accessed: January 9, 2022Google Scholar Although training complementary providers such as a physician assistant, nurse practitioner, primary care provider, respiratory therapist, or asthma educator to perform skin testing, spirometry, and drug testing will extend the knowledge of and clinical care rendered by the allergist, it may not be able to meet the demand, particularly for rural-based clinics, hospitals, and patients.12Ramsey R.R. Plevinsky J.M. Migrim L. Hommel K.A. McDowell K.M. Shepard J. et al.Feasibility and preliminary validity of mobile spirometry in pediatric asthma.J Allergy Clin Immunol Pract. 2021; 9: 3821-3823Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar,13Staicu M.L. Holly A.M. Conn K.M. Ramsey A. The use of telemedicine for penicillin allergy skin testing.J Allergy Clin Immunol Pract. 2019; 6: 2033-2040Abstract Full Text Full Text PDF Scopus (48) Google Scholar A “rural” area in the United States is defined by the Census Bureau as any area that is “not-urbanized.”14United States Census Bureau2010 Census urban and rural classification and urban area criteria.https://www.census.gov/programs-surveys/geography/guidance/geo-areas/urban-rural/2010-urban-rural.htmlDate accessed: May 1, 2022Google Scholar The Census Bureau identifies 2 types of urban areas: (1) urbanized areas, which are composed of 50,000 people or more, and (2) urban clusters, which have between 2,500 and 50,000 people. Approximately 60 million individuals in the United States live in a rural area. Within these rural areas, there are approximately 3500 rural health clinics, which provide primary care services but seldom provide specialty services such as allergy/immunology. In addition, rural health clinics are disproportionately dependent on Medicare and Medicaid as the primary payers, which may limit interest from specialists due to lower reimbursements compared with commercial insurance or self-pay patients. Although telehealth has improved gaps for the rural patient population that existed long before the COVID-19 pandemic, barriers remain such as reduced broadband internet connectivity, increased travel distances, and fewer available specialists.1Taylor L. Waller M. Portnoy J.M. Telemedicine and allergy services to rural communities.J Allergy Clin Immunol. 2019; 7: 2554-2559Abstract Full Text Full Text PDF Scopus (20) Google Scholar,2Valet R.S. Perry T.T. Hartert T.V. Rural health disparities in asthma care and outcomes.J Allergy Clin Immunol. 2009; 123: 1220-1225Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar,7Rural Telehealth and Healthcare System Readiness Measurement Framework – final report.https://www.qualityforum.org/Publications/2021/11/Rural_Telehealth_and_Healthcare_System_Readiness_Measurement_Framework_-_Final_Report.aspxDate: November 2021Date accessed: May 1, 2022Google Scholar Furthermore, rural and remote patients have higher rates of chronic medical conditions, reduced access to health education, and reduced health literacy.7Rural Telehealth and Healthcare System Readiness Measurement Framework – final report.https://www.qualityforum.org/Publications/2021/11/Rural_Telehealth_and_Healthcare_System_Readiness_Measurement_Framework_-_Final_Report.aspxDate: November 2021Date accessed: May 1, 2022Google Scholar In a cohort of 36 million individuals with commercial insurance, telehealth visits increased from 0.3% of persons prepandemic to 23.6% of patients during the pandemic15Weiner J.P. Bandeian S. Hatef E. Lans D. Liu A. Lemke K.W. In-person and telehealth ambulatory contacts and costs in a large US insured cohort before and during the COVID-19 pandemic.JAMA Network. 2021; 4e212618Google Scholar; 6.4% of all patients lived in rural areas, and their telehealth usage was significantly less when compared with that of their urban counterparts.15Weiner J.P. Bandeian S. Hatef E. Lans D. Liu A. Lemke K.W. In-person and telehealth ambulatory contacts and costs in a large US insured cohort before and during the COVID-19 pandemic.JAMA Network. 2021; 4e212618Google Scholar A retrospective Canadian study evaluating 1862 patients aged 14 to 45 years who were hospitalized for asthma observed that 14% lived in a rural area. Compared with nonrural patients, rural patients were less likely (11.2% vs 21.2%) to receive specialty care after discharge.16Kendzerska T. Aaron S.D. Meteb M. Gershon A.S. To T. Lougheed M.D. et al.Specialist care in individuals with asthma who require hospitalization: a retrospective population-based study.J Allergy Clin Immunol Pract. 2021; 9: 3686-3696Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar Thus, even when the rural patient was admitted to the regional hospital, specialty follow-up occurred less often for rural-based patients. The presence or absence and type of health insurance is also a key driver for rural and remote patient health outcomes. In a US insurance census from 2017, counties were defined as “completely rural” if 100% of the population was rural, “mostly rural” if greater than 50% of the population was rural, and “mostly urban” if more than 50% of a county’s population lived in an urban location.17United States Census BureauHealth insurance in rural America.https://www.census.gov/library/stories/2019/04/health-insurance-rural-america.htmlDate accessed: January 3, 2022Google Scholar Although nearly every county saw a decline in the percentage of uninsured individuals in 2017 compared with 2013, 12.3% of individuals living in completely rural counties lacked health insurance compared with 11.3% in mostly rural and 10.1% in mostly urban counties.17United States Census BureauHealth insurance in rural America.https://www.census.gov/library/stories/2019/04/health-insurance-rural-america.htmlDate accessed: January 3, 2022Google Scholar Also, individuals younger than 65 years who live in rural areas are less likely to have private insurance coverage and are more likely to be uninsured than individuals located in urban and suburban areas.7Rural Telehealth and Healthcare System Readiness Measurement Framework – final report.https://www.qualityforum.org/Publications/2021/11/Rural_Telehealth_and_Healthcare_System_Readiness_Measurement_Framework_-_Final_Report.aspxDate: November 2021Date accessed: May 1, 2022Google Scholar When conducting a telehealth encounter, the 3 main aspects of the visit are the originating site, the distant site, and the telehealth modality being used (Figure 1). The originating site is defined by the Centers for Medicare & Medicaid Services as where the patient is located during the telehealth encounter or visit. Other terms used for the originating site have included the spoke site, patient site, remote site, or rural site.18Lustig T.A. Rapporteur The Role of Telehealth in an Evolving Heath Care Environment. The National Academies Press, Washington, DC2012Google Scholar Depending on the patient’s resources, different telehealth scenarios can occur. Originating site options can include a personal cell phone, home landline, internet, school, church, local community clinic, nursing home, or hospital to connect with the allergist. However, the rural patient has a greater risk of a “digital divide.”7Rural Telehealth and Healthcare System Readiness Measurement Framework – final report.https://www.qualityforum.org/Publications/2021/11/Rural_Telehealth_and_Healthcare_System_Readiness_Measurement_Framework_-_Final_Report.aspxDate: November 2021Date accessed: May 1, 2022Google Scholar Rural patients are less likely to have high-speed internet compared with urban-located patients (60% vs 95%), have fewer devices that access the internet, and spend less time “connected” to the internet.19Anderson J. Singh J. A case study of using telehealth in a rural healthcare facility to expand services and protect the health and safety of patients.Healthcare. 2021; 9: 736Crossref Scopus (5) Google Scholar Although reliance on telephone calls can support this population, the lack of the visual assessment and “connectivity” with the patient, particularly if they are a new patient, can result in an incomplete assessment. A prospective study evaluated 518 encounters performed by 4 urban allergists over 45 days at the height of the COVID-19 pandemic.20Mustafa S.S. Vadamalai K. Ramsay A. Patient satisfaction with in-person, video, and telephone allergy/immunology evaluations during the COVID-19 pandemic.J Allergy Clin Immunol Pract. 2021; 9: 1858-1863Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar They observed that 42% of telemedicine encounters were deemed incomplete. Furthermore, no new patient visit was conducted telephonically—a modality that rural or remote patients may rely on more than a suburban- or urban-located patient.21Lam K. Lu A.D. Shi Y. Covinsky K.E. Assessing telemedicine unreadiness among older adults in the United States during the COVID-19 pandemic.JAMA Intern Med. 2000; 180: 1389-1391Crossref Scopus (231) Google Scholar Community hospitals are an important source of care in rural areas, particularly for medical specialists. However, since 2010, a total of 136 rural hospitals have closed, further reducing access for rural areas.22Pink G. Thompson K. Howard H.A. Holmes M. How many hospitals might convert to a rural emergency hospital.https://www.shepscenter.unc.edu/programs-projects/rural-health/publications/Date: July 2021Date accessed: January 22, 2022Google Scholar In 2017, more than 17 million people lived in rural counties without rural health clinics and 15 million people lived in rural counties without federally qualified health clinics.22Pink G. Thompson K. Howard H.A. Holmes M. How many hospitals might convert to a rural emergency hospital.https://www.shepscenter.unc.edu/programs-projects/rural-health/publications/Date: July 2021Date accessed: January 22, 2022Google Scholar When rural hospitals close, patients must travel further to access services, thus increasing known barriers for this population. Until improved, these factors adversely affect rural-based patients and increase the importance for telehealth growth and utilization. If available, a local clinic, hospital, or school often has the advantage of increased technology and internet access with video connectivity. When connecting with a location such as a school or a rural clinic as the originating site, the importance of stakeholder engagement cannot be understated. Aspects of cost, information technology, cybersecurity, and leadership engagement are paramount for adoption and long-term success.1Taylor L. Waller M. Portnoy J.M. Telemedicine and allergy services to rural communities.J Allergy Clin Immunol. 2019; 7: 2554-2559Abstract Full Text Full Text PDF Scopus (20) Google Scholar, 2Valet R.S. Perry T.T. Hartert T.V. Rural health disparities in asthma care and outcomes.J Allergy Clin Immunol. 2009; 123: 1220-1225Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 3Apter A.J. Casillas A.M. Eliminating health disparities: what have we done and what do we do next?.J Allergy Clin Immunol. 2009; 123: 1237-1239Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar The School-Based Allergy, Asthma and Anaphylaxis Management Program (SA3Apter A.J. Casillas A.M. Eliminating health disparities: what have we done and what do we do next?.J Allergy Clin Immunol. 2009; 123: 1237-1239Abstract Full Text Full Text PDF PubMed Scopus (8) Google ScholarMPRO) is a school-based engagement program developed by the American Academy of Allergy, Asthma & Immunology in collaboration with the National Association of School Nurses and can improve access to allergists and reduce asthma and allergy-related adverse outcomes such as absenteeism.23Lemanske F.R. Kakumanu S. Sanovich K. Antos N. Cloutier M.M. Mazyck D. et al.Creation and implementation of SAMPRO: a school-based asthma management program.J Allergy Clin Immunol. 2016; 138: 711-723Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar This type of program could benefit rural populations using telemedicine to connect members of the care team with parents, students, and school nurses. In 2019, it was estimated that 1800 public schools, which represented almost 1 million students, had a school-based telemedicine (SBTM) platform. However, this represents only 2% of the students and public schools in the United States.24Williams S. Xie L. Hill K. Mathew M.S. Perry T. Wesley D. et al.Potential utility of school-based telehealth in the era of COVID-19.J Sch Health. 2021; 91: 550-554Crossref PubMed Scopus (4) Google Scholar Although several models for parental involvement in SBTM have been proposed, only a few studies have reported allergy/immunology outcomes. In 1 study, parents had the option to join the SBTM visit by coming to their child’s school or could join remotely.25Perry T.T. Turner J.H. School-based telemedicine for asthma management.J Allergy Clin Immunol Pract. 2019; 7: 2524-2532Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Limited time due to work or transportation factors adversely affected parent participation. In another SBTM model, the parent and the child’s primary care provider would receive a summary by the provider after the SBTM visit was completed.26McSwain S.D. Bernard J. Burke Jr., B.L. Cole S.L. Dharmar M. Hall-Barrow J. et al.American Telemedicine Association operating procedures for pediatric telehealth.Telemed J Health. 2017; 23: 699-706Crossref PubMed Scopus (40) Google Scholar However, the financial resources to support SBTM have typically originated from grants or financial support from the hospital-based allergist. Long-term funding to support the allergist’s time to build and sustain those relationships is typically not included in the funding.25Perry T.T. Turner J.H. School-based telemedicine for asthma management.J Allergy Clin Immunol Pract. 2019; 7: 2524-2532Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar In a cross-sectional survey of more than 1000 schools in Illinois, rural schools were less likely to have undesignated epinephrine devices and written procedures for food-induced anaphylaxis than their urban counterparts.27Szychlinski C. Schmeissing K.A. Fuleihan Z. Quarnar N. Syed M. Pongracic J.A. et al.Food allergy emergency preparedness in Illinois schools: rural disparity in guidelines implementation.J Allergy Clinic Immunol Pract. 2015; 3: 805-807Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Although multiple studies have been conducted to assess asthma intervention programs within schools, only a few have been conducted in rural settings.28Perry T.T. Halterman J.S. Brown R.H. Luo C. Randle S.M. Hunter C.R. et al.Results from an asthma education program delivered via telemedicine in rural schools.Ann Allergy Asthma Immunol. 2018; 120: 401-408Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar,29Romano M.J. Hernandez J. Gaylor A. Howard S. Knox R. Improvement in asthma symptoms and quality of life in pediatric patients through specialty care delivered via telemedicine.Telemed J E Health. 2001; 7: 281-286Crossref PubMed Scopus (56) Google Scholar Perry et al28Perry T.T. Halterman J.S. Brown R.H. Luo C. Randle S.M. Hunter C.R. et al.Results from an asthma education program delivered via telemedicine in rural schools.Ann Allergy Asthma Immunol. 2018; 120: 401-408Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar conducted synchronous telehealth visits with 393 children aged 7 to 14 years (81% Black) who attended schools in a rural and socioeconomic disadvantaged region of Arkansas. Similar sessions were also provided to the school nurse and participants’ caregivers over a 2- to 3-month time frame. Although 88% of children and 61% of caregivers completed all telehealth sessions, there was no change in symptom-free days compared with usual care and 27% of caregivers did not attend any sessions. Romano et al29Romano M.J. Hernandez J. Gaylor A. Howard S. Knox R. Improvement in asthma symptoms and quality of life in pediatric patients through specialty care delivered via telemedicine.Telemed J E Health. 2001; 7: 281-286Crossref PubMed Scopus (56) Google Scholar evaluated 17 children aged 5 to 18 years (71% Hispanic) in rural Texas who received asthma telemedicine follow-up visits over 24 weeks and observed improvement in symptom-free days and quality of life compared with baseline although there was no comparative group in this small, prospective study.29Romano M.J. Hernandez J. Gaylor A. Howard S. Knox R. Improvement in asthma symptoms and quality of life in pediatric patients through specialty care delivered via telemedicine.Telemed J E Health. 2001; 7: 281-286Crossref PubMed Scopus (56) Google Scholar In an accompanying editorial regarding school-based telemedicine for schools, a critical factor was discussed—the school health care provider.30Bruzzese J. Kattan M. School-based interventions: where do we go from here?.J Allergy Clin Immunol. 2018; 143: 550-551Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar One barrier rural school staff face compared with their urban peers is fewer opportunities to engage in asthma education programs.31Johnson E.E. MacGeorge C. King K.L. Andrews A.L. Teufel R.J. Kruis R. et al.Facilitators and barriers to implementation of school-based telehealth asthma care: program champion perspectives.Acad Pediatr. 2021; 21: 1262-1272Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar In addition, common barriers identified by school nurses for SBTM included inadequate nursing time and challenges engaging caregivers.32Carpenter D.M. Estrada R.D. Roberts C.A. Elio A. Prendergast M. Durbin K. et al.Urban-rural differences in school nurses’ asthma training needs and access to asthma resources.J Pediatr Nurs. 2017; 36: 157-162Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar One study reported responses from 36 underresourced South Carolina schools. Both inadequate time to complete tasks and lack of caregiver involvement in care planning were identified in most locations.33MacGeorge C.A. King K. Andrews A. Sterba K. Johnson E. Brinton D.L. et al.School nurse perception of asthma care in school-based telehealth.J Asthma. 2021; 13: 1-8Google Scholar In a study evaluating 2 public school systems in Colorado and Connecticut, the average time the school nurse time committed for the study was 2 hours each week.34Szefler S.J. Cloutier M.M. Villarreal M. Hollenbach J.P. Gleason M. Haas-Howard C. et al.Building bridges for asthma care: reducing school absence for inner-city children with health disparities.J Allergy Clin Immunol. 2019; 143: 746-754Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar In another study, a bilingual asthma nurse educator was embedded in the school full-time for the initial year.35Gerald J.K. Fisher J.M. Brown M.A. Clemens C.J. Moore M.A. Carvajal S.C. et al.School-supervised use of a once-daily inhaled corticosteroid regimen: a cluster randomized trial.J Allergy Clin Immunol. 2019; 143: 755-764Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Both these studies were conducted in urban locations. Recommendations to create a shared vision, build engagements with stakeholders and families, and grow strong program-school partnerships exist, but these take time and significant effort, which are not reimbursed financially.31Johnson E.E. MacGeorge C. King K.L. Andrews A.L. Teufel R.J. Kruis R. et al.Facilitators and barriers to implementation of school-based telehealth asthma care: program champion perspectives.Acad Pediatr. 2021; 21: 1262-1272Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Despite the known limitations and barriers to SBTM, the school remains a valuable originating site because approximately 10% of school-age children have asthma, with rural children often having worse outcomes compared with their urban peers. The distant site is defined by the Centers for Medicare & Medicaid Services as the telehealth site where the provider (ie, allergist) is located. Other telehealth synonyms for the distant site include hub site, specialty site, provider site, consulting site, or referral site. Similar to the various options a patient has in the originating site, the allergist may also conduct the telehealth visit at any location (eg, home, clinic, and hospital). One key aspect for the allergist is to block off time for synchronous telehealth visits because these visits usually have a specific start and stop time. Although there is often less “chit chat” in a telehealth visit compared with an in-person visit, provider recognition of all aspects of a synchronous visit is key.36Persaud Y.K. Portnoy H.M. Ten rules for implementation of a telemedicine program to care for patients with asthma.J Allergy Clin Immunol Pract. 2021; 9: 13-21Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar With multiple telehealth modalit
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