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Case Study 2: Florida Initiative in Telehealth and Education for Children with Diabetes

Toree Malasanos, M.D.

This program was administered by the Florida Department of Health, Children’s Medical Services Network (CMSN), to integrate telemedicine clinical care, web-based education for children with diabetes, and virtual home-based behavioral modification. The program has served about 99 children and their families (44 with diabetes and 55 with other endocrine disorders) in Volusia and Flagler Counties since 2001.

Targeted telemedicine patients were characterized by low socioeconomic status, inadequate health insurance, poor access to care, poor understanding of the diabetes disease process, transient lifestyles, residence in an area without access to a pediatric endocrinology specialist, and overall low health literacy. The program addressed several problems encountered in the pediatric endocrine and diabetes clinic

  • poor access to care for children with chronic health care needs in remote locations
  • poor payment and minimal time for diabetes education
  • high use of urgent care for recurrent problems rather than home management
  • poor diabetes management and a high hospitalization rate

Services: Telemedicine clinical care

Patients were seen initially and then annually in person by the pediatric endocrinologist located in Gainesville, at the University of Florida. A teleconference clinic was held bi-weekly for an average of 12 families per session. Nurses in the remote clinic downloaded meter data, obtained a focused history, made basic physical observations, and transmitted the information to the endocrinologist in Gainesville. The pediatric endocrinologist then participated in patient interviews and examinations via real-time teleconferencing. Families were educated during the telemedicine visits and by the website about sick-day management and reasons to call the health care team. Families were supported in diabetes self-care by 24-hour telephone access to the endocrine team in Gainesville. Initial patient education was provided by a combination of “hands-on” education in Gainesville and the web education program. New guardians, families, teachers, and school nurses were invited to participate in the web education program, called Brainfood.

Services: Home-based behavior change

This statewide home-based virtual program replaced a model residential hospital unit with more than 20 years experience treating adolescents who had poor adherence, frequent hospitalizations, and impaired family dynamics. Families involved in the home-based program received three to five provider-initiated calls per week to encourage good diabetes self-management by addressing their individual barriers to care. Keys to the success of this program were a carefully designed curriculum based on the former residential program and provision of provider-initiated rather than family-initiated calls.

Web-based diabetes education (Brainfood)

This was an animated, multiple-literacy presentation of diabetes information (including material for non-readers), with pre- and post-testing. Children with newly diagnosed diabetes were given abbreviated in-person education at the University of Florida, which was then supplemented with Brainfood. Currently, this program is available at www.myHealth-e.com. It has been shown to increase knowledge about diabetes and its management.

Team members

Children with diabetes and their families worked as a team with the CMSN registered nurses, the pediatric endocrinologist, University of Florida registered nurses, a social worker and a nutritionist based at the remote clinic, and school nurses. A psychologist was part of the team for the home-based care.

Payment for services

The program was funded by a contract with the Florida Department of Health, CMSN. Medicaid granted a waiver for limited coverage of telemedicine services for children with special health care needs in under-served regions of Florida. A contract between the University of Florida and the CMSN provided funds for data management and research, unreimbursed medical costs including physician time, phone management for blood glucose control between visits, and the home-based behavior-change program. This program was limited to CMSN and Medicaid clients; however, in states in which reimbursement for telemedicine services is allowed, private insurers typically follow the same pattern. (Medicaid reimbursement by state is described at www.ichp.ufl.edu/documents/Telemedicine in Medicaid and Title V Report.pdf.)

Outcomes

Hospitalizations and urgent care utilization: For the three years before inception of the program, there were on average 13 hospitalizations per year (47 days) for the total group, which subsequently decreased by 88 percent to 3.5 hospitalizations per year (5.5 days) over the two years this was formally evaluated. Emergency department visits for the total group decreased from 8 per year to 2.5 per year. On numerous occasions, ketosis was managed by telephone intervention alone, relying on family-initiated calls.

Clinical measures: The mean interval between appointments was reduced from 149 days before the program began to 89–91 days over the two years this was formally evaluated. Of the children who had an A1C > 8 percent when they entered the program, the A1C dropped from a mean of 9.63 percent to 8.94 percent, p =.02. Of the children who had an A1C less than 8 percent at their entry into the program, 100 percent stayed below 8 percent. After two years, the average A1C for all the children was 8.79 percent. Nineteen of 23 children received the recommended annual dilated eye examination.

Costs: Even when line charges and equipment of $18,826 were included, this program saved $27,860 per year, by reducing hospital days ($44,419/year) and emergency department visits ($2,267/year). This does not include transportation costs and work/school time saved. An additional savings of $64,978 could be considered if Medicaid transportation costs were included in the absence of the telemedicine clinic.

Satisfaction with the telemedicine clinic: A survey of the 99 program patients (diabetes, 44; other endocrine disorders, 55) and their parents found high levels of satisfaction with the program.

Related references

Bell JA, Patel B, Malasanos T. Knowledge improvement with web-based diabetes education program: Brainfood.
Diabetes Technol Ther. 2006; 8(4):4444–8.

Adkins JW, Storch EA, Lewin AB, et al. Home-based behavioral health intervention: Use of a telehealth model to address poor adherence to type-1 diabetes medical regimens. Telemed J E Health. 2006; 12(3):370–1.

Malasanos TH, Patel BD, Klein J, et al. School nurse, family, and provider connectivity in the FITE diabetes project.
Telemed Telecare. 2005;11 Suppl 1:76–8.

Malasanos TH, Burlingame JB, Youngblade L, et al. Improved access to subspecialist diabetes care by telemedicine: cost savings and care measures in the first two years of the FITE diabetes project. J Telemed Telecare. 2005;11 Suppl 1:74–6.

February 2013

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