Telehealth turned Jill Hill's life around.
The 63-year-old lives on the edge of rural Grass Valley, an old mining town in the Sierra Nevada foothills of northern California. She was devastated after her husband Dennis passed away in the fall of 2014 after a long series of medical and financial setbacks.
"I was grief-stricken and my self-esteem was down," Hill remembers. "I didn't care about myself. I didn't brush my hair. I was isolated. I just kind of locked myself in the bedroom."
Hill says knew she needed therapy to deal with her deepening depression. But the main health center in her rural town had just two therapists. Hill was told she'd only be able to see a therapist once a month.
Then, Brandy Hartsgrove called to say Hill was eligible via MediCal (California's version of Medicaid) for a program that could offer her 30-minute video counseling sessions twice a week. The sessions would be via a computer screen with a therapist who was hundreds of miles south, in San Diego.
Hartsgrove co-ordinates telehealth for the Chapa-de Indian Health Clinic, which is a 10-minute drive from Hills's home. Hill would sit in a comfy chair facing a screen in a small private room, Hartsgrove explained, to see and talk with her counselor in an otherwise traditional therapy session.
Hill thought it sounded "a bit impersonal;" but was desperate for the counseling. She agreed to give it a try.
Hill is one of a growing number of Americans turning to telehealth appointments with medical providers in the wake of widespread hospital closings in remote communities, and a shortage of local primary care doctors, specialists and other providers.
Long-distance doctor-to-doctor consultations via video also fall under the "telehealth" or "telemedicine" rubric.
A recent NPR poll of rural Americans found that nearly a quarter have used some kind of telehealth service within the past few years; 14% say they received a diagnosis or treatment from a doctor or other health care professional using email, text messaging, live text chat, a mobile app, or a live video like FaceTime or Skype. And 15% say they have received a diagnosis or treatment from a doctor or other health professional over the phone.
Those survey findings are part of the second of two recent polls on rural life and health conducted by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.
The Chapa-de clinic offers telehealth services not only for consultations in behavioral health and psychiatry, but also in cardiology, nephrology, dermatology, endocrinology, gastroenterology and more.
Hill feels fortunate; she knows most rural health facilities don't include telehealth services, which means most patients living in remote areas would need their own broadband internet access at home to get therapy online.
And that's out of reach for many, says Robert J. Blendon, co-director of NPR's poll and professor of health policy and political analysis at the Harvard Chan School.
The poll found that one in five rural Americans say getting access to high-speed internet is a problem for their families.
Blendon says advances in online technology have brought a "revolution" in healthcare that has left many rural patients behind.
"They lose the ability to contact their physicians, fill prescriptions and get follow-up information without having to go see a health professional," he says.
Critical care pediatrician James Marcin at UC Davis Children's Hospital, directs the University of California, Davis, Center for Health and Technology and regularly consults via a telehealth monitor with primary care doctors in remote hospitals in rural areas.
"We're able to put the telemedicine cart [virtually] at the patient's bedside," Marcin says, "and within minutes our physicians are able to see the child and talk with the family members and help assist in the care that way."
If not for telehealth, Marcin says, the costs of getting what should be routine care "are significant barriers for those living in rural communities."
"We have patients that drive to our Sacramento offices and they have to drive the night before," he says, "and spend the night in a hotel because it's a five-hour trip each way." And there are additional costs for many patients, he says, such as childcare services, and missed days of work.
With telehealth, "a video is truly worth a thousand words," he says; it can mean patients don't have to make costly time-consuming trips to see a specialist.
Though Hill initially had reservations about meeting with a therapist online, she says she's been amazed by how helpful the sessions have been.
"She gives me assignments and works me really hard," Hill says, "and I have grown so much — especially just in the last few months."
Her latest assignment in therapy: writing down positive characteristics of herself. Initially, she could only come up with three: loyalty, compassion and resilience. But the therapist questioned that, and encouraged Hill to consider that there might be more.
"She wanted 10," says Hill, who proceeded to work through some other issues and talk more with therapist. "Now I've got like 15 at least," Hill says, "and I keep adding to the list; once I started writing things down, I started really seeing that I have a lot of strengths I didn't even know I had."
Attorney Mei Kwong, executive director of the Center for Connected Health Policy in Sacramento, says telehealth services have the potential to remove many barriers to good health care in rural America.
But policies that regulate which telehealth services get paid for "lag way behind the technology," Kwong says. Many policies are 10 to 15 years behind what the technology is able to do, she says.
For example, high-resolution photos can now be taken – and sent anywhere digitally — of skin conditions that many doctors say are better than "the naked eye looking at the condition," she says. But the policies on the books of what Medicare, Medicaid and private insurers will pay for often means these services are not fully covered.
That's unfortunate, Kwong says, especially for underserved communities where there is a shortage of specialists.
Changes are starting to be made in state, federal and private insurance policies, Kwong says. But it's "slow going."
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For people living in rural communities, accessing health care can be a challenge. Hospitals have closed. Doctors are in short supply. Advances in technology may help solve some of these problems. Polling by NPR finds that many rural Americans are using and liking technologies that can provide diagnosis and treatment, even when the health-care provider is not in the room with the patient. NPR's Patti Neighmond reports on the findings of the poll conducted by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.
PATTI NEIGHMOND, BYLINE: Beautiful but isolated is how Jill Hill describes where she lives. Grass Valley's an old mining town in the Sierra Nevada foothills of Northern California. Jill gives me a tour of her garden, framed by a fence handmade from pieces of old wooden slats and gnarly tree branches.
JILL HILL: We've got kale, lettuce, parsley. We'll have tomatoes going. And we grow pumpkins and cantaloupe.
NEIGHMOND: Hill's grown to love it here. But at 63, she never thought her life would be like this.
HILL: We were living in Arizona. My husband was in construction.
NEIGHMOND: A project manager for a multi-million-dollar homebuilding company.
HILL: We had health insurance. We had life insurance. We had the American dream.
NEIGHMOND: Then the housing crisis hit in 2008. Her husband lost his job and his health insurance. He got sick and ended up on dialysis. They decided to move back to California and rebuild their lives, but her husband passed away a few years later.
HILL: I was grief-stricken. And my self-esteem was down. I didn't care about myself. I didn't brush my hair. I isolated. I just kind of locked myself in the bedroom.
NEIGHMOND: She knew she needed therapy, but the nearby community health center in this rural area had only two therapists. She could see one once a month. She knew she needed more.
HILL: So then Brandy called me and said, hey. We've got this telehealth program, where they bring the therapist in on a computer screen, like Skype. And do you want to try it?
NEIGHMOND: Brandy Hartsgrove coordinates telehealth for the Chapa-de Indian Health Clinic. Telehealth sounded a bit impersonal to Hill, but she says she was desperate and willing to try it.
HILL: This is my chair.
NEIGHMOND: For almost a year now, Hill's been sitting in this chair in front of a large computer screen. Twice a week for 30 minutes, she speaks with a clinical psychologist hundreds of miles away in San Diego. Her latest assignment in therapy; write down her positive characteristics.
HILL: And I had three.
NEIGHMOND: What were they?
HILL: Oh, loyalty, compassion and resilience. She said, only three? She wanted 10. And I said, well, I'm just getting started. Well, then she and I started talking. And now I've got, like, probably 15 at least. And I'm - keep adding to the list. But once I started, like, writing things down, I started really seeing I have a lot of strengths.
NEIGHMOND: Hill says she's lucky. The Chapa-de clinic offers telehealth. Many clinics don't, which means people have to rely on their own resources. And in many rural areas, that's nearly impossible, according to Harvard professor Robert Blendon, who co-directed our poll about life and health among rural Americans.
ROBERT BLENDON: The majority - essentially, 8 in 10 people living in rural America - have access to high-speed Internet. But 1 in 5 really have a problem having access to it. And that means they don't have the ability to get critical information in today's world.
NEIGHMOND: This includes information such as diagnosing a problem, providing treatment or getting medical advice.
BLENDON: They lose the ability to contact their physicians, to fill prescriptions and to get follow-up information without having to go see a health professional.
NEIGHMOND: In our poll, a vast majority of those who were able to use telehealth reported being satisfied with the diagnosis or treatment they received. An important note here - telehealth comes in many forms. It can be a patient speaking directly with a health care provider via text, email or on-screen like Jill Hill. It can also be doctor-to-doctor like it is for critical-care pediatrician James Morrison with the UC Davis Children's Hospital, where patients often face long, costly trips just to get needed specialty care.
JAMES MARCIN: We have patients that drive to our Sacramento offices that have to drive the night before, spend the night in a hotel because it's a five-hour trip each way. And if you're talking about taking time off of work or school, the costs of getting what should be otherwise routine care are significant barriers for those living in rural communities.
NEIGHMOND: Telehealth can remove those barriers, says Marcin, by bringing UC Davis specialists to the patient's bedside hundreds of miles away.
MARCIN: In the emergency department, they're able to put the telemedicine cart at the patient's bedside. And within minutes, our physicians are able to see the child and talk with the family members and help assist in the care that way.
NEIGHMOND: It's not just emergency care. It can also be cardiology, gastroenterology, dermatology - any number of specialty services. Attorney Mei Kwong with the Center for Connected Health Policy agrees telehealth holds great potential to reduce disparities. But she says payment policies for telehealth services lag way behind the technology.
MEI KWONG: A lot of the policies that are out there are probably about 15 to 10 years behind, unlike what the technology can do now. So stuff that they have on the books regarding telehealth maybe made sense about 10 or 15 years ago because the technology wasn't at a place where it is today and what it can do and what it can safely do.
NEIGHMOND: For example, services like high-resolution photos, retinal screenings for diabetic patients or consultations between a specialist and primary care doctor may not be paid for by Medicaid, Medicare or private insurance. Today change is happening, says Kwong, but it's slow-going.
Patti Neighmond, NPR News.
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