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Telehealth and Closing the Referral Loop

10/14/2016 9:31am

The Pennsylvania Community-Clinical Integration Initiative (PA CCI) aims to increase statewide access to diabetes education and prevention programming.  This project includes addressing barriers such as clinician referrals and patient awareness, providing technical assistance to increase the number of certified sites, increasing capacity of certified sites, and providing resources for sustaining programs.  While state-funded initiatives like PA CCI sustain and strengthen the current infrastructure of these programs, issues such as healthcare worker shortages in areas of need serve as a fundamental barrier to access, particularly in remote areas.  One key component of PA CCI’s strategic plan is to increase community-clinical partnerships in an effort to close the referral loop for diabetes care to ensure the sustainability of programs as well as high quality patient care in all regions of the state. While lifestyle intervention programs dedicated to diabetes management have been instrumental in preventing and controlling the disease, several barriers continue to prevent vulnerable populations from accessing these essential services (Condon and Eichorst).  In Pennsylvania, the availability of diabetes self-management education (DSME) and diabetes prevention programming (DPP) in rural regions of the state continues to be an issue primarily due to the shortage of healthcare providers in these remote areas. 

Telehealth, or the employment of technology via audio and video communication to deliver healthcare services, provides a viable option to ameliorate this issue (Pearson, 2013).  Research conducted by national organizations, such as the American Telehealth Association has been useful in the development of an optimized infrastructure for the utilization of telehealth services.  For example, telehealth has a high utility in diabetes management and prevention, and the National Standards for Diabetes Self-Management strongly supports the utilization and integration of telehealth for DSME and DPP delivery (Pearson, 2013). 

A University of Arkansas quality improvement study in 2009 described the delivery process and results of a pilot telehealth-based DSME program in which 25 participants completed 6 biweekly group video sessions.  Although the program was not certified, the format of the program incorporated American Diabetes Association recommended curriculum, and found that self-care practices were enhanced by the telehealth-based DSME program when comparing the patient’s previous health condition.  As a result, the study produced significant clinical outcomes supporting telehealth as an effective strategy for DSME delivery in remote areas (Balamuruga, A et al, 2009).

Additional telehealth-based studies support the University of Arkansas’ findings.  For example, the 2011 “Addressing Diabetes in Tennessee” project found a significant improvement of HbA1c levels after 3 months of telehealth-based care, and an improvement in patient satisfaction, blood pressure, HDL, and triglycerides following 12 months of telehealth-based care.  The Prevent pilot, an online diabetes prevention program also found significant patient improvement, and satisfied the CDC’s standard of 5% weight loss at 16 weeks, and decreased HbA1c levels for individuals with prediabetes (Nyewwe, et. al, 2011).

“Live video specialty consultations”, similar to telehealth, are also eligible for reimbursement by Medicaid and Medicare in Pennsylvania (The Center for Connected Health Policy, 2016), and in June 2016, State Representative Marguerite Quinn released a memo promising the introduction of legislation to provide clarity on telehealth in Pennsylvania in addition to expanding coverage for telehealth services (Quinn, 2016).  Although many policies permit the utilization of telehealth, there are still barriers that prevent full coverage for vulnerable, isolated populations.  For example, Registered Nurses (RNs) and pharmacists are key community level DSME educators, but are not eligible to provide telehealth services (AADE Practice Advisory, 2011).  In addition, only larger health systems have the capacity to sustain telehealth delivery, but often fail to utilize community-clinical partnerships.  This results in a lack of resource allocation and an inability to maximize the capacity of the program’s reach. 

Telehealth systems have been utilized since the 1990s; however, its full integration into healthcare systems has not been realized, and there seems to be an overall lack of a structural framework to support its vast use in practice.  Factors such as a lack of funding for telecommunications equipment is often a barrier for pursuing telehealth, as well as a lack of dialogue between key community and clinical stakeholders.  An absence of a shared organizational mission also serves as a barrier of telehealth integration.

In conclusion, telehealth serves as a viable delivery method for chronic disease, especially diabetes self-management.  Several drawbacks must still be addressed, such as insurance reimbursement restrictions, system improvement and support for implementation. With strategic targeting, telehealth can provide quality health services and DSME or DPP education to vulnerable, isolated populations.




AADE Practice Advisory: Telehealth and the Impact on Diabetes Self-Management and Training (DSMT). The American Association of Diabetes Educators. 2011. Retrieved July 2016 from

Balamuruga A, Hall-Barrow J, Bevins MA, Brech D, Phillips M, Holley E, and Bittle K. A Pilot Study of Diabetes Education via Telemedicine in a Rural Underserved Community – Opportunities and Challenges. The Diabetes Educator, 2009;35:1 p147-154.

Condon JE and Eichorst B. Medicare Billing for DSMT and MNT Services. Webinar, American Diabetes Association. N.d. Retrieved July 2016 from

Nyenwe EA, Ashby S, Tidwell J, Nouer SS, and Kitabchi AE. Improving Diabetes Care via Telemedicine: Lessons From The Addressing Diabetes in Tennessee (ADT) Project. Diabetes Care, 2011;34.

Pearson, TL. Telehealth: Aiding Navigation Through the Perfect Storm of Diabetes Care in the Era of Health Care Reform. Diabetes Spectrum, 2013;24:4 p221-225.

Quinn, M. Legislation Establishing a Telemedicine Law for Pennsylvania. Pennsylvania House of Representatives. Harrisburg, PA. June 2016. Retrieved on August 2016 from