Using Virtual Care Tech to Curb Care Barriers in Rural South Carolina

November 29, 2023 - Rural Americans are often caught in a healthcare bind. This population is more likely to suffer from various healthcare issues, including chronic conditions, unintentional injury, and the opioid crisis, but are less able to access the healthcare services they need. In recent years, virtual care has become a critical tool in extending much-needed healthcare access in rural areas, but there are numerous barriers to implementing these programs.

Like most other healthcare organizations, Clemson Rural Health turned to virtual care amid the COVID-19 pandemic. Part of Clemson University’s College of Behavioral, Social and Health Sciences, Clemson Rural Health comprises brick-and-mortar locations in South Carolina and a fleet of mobile health units.

The mobile units have operated since the 1990s, extending services to migrant seasonal farm workers at local farms and offering preventive cancer screenings for the uninsured or underinsured. The units were sent from a hub clinic on the university campus in Clemson. Eventually, at the behest of Oconee County, the organization launched a full-time primary care hub clinic at a South Carolina Department of Health and Environmental Control (DHEC) building in Walhalla in 2018. The third hub facility opened in Orangeburg, South Carolina, in 2022.

“When I say hub, think of a [hub-and-]spoke model where the mobile clinics go out to four or five counties surrounding the hub and can deliver the same services that we do onsite,” explained Caitlin Moore, associate director of clinical operations at Clemson Rural Health, in an interview with mHealthIntelligence.

The hub clinics have a tri-fold mission: clinical service delivery, educating future health professionals, and research with Clemson University. They provide numerous clinical care services, including comprehensive primary care, chronic disease management, opioid use disorder treatment, and hepatitis C and HIV screening and treatment.

“We're still a relatively small organization, so less than 70 employees statewide, but we have over 220 collaborators in the state, and that's the only way that we could reach all of the patients that we do,” Moore said. “So, if somebody's already doing something really good in a community and reaching those hard-to-reach populations, we partner with them to provide whatever services that population is not getting.”

One such partnership is with Palmetto Cares Connections, a non-profit organization that provides technology, broadband, and telehealth solutions across rural and underserved areas in South Carolina. Under a collaborative agreement that began during the pandemic, the organizations are working to install telehealth equipment in community-based settings.

Clemson Rural Health leverages several different technology platforms depending on the project and the patient, such as Doximity and Carium. For instance, it uses Carium to support its remote patient monitoring (RPM) program and nutrition services.

The RPM program focuses on enhancing care for diabetes, hypertension, and chronic kidney disease and reducing infant mortality.

“We also are doing some work out of our Orangeburg clinic focusing on preventing diabetes,” Moore said. “So, we do have some patients who aren't diabetic yet but have the risk factors [and our clinic is] using the remote patient monitoring technology to support the education that we're giving them to hopefully prevent that transition to chronic disease.”

The Clemson Rural Health care team includes clinical staff, like physicians and nurse practitioners, as well as social workers and dieticians. It has funding to provide its RPM patients with cellular-enabled tablets and devices like blood pressure and glucose monitors that integrate with the tablets via Bluetooth.

“We found when we started this that if we were trying to help patients who did have cell phones install the app on their own cell phone, they didn't remember their email passwords or they couldn't get in, they were locked out,” Moore said. “We were having to do a lot of troubleshooting, and it was taking us an incredible amount of time, which the patients didn't really love.”

Giving patients the tablet fully set up allowed the care team to focus on clinical services and patient care, she added.

One of the main goals of expanding telehealth and RPM to rural areas in South Carolina is to address the severe provider shortage. In the state, 41 out of 46 counties are designated Health Professional Shortage Areas (HPSAs), according to the Rural Health Information Hub.

“There may be only one physician practice in a whole county to take care of patients,” Moore said. “I know that one of the hospitals we work with in a small town only has a part-time dietician. So, there are just not enough care providers in the areas that we go to.”

While the mobile units help care teams reach patients in these underserved areas, they cannot enable routine connections between patients and providers. Virtual care technology helps Clemson clinicians track patient health metrics between in-person mobile unit or hub clinic visits.

According to Moore, implementing virtual care technology has led to improvements in diabetes and hypertension, as well as infant mortality, with the technology helping prevent pre-term births.

“That's been a really big win to work with these moms across the state,” she said. “When you think about those moms, if they've got one or two kids, it's hard to get to that high-risk OB appointment. So being able to follow them through technology and with those devices helps save them time and effort, but also helps them have healthier babies.”

However, Clemson Rural Healthcare had to overcome several hurdles when implementing virtual care technology.

One of the biggest hurdles was the burden initially placed on provider teams as they were tasked with educating patients on the technology and setting them up. To address this issue, the organization hired a care coordinator who takes on patient-facing tasks related to technology use.

The care coordinator spends about an hour at the enrollment appointment showing patients how the technology works. They also troubleshoot technical problems with enrolled patients.

A potential future hurdle is the lack of reimbursement for virtual care efforts. Moore noted that most health plans in South Carolina don’t reimburse well for RPM, and there is little clarity around which disease states they will pay for.

“We've got funding, we're thankful for that, so we don't have to worry about it right now,” she said. “But as part of our sustainability plan, we're looking at that over the next two years to see what we can get insurance to pay for.”

While the reimbursement issue remains uncertain, Clemson Rural Health does not plan to scale back its virtual care efforts.

On the contrary, the organization is currently working with Palmetto Cares Connections to pilot telehealth carts in the community. They are deploying these carts in common community areas like churches and senior centers in the Orangeburg area. The carts have built-in internet access and devices like stethoscopes, otoscopes, and ophthalmoscopes. Patients can connect with a remote clinician supported by a tele-presenter who helps gather vital signs.

Overall, Moore recommends using virtual care in rural settings, encouraging healthcare provider peers to adapt care services to the digital landscape.  

“I think my biggest advice would be to not be scared of it and just do it,” Moore said. “And if you're excited about it, then a lot of times, you can get your patients excited about it, and they will engage. I think a lot of people just believe that because somebody's in a rural area, this would not be a good solution for them, and that's not what we're seeing. Our patients may live somewhere that is very far out, but they still are using this technology, they're excited about it, they're giving us good reports, and they're having good outcomes.”