Cherokee Health Systems (CHS) provides a broad range of primary care and behavioral health services to nearly 60,000 Tennesseans each year.  Since its origin as a small mental health office in Morristown in 1960, CHS has grown to include 22 service locations across East Tennessee and a vast outreach and consulting services program.  Although known nationally for its innovative care model, in most East Tennessee communities, Cherokee is known best as the safety-net provider that cares for anyone, regardless of ability to pay.  Because East Tennessee is a medically underserved region, CHS began offering primary care and behavioral health services via interactive video conferencing in the late 1990s to increase residents access to specialty care and behavioral health services. The CHS telehealth/telepsychiatry model was well received by both providers and patients, resulting in thousands of remote visits over the last ten years.

East Tennessee presents unique challenges to the delivery of quality healthcare: it is rural and mountainous and a high proportion of residents have low income and lack health insurance.  East Tennessees Sevier County is the tourist capital of the state with attractions such as Dollywood, the Great Smoky Mountains National Park and Ripleys Aquarium.  The tourist industry creates a transient workforce of predominantly uninsured, hourly employees.   The combination of all of these factors is evidenced in the Sevier County school system where 50% of the children in the county qualify for free or reduced cost lunches, and in some of the schools, the number exceeds 80%.

In response to a request from the Sevier County school system for help in delivering healthcare to its elementary school students, CHS suggested telehealth.   After a thorough due-diligence process, they placed a video conferencing system with specialized telemedicine accessories in each of the countys 17 elementary and middle schools.  With a high-speed data connection directly into the school system telecom vendors switching center, CHS offers immediate access for each school clinic to a nurse practitioner with a full range of back-up such as medical doctors and behavioral health specialists.  The ultimate goal of this seamless, on-demand access is to improve the health of the children.  However, it also keeps the students in school and their parents at work, instead of both spending hours at a doctors office or in an emergency room.  

The telehealth program changes and improves the lives of the school children of Sevier County and their parents.  The students have access to a higher level of care than what a school nurse can provide and treatment begins sooner than if they had to wait for a regular doctors appointment.  The children also do not miss valuable school time which allows the school system to maintain higher attendance scores.

Parents, many of whom are hourly employees, do not have to miss hours or days of work and lose the associated income because they are taking sick children to the physicians office.  Job loss is also a serious concern for these parents when they are required to miss work for doctors appointments.

The program also allows CHS to provide healthcare access to a large patient population in a cost and time-effective manner.  There are nearly 10,000 children in the 17 Sevier County elementary and middle schools.  No other healthcare delivery method would allow the health system to offer care to this broad a group on a daily basis.

Video conferencing technology and high-speed data connectivity is at the core of the Cherokee Health Systems Telehealth Program.  Several different care models were considered for delivering healthcare to the 17 Sevier County K-8 schools, but with enrollments ranging from a high of 888 to a low of only 192, no schools could provide the volume necessary to support a full-time provider.  Even in a non-profit healthcare organization, adequate revenue streams are essential to maintaining quality systems of care.  That is why the architects of the program decided to leverage its resources with video conferencing technology as a way to broaden access to care while keeping children in school and parents at work.  Video conferencing gives CHS the ability to cover 17 sites with only two to three nurse practitioners, a feat that would quite simply be physically impossible to achieve without the use of technology.

The CHS Telehealth Program network is based on Polycom's industry-leading video conferencing systems.  CHS deployed a Polycom unit at each of the 17 Sevier County elementary schools.  CHS chose medical peripheral devices from AMD Telemedicine, which include a camera and illumination unit, an ear nose and throat scope, and an IP stethoscope that integrate directly into the Polycom video conferencing units.  Images are presented on Vizio 26 LCD televisions.  High-Definition units were considered but current bandwidth limitations would not have allowed for the full utilization of HD capabilities. 

A single metro-ethernet circuit connects CHS to Education Networks of Americas (ENAs) network.  Since ENA provides data services to all Sevier County schools, expansion into its High Schools will require no additional circuits.  The great part about partnering with ENA is that any school on their network could potentially access the same level of care with minimal cost.  While end-point video-conferencing units and high-tech medical cameras are valuable for providing quality care, high quality data service is essential.  IP packets must get from point A to point B.  CHS core WAN infrastructure is based on Cisco routing and switching technology with end-to-end QOS.  

While the technology behind this telehealth program is state-of-the-art, providers are able to access it with the simplicity of a remote control.  The end result is that medical providers are able to conduct comprehensive, face-to-face medical exams in real time at any Sevier County K-8 school without leaving their office.   

Yes

Yes

The advantages provided by the Cherokee Health Systems Telehealth Program extend to students, parents, schools, the healthcare provider, the county and the state.

The Cherokee Health Services Telehealth Program provides children with rapid access to healthcare, bucking the trend throughout the United States of increasing wait times for scheduling and accessing care.  Many children do not have a regular pediatrician or primary care doctor and it can take weeks to get a new patient appointment.  The children in Sevier County have immediate access to any primary or behavioral healthcare they require.

Having medical care available for their children at school is keeping parents at work, a must for hourly employees to avoid losing wages.  Job security can also be low for those employed in the tourism industry and missed work can result in termination.  As with all of its offices, CHS charges for care on a sliding fee scale based on a patients ability to pay.  This allows parents to pay as little as $5 for their children to be seen through the Telehealth Program.

Sevier County schools have seen attendance rates increase significantly since implementing the Telehealth program.  Not only does this boost student achievement, but with school funding tied to attendance, it helps preserve money, a scarce resource in the current economic climate.

Through its Telehealth Program, CHS is able to fulfill its commitment to the community by offering high-quality healthcare to a broad new patient segment when and where its most needed.

The ongoing healthcare crisis in the United States has led to an alarming over use of emergency room services.  Some Sevier County parents end up using the emergency room for routine primary care issues due to a lack of money or health insurance, or because the wait to see a doctor for their child is days or weeks.  Offering primary care in the schools may also reduce the number of emergency room visits, resulting in a substantial cost savings for the county and state. 

The following are quotes from parents and faculty at Sevier County elementary schools.

Administration and faculty quotes:

Within the first four months of Telemed being implemented, the attendance has increased each 20 day period.  All school administrators believe it could be the biggest difference maker in academic improvement in years.  Student basic health needs are being addressed with positive results.
Don Best, Coordinator of School Health, Sevier County School System

Telemed is an example of education at its very best; meeting the needs of the total child.
Glenn Bogart, Principal Pi Beta Phi Elementary School, addressing a visiting delegation of Hindus from India
 
Parents have often expressed their appreciation of the program and medical help that their child received without leaving school with Telemed.
Nancye Williams, Principal, Pigeon Forge Primary School

Parents are so grateful for being able to use the telemed system because her doctor did not have any openings to see her child that day and her other option was to go to the ER.
Nancy Thurman, School Nurse, Pigeon Forge Primary

Parent Qutoes:
Amazed at the clarity of communication from the school health clinic to Cherokee Health Systems location.  So much like having a visit to my doctor.
Sevier County School System Parent

If I would have known it was this easy to be seen and treated, I would have signed up a long time ago.
Sevier County School System Parent ( NOTE:  Parents must authorize a childs participation in the telemedicine program)

This is better than waiting for days to actually get an appointment with the doctor. 
Sevier County School System Parent 

When CHS embarked on its mission of bringing primary and behavioral care directly into the elementary school setting, it had to chart its own course, there was no history of any other organization having done this before.  The project is exceptional in its ability to cover the healthcare needs of an entire elementary school system for a whole county, the effort is unprecedented.  

CHS is also considered exceptional for its integrated approach to care combining physical and mental well-being to treat the whole patient.  Thanks to the availability of video conferencing, CHS is able to extend the benefits of its holistic care model to its virtual patients, a population of nearly 10,000 children.   During a video consultation with a student, if the nurse practitioner needs assistance, the help of a medical doctor or a behavioral health specialist is literally down the hall.  And of course, CHS turns away no child due to ability to pay, whether theyre being seen in a clinic or virtually over a video monitor.
 

For CHS, technology was not an obstacle.  The organization was able to model the school Telehealth Program after the successful telemedicine operation it had been running for a decade.  The major issue the organization faced was funding.  At $17,000 per school for video conferencing systems and medical peripheral products, securing the financial resources would make or break the project.  Fortunately, in this situation, the school system saw the value of the program and invested the majority of up-front capital.  Several private and corporate sponsors, including insurance companies managing the care for the States Medicaid population were approached for potential support but no outside funds have yet to be given for the project.

Another obstacle, ongoing to this day, is dealing with insurance companies.  CHS bills like a traditional medical practice, either directly to the patient or to the patients state or private insurance, for all of its school telehealth visits.  Unfortunately, some insurance companies still classify telemedicine as experimental treatment and refuse to pay.

Coming up with the hundreds of thousands of needed to equip an entire school system for telemedicine visits is a daunting task.  CHS brought the health and technology experience but the school system was the primary champion in providing the funding.  This concept was so new to everyone involved it is amazing that the entire program was designed and implemented in a matter of months.  Strong support from the school health director and school superintendent drove the process.  With their help, buy-in from the leadership was secured and in the end it came down to the fact that the school system believed so strongly in the project that they made it happen.  Some funds will flow back to the school since CHS contracts with the school system for nursing support and use of the schools space and equipment.  CHS management and staff have a history of supporting innovative program models and partnering with like-minded service oriented organizations allows the clinical model to drive the process rather than trying to fit a specific financial model. 

In order to ease the billing issues and open up the virtual visits to as many children as possible, CHS is working closely with insurance companies to encourage support and acceptance of telemedicine services.  Under TennCare, the Tennessees Medicaid waiver program, managed care organizations (MCOs) are required to reimburse telemedicine services at the same levels as regular services.  With such a large percentage of low-income families in this rural county, TennCare is expected to be the major payer.  Commercial payers do not have the same requirements but seem supportive of the concept.  Unfortunately, some will require a lengthy appeals process to get permission to use what they consider to be experimental.

Achieved

The Cherokee Health Systems Telehealth Program is an example for other counties to follow.  Sevier County Schools and CHS have already been contacted by school systems around the country looking for guidance and advice.  The issue of affordable, accessible, high-quality healthcare for children is not limited to Sevier County, TN.  Solutions are needed in rural regions throughout the United States.

The benefits of the program are so immediate and clear that both the schools and parents have enthusiastically embraced it.  CHS initially offered the Telemedicine Program to the students who needed it most desperately  the indigent and uninsured.  But as it is expanding, reaction and adoption continue to be positive.  With its current staffing levels, CHS has the capacity to see up to 27 virtual school patients per school day. 

Expanding the definition of users to all parties impacted by this care model requires that we also mention the acceptance by providers and payers.  CHS, as an organization, practices telemedicine regularly.  Every day, primary care and psychiatric providers are seeing patients across CHS wide-area network using this technology.  While not all individual providers are comfortable with the technology, they all see its value and support the organizations mission.  In much the same way, not all insurers accept telemedicine services as they do regular face-to-face care.  However, more payers are coming around to the realization that telehealth is here to stay and if they want care delivered in a cost-effective manner to their members when they need it most, their contracts will need to support the services.