Other Programs

Telehealth

Notes:

1. It is estimated that in the new cohort (2006) 10 % of the patients enter in telehealth diabetes case management program with ideal glycemic control (hemoglobin A1C at or below 7%) and, during the first year, this cohort will achieve a 45% increase to 14.5 percent achieving ideal control.  With funding in FY 2007, this cohort of programs will achieve 21% of their patients under control and those in the cohort funded in FY 2008 will have 30% of their patients under ideal glycemic control. In 2009, the process begins again with a new cohort of patients entering with 10% having ideal glycemic control, increasing to 14.5% in the first year of the new cohort.
2. These targets are cumulative building on the 489 Sites and Services achieved through the 2003-2006 cohort. This cycle will begin again in FY 2009 with the new cohort - annual targets were established based on the 2006-2009 cohort experience. Current targets are ambitious in that grantees continue to face significant barriers to deploying telemedicine and with each new set of grantees, the program funds grantees who add more difficult services, as grantees explore the boundaries of providing these services, e.g., innovative use of telehealth for physical therapy, stroke assessment and post-treatment rehabilitation, teledentistry, etc. Please note in FY 2006, we exceeded the targets for FY 2007 and FY 2008, but current reporting rules do not permit adjusting these targets.
3. Please note: Because this is a demonstration program, every three years each cohort of TNGP grantees "graduates" from its three-year grant while a new cohort of grantees commences a new three-year cycle of grant-supported telehealth activities.   The data are calculated as a cumulative number. 
4. This measure provides the number of sites and services made available to people who otherwise would not have access to them per million dollars of program funds spent.  Every three years, a new cohort of grantee commences a new three-year cycle of grant supported activities, gradually expanding sites and services per dollar invested.  With each cohort, there a start-up period where services are being put in place but are not yet implemented.  Over the three years of the grant, efficiency increases as grantees implement sites and services.
   
   *   This long-term measure does not have annual targets.

INTRODUCTION

The Telehealth Network Grant Program’s (TNGP) performance measures allow the Program to track progress in achieving its objectives of improving access to quality health care services, particularly to rural and other underserved populations, and promoting the implementation of evidence-based technologies and best practices.  Strategies used that support efforts to meet performance targets include sharing best practices, offering technical assistance to grantees, and encouraging grantees to offer specific types of services to address their communities’ needs.

DISCUSSION OF RESULTS AND TARGETS

Long-Term Objective:  Expand the availability of health care, particularly to underserved, vulnerable, and special needs populations.

34.II.A.I.  Increase the proportion of diabetic patients enrolled in a telehealth diabetes case management program with ideal glycemic control (defined as hemoglobin A1c at or below 7%).

At the end of FY 2006, HRSA began to fund a new three-year cohort of grantees under the Telehealth Network Grant Program (TNGP).  The data indicate that, among this FY 2006 cohort of patients, 34% had ideal glycemic control. When the original targets were developed, it was estimated that in this new cohort 10 % of the patients who entered a telehealth diabetes case management program would have ideal glycemic control (hemoglobin A1c at or below 7%) and, during the first year, this cohort would have achieved a 45% increase to 14.5 percent achieving ideal control.  It was estimated that this cohort funded in FY 2007 would achieve 21% of their patients under control (data available in March 2009) and those funded in FY 2008 would have 30% of their patients under ideal glycemic control. These targets were exceeded in the first year of this cohort. (See section below on “Targets Substantially Exceeded or Not Met.”)  In FY 2009, the process begins again with a new cohort of patients entering with 10% having ideal glycemic control, increasing to 14.5% in the first year of the new cohort.

34.1.  Percent of Telehealth Network Grant Program (TNGP) grantees that continue to offer services after the TNGP funding has ended. 
(Baseline – 2005: 100%; Target – 2012: 95%)

Sustainability of grant-funded programs resulting in increased access to health care for more Americans is a key objective of this program.  History suggests that 100% of grantees continue to provide some level of telehealth services.  It is reasonable to set a target of 95%, allowing for unforeseen events associated with a more heterogeneous program and changes in the healthcare environment over a period of six years.  The Program does not anticipate significant challenges to achieving this target.

Long-Term Objective:  Promote the implementation of evidence-based methodologies and best practices.

34.III.D.2.  Expand the number of telehealth services (e.g., dermatology, cardiology) and the number of sites where services are available as a result of the TNGP program.

The first cohort of grantees in this program was funded in FY 2003 and the second funded in FY 2006. As grantees mature, learn best practices from other grantees, and learn of new needs in the communities they serve, grantees may make additional telehealth services and service locations available.  It is anticipated that the program will experience a slightly reduced rate of growth in the future, after adjustment for carrying over existing sites that continue into the second cohort, that began in FY 2006.  As of August of 2007, this cohort of TNGP grantees provided a total number of 96 clinical services, across 690 sites in underserved rural communities for a total of 786 sites and services.  When added to the baseline of 489 services, the TNGP supported 1,275 sites and services in these communities since FY 2005.  This result exceeds the FY 2007 target by 332 sites and services.  The targets for the second cohort of grantees reflect a slight reduction from the first cohort because beginning in FY 2006, the program requires that grantees put greater emphasis on evaluating services rather than on expanding the number of sites where services are provided in accordance with Congressional directives.  The targets are cumulative, building on the 489 sites and services made available in the first cohort (2003-2005) through TNGP funding, and are calculated by adding the number of projected services offered by each grantee to the number of sites operated by the grantee’s networks in each year to the baseline (i.e., 489).  FY 2009 begins a new cohort of grantees, and the target of 1,371 services and sites assumes a similar rate of growth as experienced in past cohorts.  Achieving this target will be dependent on the FY 2009 level of funding and whether past trends of gradual growth continue into the future.  Of particular note is the challenge of clinical and payer acceptance, which is influenced by the development of solid models of best practices.  HRSA’s Telehealth programs strive to glean solid models of best practices from the grants that then can support enhanced clinician and payer acceptance of Telehealth services.

34.III.D.1.  Increase the number of communities that have access to pediatric and adolescent, and adult mental health services where access did not exist in the community prior to the TNGP grant. 
(Baseline – 2003: 79 Peds / 51 Adults)

The cumulative targets and data include the first 3-year cohort whose funding began in FY 2003, and whose project period ended in August 2006; the second 3-year cohort whose funding began in FY 2006 and whose project period will end in September 2009; and the FY 2009 target for the first year of the third cohort.

With funds awarded in FY 2003, 79 communities had access to pediatric and adolescent mental health services and 51 communities had access to adult mental health services as a result of the TNGP grant.  With funds awarded in FY 2004, 99 communities had access to pediatric and adolescent mental health services and 62 communities had access to adult mental health services.  With funds awarded in FY 2005, 101 communities had access to pediatric and adolescent mental health services and 72 communities had access to adult mental health services.  Finally, with funds awarded in FY 2006, 190 communities had access to pediatric and adolescent mental health services and 125 communities had actually gained access to adult mental health services as a result of the TNGP grant, demonstrating the continued significant impact of the program on expanding access.  When the original targets were developed, it was estimated that grants funded in FY 2007 would expand access to pediatric and adolescent mental health services to 160 communities and 125 communities would have gained access to adult mental health services as a result of the TNGP grants (data available in March 2009).  In FY 2008, the target was increased to 134 communities for adult mental health services.  Although these targets were exceeded in the first year (FY 2006) of this cohort, data for the second year have not been received, and the Program is concerned that these first year results may be anomalous.  Thus, the Program is not prepared to readjust these figures until the March 2009 results are readily available.  The FY 2009 cumulative targets of 207 and 175 communities gaining access to pediatric and adult mental health services, respectively, through telehealth networks are based on prior experience.  In addition, the FY 2009 target reflects the beginning of a new cohort of grantees.

These targets take into account the environmental challenges experienced by grantees even when grant funds are available.  For example, difficulty in obtaining services due to the shortage in the supply of mental health specialists and continued low reimbursement for these services.  In the second cohort, 16 programs were funded, but three of the sixteen are required to focus on providing and evaluating tele-home care services in accordance with Congressional directives.  Moreover, fewer programs are offering pediatric/mental health services in the second cohort compared to the first (6 programs vs. 10 programs), and the targets reflect this fact.  The number of programs offering these services is difficult to predict as the legislation authorizing the TNGP grants provides grantees with wide discretion as to what they propose to provide, based on community need.  Nevertheless, the Program will continue to encourage applicants in the guidance to propose these services and provide continuing technical assistance to those that do provide services.

34.E.  Expand the number of services and/or sites that provide access to health care as a result of the TNGP program per federal program dollar expended.
(Baseline – 2003: 105/million)

One measure of the Telehealth Network Grant Program’s (TNGP) efficiency is the number of sites + services that provide access to health care as a result of the TNGP grant per $1 million Federal program dollars.  The Telehealth program’s efficiency measure captures the fundamental underlying mission of the program: namely to expand access to services in underserved communities at an affordable cost.  This is a consistent indicator that can be tracked over time.  For example, with funds awarded in FY 2003, grantees were able to achieve an efficiency of 105 sites + services per million dollars appropriated ($3.9 million).  With FY 2004 funding, the efficiency factor increased to 119 per million and to 125 per million with FY 2005 funds.  In FY 2006, a new set of programs was awarded telehealth grants, with slightly more funding ($4.55 million).  When the original targets were developed, we anticipated having fewer sites as a result of the program requiring that grantees put greater emphasis on evaluating services rather than on expanding the number of sites where services are provided.   However, with FY 2006 funding, the efficiency factor increased to 168 per million, as a result of the three additional Tele-homecare grantees, which provide care in the homes, resulting in significantly more sites. This has resulted in a higher efficiency factor for FY 2006 than anticipated when the targets for FY 2006, 07, and 08 were established.  The original FY 2009 target is also low compared to the FY 2006 actuals, assuming a similar pattern to that experienced in earlier cohorts.  That is, a decrease in sites and services offered in the first year of a new cohort and an emphasis on evaluation of the quality and cost of services rather than a simple increase in the sites and services provided. It is anticipated that the efficiency will rise each year within the new cohort, similar to prior years, as new sites and services are implemented.  Although all of these targets were exceeded in the first year (FY 2006) of this cohort, data for the second year have not been received, and the Program is concerned that these first year results may be anomalous.  Thus, the Program is not prepared to readjust these figures until the March 2009 results are readily available. 

TARGETS SUBSTANTIALLY EXCEEDED OR NOT MET

Measure:  Increase the proportion of diabetic patients enrolled in a telehealth diabetes case management program with ideal glycemic control (defined as hemoglobin A1c at or below 7%)

FY 2006 Target:  14%
FY 2006 Result:  34%

Although the target was exceeded in the first year of this cohort of grants (34% under ideal glycemic control compared to target of 14.5% in FY 2006), data for the second year have not been received, and the Program is concerned that this first year result may be anomalous. Thus, the Program is not prepared to adjust the target figures until the March 2009 results are available.