♪ >> I like living in a rural community because everybody knows everybody.

And I think that it's a lot more personable.

If you're in a big city, nobody knows who you are and nobody cares to know who you are.

♪ We have patients scheduled every, every 20 minutes, but then we'll have work-ins in between, so especially if a sick patient will be worked in.

So I start seeing patients at eight and I usually finish...

It's usually a little after one before I finish for the morning, and I just see patient after patient.

It can be plus-minus as a physician.

Sometimes they are asking you questions in the grocery store, but that's okay, you get used to it.

You know, you're treating your friends, the people you go to church with, the people that you know on a personal basis, you're also known on a professional basis.

So I think small town living is wonderful.

♪ >> Good morning, everybody.

It's Thursday.

All right, game plan for today: Brittany and Rene, you're going to be in work-up.

Dr. McAlhaney has got two telehealths this morning.

>> We're the largest practice in Bamberg.

There's five providers here.

So primary care is readily available here.

Specialty care is not, with the exception of the Cardiologists Office.

Any other specialty care, you pretty much have to go out of town for.

That is another place that Telehealth has come in handy, in that we've been able to connect patients with a specialist.

Patient>> I don't think so.

Dr. McAlhaney> Have you had your immunization?

I got involved in Telehealth with Medical University and Palmetto Care Connections when they first started doing the specialty consults, and we were the first practice to utilize those.

We were doing diabetic education to start with and moved into a lot of telepsychiatry.

Those are the two places that we've mostly used the Telehealth through specialty.

Then Palmetto Care Connections wanted us to reach out and help with the school Telehealth.

So we became involved in that, initially doing the Telehealth for the Bamberg School District.

And then this year, we're going to be providing services for both Bamburg and Denmark school districts.

>> Palmetto Care Connections was founded in 2010 for the purpose of growing and expanding access to quality health care services in our rural and underserved areas as we worked in the Telehealth field and trying to get Telehealth into our rural communities, we realized that one of our biggest barriers was the lack of broadband, not only in our homes and by our consumers and our patients, but several years ago, we had had issues with our healthcare providers having adequate access to internet services, to be able to provide Telehealth and to grow those Telehealth services.

So PCC became really engaged in expanding broadband access.

We assist our healthcare providers in obtaining Federal subsidies to help pay for these broadband upgrades that are needed to expand their Telehealth capabilities, and now folks, through Telehealth, have learned that Telehealth makes their life easier.

It's convenient, and they can actually receive the healthcare services that they need from their couch, from their office, from their car.

So instead of the physician actually going to the house to provide the care, the physician virtually is going to the home to provide the care.

So the house call market is back in play again, and I think our patients love it.

[indistinct conversations] So Telehealth is like house calls.

The philosophy we started out with that we're going to try to get to the patient, and we used to always say that if you could try to bring patient care to the patient, it was like the old days of making house calls and visiting.

So caring for a patient in an artificial setting may get the job done, but you may miss a lot, and you may make things harder.

You may make assumptions you're not.

The power of caring for a patient where they're supposed to be is probably untapped in modern medicine, and probably something that providers knew when they used to do house calls back in the day, they knew that going in understanding the dynamics of the family, dynamics of the household, their environments, and if they have to go up and down stairs or not, if they have a neighbor to support them when they're elderly, and those kind of things.

All of those things are really important, not necessarily to diagnose and say it's x condition or y condition, but to help the patient live with their health status, and I think that's a bit of a lost art, and so I'm hoping that Telehealth brings it back, as the therapists, the home therapists, really know what it means to care for a patient in their own life.

And so Telehealth very much has moved towards returning to house calls.

[voice on cell phone] <Dr.

McAlhaney> Initially we started by connecting them through our office.

So they would come in here, we would set them up on the computer, and they would have their visit through Telehealth here which was nice in that we would know that it was getting a good connection.

We would know that they were set up properly, and then covid hit.

Reporter>> A 12th fatality has now been reported here in the United States.

Reporter 2>> With covid cases climbing in 17 states, our national plateau is giving way to a steady rise in infections.

Reporter 3>> Tonight, covid wards packed, and healthcare workers exhausted, as hospitalizations climb across much of the country.

Reporter 4>> The U.S. surpassed 60 million covid cases since the pandemic began.

Reporter 5>> Now the Omicron surge is continuing to set new records across the U.S. Reporter 6>> South Carolina officially surpassed the one million mark for covid-19 cases.

This comes less than two years after the first cases were confirmed in our state in March of 2020.

>> Good to see you.

Sorry, it's under these circumstances.

I was just wondering if you can help me with some of the symptoms I've been having.

I'm trying to avoid coming in just in case it's something contagious.

>> And when did this start?

Dr. McElligott>> So Telehealth has grown exponentially in the last 5 to 10 years.

You would have thought in 2018 that we were rocking and rolling with Telehealth.

A lot was happening.

A lot of companies were being developed and those kind of things, and it really was increasing exponentially, but we all knew it sort of... You know, there was a nervousness about it.

Would it be fraudulent?

Would all these other things have held us back?

And so we were designing services that really were specific to a certain niche.

None of these extension services were there.

We weren't trying to say, "Everyone's going to use it tomorrow."

And then, of course, covid hit.

And everybody said, "Well, we'll do away with the rules for now and let people just go," and it was amazing.

The proportion of healthcare that started to be delivered via Telehealth was really on the radar and it was the majority of during the beginning of the pandemic, more health care on the outpatient side delivered via Telehealth than otherwise in some institutions.

And so it really flipped the switch, and people then realized that you can do this at scale, and they also realized that providers and patients will right size their needs by and large to what they need done.

If they can do it via video from in your home, they should be able to do it.

If they need to see you, well, they tell you to come in.

So it was nice to see everything blow up to huge scale, but then sort of get right sized by specialty, and that is happening all across the country to the point that it used to be less than 1% of care, and we thought it was a lot of care happening.

We had Telehealth.

Now, it's depending on the specialty, anywhere between 5 and 75% of care.

And so the amount of Telehealth happening has really come into its day, and is really just part of everyday health care for basically all professions that practice the outpatient setting.

Kathy>> The South Carolina Telehealth Alliance is a statewide Telehealth network that works with all types of health care providers: hospitals, behavioral health sites, primary care providers.

And it really takes our Telehealth hubs which are our larger healthcare systems, and they work to bring services into those smaller communities.

Dr. McElligott>> The Telehealth Alliance is administered out of the Medical University of South Carolina.

Here at the Medical University of South Carolina, we receive some state Appropriations to apply towards the Telehealth Alliance and are mandated to have a collaboration.

And hence, that's how we formed the Telehealth Alliance.

We have an Advisory Council that has the largest health systems in the state, some key nonprofits, and other support agencies at the table.

And we have a larger group of stakeholders and participants that are involved in different elements of a strategic plan.

Woman speaking>> Don, we did find space for y'all.

Kathy>> The Telehealth Alliance was started several years ago, and our legislature in their wisdom decided six or seven years ago that it was time to expand Telehealth across the state, not just in our urban areas, but the real goal was to make sure that we had affordable health care across the state in every community in our state.

And so the Telehealth Alliance's goal was to create an open access network so that a provider could work with any provider of their choice.

Nobody was restricted to work with one particular healthcare system or one particular vendor.

The technology would allow them to bring services from any area of the state or even outside of the state.

So the Telehealth Alliance has really brought a lot of different types of providers together, not just healthcare providers, but we work with our local legislature.

We work with our municipalities, our state and local governments to expand Telehealth, and they were able to bring lots of folks together for the purpose of growing Telehealth and creating access points all across the state.

[meeting attendees speaking] Dr. McElligott>> All across the country, there are different arrangements of collaboration around Telehealth.

I think we are unique, and we've been awarded for this, gotten awards for this before, but one, in our collaboration, we've been able to stay at the table for a decent amount of time now.

The second is our focus on planning, and a lot of the times a state may have established eight years ago a Telehealth strategy where periodically, every year, we get everybody back together and we refresh our strategy, and we refresh what we're doing and what we're committed to.

We've been doing it every year since around 2014, so that commitment to making sure that we're making action and keep maturing and keep growing and keeping coming back to the table, which isn't always easy when the healthcare landscape is designed with competition in mind a lot.

But, you know, we are, we have a common purpose and we return to it, and you have to commend all the participating entities that aren't Medical University of South Carolina in that to keep coming back and keep working together, and importantly the nonprofits like Palmetto Care Connections and others.

So just commitment to vision, the ability to keep collaborating, and, you know, putting in the time and energy to be involved in strategic planning every single year.

So, I think that's what makes us different.

It also makes us different that the state keeps trusting us and keeps funding initiatives.

[birds chirping] >> You hear the horror stories about the ones that were hospitalized or the ones that didn't make it, and those thoughts start running through your mind like, "Is this going to happen to my family?"

or "Are we going to have the mild case that some had?"

or "Will we have no symptoms?"

>> Her son was diagnosed first, and he was actually very sick.

Respiratory wise, he was kind of declining in a way that we really don't like to see, especially in younger individuals.

So she was able to talk with me, her and her son, and get some acute care measures under way so that he wouldn't require that ER visit.

<Shirley> When I was able to get with her through Telehealth, it made it a whole lot easier.

I knew then that I had somebody that I could depend on, I could call with whatever problems we had going on, and she would be able to help us through the process.

[birds chirping] >> CARE South Carolina is a federally qualified healthcare center in the Pee Dee region of South Carolina.

So an FQHC is a federally funded organization that provides comprehensive services to their patients.

So CARE South Carolina utilized Telehealth back in the very beginning of the pandemic to treat covid patients and non covid patients.

We are able to continue to provide care to patients who had covid-19 and had to self isolate who otherwise probably would have utilized the emergency room only.

We were able to connect to those patients virtually.

We were also able to connect to patients who were high risk and were unable to or were uncomfortable coming into the office setting, and still are, so we provide that care via Telehealth.

<Shirley> I feel like if we wouldn't have had the convenience of having Telehealth available, we would have probably been going to the emergency room for our symptoms in and out exposing other people to the sickness.

>> Everyone in their house was sick unfortunately, and they couldn't just come out or go to urgent care or come to our clinic.

So to have that access, it made things a lot easier, more convenient, and I also think it helped with the anxiety of "Oh, no, I don't know what to do.

What if this happens, what if this happens?"

It gave them an avenue to ask questions and ease their worries and to talk and discuss 'what ifs.'

So Shirley was very, very thankful, and we were able to get her in pretty much immediately, thanks to Telehealth.

<Shirley> Probably around day seven, my son started to get better.

He started getting back to himself, eating, drinking.

<Lauren> You know, they followed the treatment regimen and it really prevented him from going down a very complex road.

<Shirley> For me, it was a little longer, only because I've had some underlying health conditions.

For me, it was around day 20.

I felt much better.

I was still fatigued, but my symptoms were alleviated.

So I was able to get back to some normality that point.

<Jeri> So I think that we've just scratched the surface of possibilities with Telehealth in healthcare.

I think we're going to see improved patient outcomes, improved patient access, decreased costs.

So if you think about sometimes what it may cost a patient just to come to an office visit, there are transportation costs associated, missed work time, there could be childcare costs.

If you're a caregiver for a family member, you may have to pay someone to take care of that family member.

With Telehealth, all those costs are erased, because you are able to see your provider in the comfort of your own home without worrying about missed time from work, without worrying about transportation costs.

I think in the near future Telehealth is going to be the preferred method of care delivery.

>> For Telehealth, it's just clear that we're not going to connect rural communities to appropriate healthcare services effectively with our broadband.

It is pretty well accepted that what changed rural America was electricity.

and I often tell the story of the gentleman who stood up in a Tennessee church one night and said "Ladies and gentlemen, I want to tell you something.

"The greatest thing on earth "is to have the love of God in your heart.

"And the next greatest thing is to have electricity in your house."

That's how important electricity was to rural America 80 years ago.

And that is just as important in this century as it was in the past.

But I always show people in the 21st century, it's broadband.

What will connect communities today is high-speed affordable broadband.

>> Telehealth, in order for Telehealth to work in the family home or even out remotely, when you're in the Walmart parking lot or somewhere like that, you need good quality connectivity to be able to have a good conversation with your doctor.

And your doctor is not going to render a diagnosis if they can't hear your voice clearly, they can't see your face.

Patient>> Hey, how ya doing, Dr. 'Mac'?

Dr. McAlhaney>> Good.

What's going on today?

Jim>> Having good quality connectivity is really important.

So, connectivity can come to you in both cellular on your cell phone, but it can also come to you and your family home with wired residential internet.

And that's the thing we're really trying to do is get that wired residential capability into as many homes as possible.

The Federal Communications Commission defines broadband as 25 megabits per second download speed, 3 megabits per second upload speed, so we have very precise maps done, so we know at a census block level who has service and who doesn't.

Then that's our job, is to close the holes.

In the state of South Carolina, there's roughly 170,000 homes that do not have connection to the internet right now, and it won't surprise you that that's predominantly in our rural areas.

>> So when you talk about broadband, broadband is essentially another word for high speed internet.

There's a number of different ways to deliver that.

What we're doing here today is fiber, Fiber to the Home Solutions.

That's kind of the gold standard when it comes to high speed internet.

So the biggest challenge with rural broadband expansion is the availability of funds, it's infrastructure.

It's not just us flipping a switch and deciding to turn the internet on.

It's very capital intensive.

Jim>> It's so difficult to fix the internet in rural communities because it's expensive.

It's roughly $40,000 a mile to put one mile of fiber underground.

It's about $28,000 a mile to put one mile of fiber on a telephone pole.

So when you do the math in the sparsely populated area, it gets really expensive really fast.

So, to go five miles to reach five or six homes, that's a very expensive investment when the return is in the form of a monthly payment that might be $50 to $100 a month.

So the economics will never make sense if you're a private business.

That's where the federal and state subsidy comes in because it changes the calculus and it allows infrastructure to get built.

<Sarah> When the pandemic hit, that really accelerated the need for funding, accelerated the need for internet for folks at home for Telehealth for working from home.

So, that just really put us into full gear into securing those funds and getting us work in place.

Sen. Clyburn>> I think if you were to take all of the funding streams that have already been put into law, CARES Act being one of them, the so-called Bipartisan Infrastructure Plan being another, or even parts of the American Rescue Plan where you find another bucket of money, and then there's another bucket of money in the FCC.

If you look at all of those buckets, it come somewhere in the neighborhood of between five and six hundred million dollars for South Carolina alone.

And all the experts tell me that that ought to allow South Carolina to build out 100% within four to five years.

I think it's true.

We can do that, and we ought to move forthwith to do it.

Jim>> We have a rare, you know, a rare moment in time.

This is actually historical in perspective.

The only other time in U.S. history when this occurred was when we pushed electricity into rural America.

So that happened in 1935 when Franklin Delano Roosevelt signed the Rural Electrification Act, and we're at that same moment in history right now where it's our generation's chance to lift up the economy and do some special things.

So getting internet into rural homes will have the same effect that electricity did.

>> When we look back to that time, electricity enabled electric pumps to work, and we actually got fresh water at the same time.

Kind of a similar thing is happening with internet, where we are extending internet, but that becomes the platform for complete economic development and quality of life change all over the state.

<Sarah> At HTC, we talk about the 3 a's of broadband.

There's the access, there's the affordability, and there's the adoption.

What we're working on today is the access problem.

And once we solve that, which I think we will in the state of South Carolina, the question's going to be about how do we make it affordable and how do we increase adoption rates?

Because we could be doing all this work, and folks don't subscribe, and then it was kind of all for nothing.

So on the adoption end, what we're doing now before we even complete this work is developing community outreach and education plans to help folks understand, not just the importance of the internet, but how to use them.

>> You have broadband, but you don't have people, and it could be the primary care practitioner, it could be somebody in the family, understand how to use it.

So they've got the iPad.

That's great.

But they don't even know how to get onto the platform.

I'm encouraged by the fact we're realizing that you've got to match all this up.

You've got to have the providers of the service.

You've got to have the technology which includes both broadband and the equipment to be able to handle doing those kinds of Telehealth based assessments.

And you've also got to have digital literacy.

So basically in that situation, it's making sure both the person that's providing the Telehealth services is comfortable doing care and providing services via Telehealth.

It's not quite the same as doing a facing face-to-face visit, as well as making sure those who are receiving the services and presenting patients for services are comfortable as well.

So I think we realize it's kind of a three legged stool.

We've got to be able to do all of those three, and we've learned that more and more during the pandemic.

So I think that's what's going to be key, is to make sure we have those resources and the funding to support those resources, so that not only can we say we can offer Telehealth services across any area of the state, but it can be accessed and it can be used effectively.

[indistinct chatter] <Kathy> The senior population all over the nation is growing, and South Carolina has a large senior population.

During the pandemic, this was probably the most vulnerable group of folks that were exposed to the virus.

And so they have been impacted significantly through isolation, through not being able to go to their healthcare provider.

They were fearful of going out into the open, and so now we're trying to make it so they can actually leave their home but not really leave their home.

>> ...that you had tapped open, was closed out.

Digital literacy is knowing how to communicate, interact digitally, whether it's through email, virtual calls, those type things, across a variety of different devices.

<Kathy> We have partnered with Rural LISC, the South Carolina Department on Aging and the South Carolina Arts Commission to teach senior citizens about digital literacy.

We've given them a tablet and a year's worth of cellular service from Verizon as part of the program, and we are teaching them how to use the tablet.

We're teaching them what digital literacy is.

We're teaching them about the value and benefit of the internet, why they need it, and then we're teaching them how to do Telehealth visits.

[indistinct conversations] >> It is so very important, especially after covid when a lot of the seniors were confined to home, and the only external outlet they had was their phones, which were small and hard to read, and their television, which was mostly news and just local kinds of things.

But with the tablet they're able to extend out into the world.

>> Social isolation is a huge problem for seniors.

According to AARP, one in five seniors is socially isolated.

That means they're at high risk for depression.

They are at high risk for anxiety, high risk for obesity, and high risk for dementia.

That's why it's very important that we get our seniors moving and get them active and get them going, get their mind stimulated.

That's why this social isolation project is so important for seniors, because it helps them connect, it stimulates their minds and keeps them active, so they can spend their latter years living in vitality in their own homes.

<Kathy> The goal of the project is to provide digital literacy training, provide them with a device, help them with cellular service, but to also help them get permanent internet service in their home, so that after the pilot project is over after 12 months, they will have service and can continue to utilize their device, continue to connect with family and friends, continue to connect with their providers virtually.

So, one of the things that we teach in this training is how to actually do a Telehealth visit.

And we survey each of the seniors before they attend the training session, and identify who their healthcare providers are.

And then we reach out to that healthcare provider to make sure that they will do Telehealth or are doing Telehealth, and then we make that accessible to that senior through their tablet.

[indistinct conversations] >> If you don't learn technology, you're going to be left behind, and a lot of folks are left behind now.

Everything is evolving fast, quick technology, and isolation, that combination is not a good thing for anybody.

So you have to find a way to communicate, connect, and this is perfect, absolutely perfect.

<Dr.

Foster> One of the real challenges in South Carolina is that we have just a broad mix of social, economic, environmental and healthcare factors that are affecting people in communities across the state.

Unfortunately, those social factors and economic and environmental factors tend to affect some people in some communities more than others, especially those who live in rural areas, communities of color, those who have disabilities and other factors that caused them to be disadvantaged, and unfortunately, those who have more of those profound social determinants tend to have poorer health status and poorer health outcomes.

<Kathy> Social determinants of health are very widespread.

They can mean anything from making sure that a person has a proper education to making sure that they have access to healthcare services, making sure they can become employed because there are employment opportunities in their environment, making sure that economies of scale are taken advantage of and social determinants of health truly play a part in a person's health.

If a child goes to school and the school is focused on making sure that child receives a good education, but they go to school, they're hungry, maybe they have an earache, maybe they have an abscessed tooth.

That child cannot learn in that environment in that classroom because they're too busy in pain thinking about their pain.

And so when we're trying to take care of the whole person, we have to look at all of those social determinants of health, and Telehealth is a way to break down some of those barriers.

>> In terms of our social determinants of health approach, really access to care is our main focus, because some of these families live 30, 45 minutes away from any healthcare organization.

They may live near a Walmart.

They may live near a CVS.

They have Minute Clinics and they have quick fixes, and those are good.

Those are very helpful.

But in terms of pediatricians, in terms of your specialty care, what if a child has diabetes?

What if a child has asthma?

What if a child needs mental behavior care?

Those type of facilities are 30, 45 minutes away for a lot of these families.

What our Telehealth program can do is connect people to the correct resources that they need.

<Dr.

Foster> Those communities, especially rural communities and other underserved communities where the health is not as good because they don't have the range of resources including access to healthcare, that not only affects the health of those communities, but it negatively impacts the help that the overall state.

And so, from an economic standpoint, that's not a good situation for the business community.

It actually contributes to increased healthcare costs.

So if we can find more effective ways to provide help and social services to those individuals living in those underserved areas now, not only will it help improve their health and well-being, but also will end up helping to improve the overall health and economic well-being of our state.

<Dr.

McElligott> When I first started as a general pediatrician, sort of the dark secret was I was very interested in health disparities, and I wasn't bad with technology but I wasn't that interested in technology, and so doing Telehealth wasn't the funnest thing for me, being a pioneer in there.

My peers weren't doing it, and setting it up in these schools was difficult sometimes, but it was really about the kid, though.

It became very apparent that when I did care in a school setting via video with the school nurse, I mean, we had, between the school nurse and I and the parent, we really solved the problems for the child, and they never went anywhere.

So, it quickly became not about me, but about entering the life of that individual and caring for them in the place where they work and they breathe.

So doing a house call in the old days was that.

[indistinct conversations] >> The school-based Telehealth program began in South Carolina, in 2013, when Dr. Jim McElligott received a small grant, and he began with two schools in Williamsburg County and one school in Charleston County.

From there, as we expanded, Williamsburg County was the first county in which we placed Telehealth equipment in all of the schools.

>> The school-based Telehealth program was really started as a way to combat healthcare disparities for children.

Dr. McElligott started the program as a pilot in Williamsburg County, because at the time, there was no pediatric care in Williamsburg County.

And so, we knew statistically, the children in Williamsburg County, were getting less preventive care visits, because they had less access to care.

[indistinct conversations] <Dr.

Garber> So since 2014, really, end of 2014, early 2015, all students in Williamsburg County have that access to healthcare through the school-based Telehealth program.

It's a wonderful program.

The people in Williamsburg are amazing.

And it's been my pleasure to serve the students in Williamsburg since its inception at the end of 2014.

Dr. Garber>> How are you?

Patient>> Good.

Dr. Garber>> Can you hear me ok?

Patient>> Yes, ma'am.

>> My first experience with Telehealth came when my son Tristen, my son had a...

I think it was a rash or some type of fungus, if I can remember.

And I said, "Well, you know what?

"Instead of me trying to take off "to take him to the doctor and come back, I'm gonna try this out."

I called over to the school nurse.

She got to set up, and we did.

I mean, they looked at the fungus, told me what it was, even called in the prescriptions.

So it made it feel real easy and very fast.

>> They helped me a lot, get better.

The doctor sees me and the telemedicine, telemedicine machine and the doctor, they combined their powers like basically, and it helps me a lot to get better.

The difference between it is the telemedicine machine is more faster instead of having to wait in the patient room when you're at the doctor's office.

<Dr.

King> As the program grew, Williamsburg became sort of our model for how to roll this out.

What we did when we thought about how to best grow the program, we thought about what diseases most impact children and most impact children who experience healthcare disparities.

And in children, the most common and costly chronic disease of childhood is asthma.

It's also one of the leading causes of absenteeism from school.

Patient>> I didn't know I had asthma until I couldn't breathe.

I used Telehealth since I was in Anderson to see Miss Kelli.

Every time I come to her, we always do my lungs and stuff and they always check my ears.

It's like a place that I don't have to worry about leaving my town, because if I already did it while I'm at school on the computer, I don't have to worry about going to the doctor.

>> I started looking at health disparities as an academic interest.

You know, the scope of the problem just seems so big.

One kid at a time is good for me.

It makes me feel better.

But, you know, really getting to a point where you can change things at a broader scale, and I'm not sure I ever thought even Telehealth would make every difference in my career, but I've seen the data from our asthma evaluation of Williamsburg County, and I've seen some things happen.

I've seen the programs go to a scale that I never would have thought, from five patients, ten patients and now thousands of patients and millions of interactions and just being part of this change.

I don't think I ever really liked Telehealth.

I didn't like doing video visits even though I was an earlier pioneer in doing it, but it was by necessity, because the kids needed it.

<Dr.

Garber> We've expanded the program from three schools in those very early days to over 80 schools across the state.

>> In select schools we have the chronic care management for ADHD as well as telemental health specifically for trauma-focused cognitive behavioral therapy or TFCBT, a therapy that's for students who have experienced post-traumatic stress syndrome type symptoms.

So in select schools we have a wonderful team that provides that type of care.

We do anticipate continuing to expand across the state in the future.

So I think we will continue to be able to help a lot of children, particularly in those very rural and underserved areas.

Kimberly>> Back in 2016, Prisma Health, which we were Palmetto Health back then, we had a grant with the USDA to help provide rural health Telehealth services to several communities which we identified as rural.

That was in lower Richland County: the Hopkins, Gadsden, Eastover, Horrell Hill, that area, because services down there are a lot different than in urban areas.

[indistinct conversations] We initially started out with a clinical Telehealth approach.

We also started doing education and then added in diabetes, Type 2 diabetes prevention.

We're in, officially, right now, today, three districts in the Midlands.

Those include Lexington County District One, Lexington County District Four, and Richland County District Two.

In Richland County District One, we actually have education programs running in several schools there, but the other three, we have clinical services.

<Dr.

King> We've learned a couple things.

One is this kind of program when we surveyed parents and families about their barriers to care and whether this program overcame their barriers to care, overwhelmingly, we got a positive response that families feel like this helps overcome their barriers to care: transportation, leaving work, missing school.

We've also seen school nurses really being pivotal in these programs.

So when school nurses are engaged, and they see the value of the program to both their children and to their jobs, it really makes the program more successful.

And then, of course, we're seeing the downstream impact on the health of the child, and keeping them out of the emergency department.

Kimberly>> I think the challenge in the program setup and creation is a little bit of awareness, although, with covid and the atmosphere that we're in now, the environments that we're in now, everybody really is starting to understand virtual health, digital health, telehealth.

So in a way that challenge has been a little bit eliminated.

However, when you talk about it in the schools, in terms of clinical and education programs, awareness is still there, but I think again with the covid-19, that whole pivoting, I think people are more accustomed to it.

Other challenges are, you know, nurses.

School nurses already have a lot of work to do, especially around covid-19.

There's a lot of paperwork.

School nurses are administering medicines.

There's just a lot on that school nurse already.

So, sometimes adding one more thing can be a little bit challenging.

Although, once we train the school nurses, once we explain the benefits, they are very much in favor of doing these types of programs and solutions, because they know that overall, this is benefiting the student.

They know that parents may be 30 minutes away from the school and picking up their child, 30 minutes away, coming back to a pediatrician that may be even further away, may be very difficult, and maybe that student would not get that care, unless this type of intervention was provided.

So I think once school nurses understand that benefit and understand that this is helping the whole child, the whole family, then there is a lot of support there.

>> You can't do everything, as far as healthcare via the Telehealth platform, but the range that you can do, we learned, is so important.

And it's everything from primary care to outpatient urgent care to counseling and nutrition services and behavioral help treatments.

But also on the inpatient side, being able to provide critical care services, stroke care services that otherwise would not have been able to be provided before, so it's the full range.

It's pretty amazing what we can accomplish across the life continuum, and for people, no matter where they live in South Carolina, it's just we have to have all those key pieces in place in order for us to both sustain and spread that work.

>> When you think about transforming Healthcare, keep in mind pre-pandemic, we had some significant issues in the healthcare system in the US, the first being access to care, inconsistent access.

And so, many folks in many communities across the country would have to wait 30, 40, 60 days to see a primary care physician.

So the issue of access was really important.

The second is that there was inconsistent distribution of evidence-based guidelines.

So the fact that you lived in a certain community meant that you were more likely to have this type of care versus another community.

And so, neither of those made sense, and what has really happened with Telehealth, is that instead of your geography defining your healthcare destiny, it really serves to level the playing field so that all Americans should get access to care, and all Americans should get access to great care.

An example of that that's really been very top of mind for many Americans is in the issue of Behavioral Health Services.

So pre-pandemic, one out of five Americans had a mental health issue and over 50% of counties in the US, I think it's closer to 75% of counties in the U.S. had no mental health services available.

And what Telehealth has done has really transformed the delivery of mental health services so that people are much more likely to have access to these services.

From the clinicians perspective, they have greater visibility into their patients, their homes, and it has really provided a much easier way to access those services, and people show up for their appointments.

So the no-show rate has dropped as well.

So it's a great example of how Telehealth has transformed healthcare.

<Dr.

McElligott>> All the old obstacles to holding us back from Telehealth integration are still there: provider buy-in, rules and regulations, inconsistent payment policies, slower to develop protocols for certain conditions and things like that.

But for the most part, a lot of that has been accelerated and worked out a lot.

I think the biggest thing that health systems need to worry about is, or that need to get out in front of, I should say, in order to make sure that this level of access and this innovative care continues, is really making sure it fits into the structure of the health system, and unfortunately, I largely mean financial.

If you imagine that just a few years ago, almost all care happened in person, you had a certain number of buildings, you had your staff working in a clinic.

Now, you don't need as much building, and perhaps your staff should be working from home or somehow virtually supporting things.

And you don't necessarily need a front desk, but you need a way to get a consent form and all these other things.

And so, we're kind of structured wrong.

Even if you're doing 20% or 15% of your care via virtual, that doesn't sound a lot, but that's a big chunk of expense that a health system might be losing out on, and it's just a pivot point, perhaps, depending on what you choose.

But if you decide that this is too much of a risk, and you want to make sure you bring all the patients in, and they come to you, and you get all your studies and everything done, and you don't miss anything, because you're so nervous about keeping your doors open or whatever, then you miss the opportunity to sort of become nimble or become more flexible and to change your infrastructure.

I would say the biggest barrier, really, is the intent of the health systems and how this new type of care that's happening at scale, not new, but new at scale, fits.

And if it fits, if we can make it fit, if we can lower the overall cost of care and be beneficial to everyone, it'll stick in the long run.

If we can't make it fit, even our best intentions will sort of be lost to the unfortunate hard blowing winds of, you know, financial needs of keeping your doors open.

<Dr.

Foster> We've learned a lot from the pandemic.

There's been a lot of negative experiences, but one of the positives, we've realized that there's even a broader range of health related services can be provided via Telehealth.

Obstetricians and other prenatal care providers have been able to provide some level of prenatal care and post pregnancy care to pregnant women when they're not able to come in, either because at the height of the pandemic, not putting them at risk for exposure, or because of even other problems as far as getting into the care setting.

And so, there are areas like that and other types of services we've realized that we can provide very effectively through Telehealth.

Fortunately, during that time also, at both the federal and state level, we've seen expanded coverage and reimbursement for those.

And so it's going to be critically important that we don't take a step backwards, and we make sure that those services that can be effectively done via Telehealth, diagnostic services, treatment services, counseling and therapy services don't go away, and all of a sudden, we have people who finally were able to get access to those kinds of care and services, not have it again.

>> So the future for Telehealth reimbursement is a really good question, and we've been trying to find the true answer to that.

I think during the pandemic, our private insurers such as Blue Cross Blue Shield, United Healthcare, they did a phenomenal job of stepping up and reimbursing Telehealth very well.

Medicaid did a really good job of reimbursing, and, of course, Medicare through the federal government did, and we are in a wait-and-see sort of mode.

We have reached out to our private insurers.

We've had multiple phone calls with Medicaid, trying to make sure that they have the data they need that justifies the need for continued reimbursement for Telehealth.

We've done a really good job of getting our healthcare providers to the table to install the equipment, to expand their Telehealth service lines, because they were getting paid.

They cannot provide services that they do not get reimbursed for.

We can't go back and yank that away from them.

If we do, instead of being 10 years moving forward, which is where we have been the last couple years, we're going to push ourselves back.

<Ann> We all have an important role to play in ensuring that Telehealth becomes a permanent modality.

Remember that when I say "Telehealth," it is audio only, just speaking on the phone with your clinician, it's audio-video, it's chat, it's what we call store and forward.

It is a number of different modalities: remote monitoring, the ability to have your doctor have a monitor on you and know if something's not going very well.

So, Telehealth in all its forms, should be a permanent fixture.

And our opportunity is to remind our publicly elected officials both at the federal and state level that you want to have access to these services even after the public health emergency.

When the public health emergency goes away, Telehealth has to stay.

<Dr.

McAlhaney> I think that the funding for Telehealth is going to be an issue, and that's where the politics needs to come in, and they really need to provide funding that is equitable for that service, because it is a service that is much needed, and it's especially needed in rural communities.

So we need to make sure that the FQHC's and the rural health clinics are able to build for these services.

>> What we're really looking forward to in the future is not necessarily parity laws but equitable payment for service delivered.

So, you know, the idea that we're trying to lower costs, I think it's a fair conversation that some of the benefit of lowering cost, a lot of it needs to go to the patient, some to the providers and some to the insurance companies, we all need to win in it's design.

So if you really, you know, we're becoming much more open now that Telehealth is established, with the idea that payment doesn't have to be exactly the same, but it should be fair, and that's been a really great conversation, to be honest.

Do we all trust each other and all those parties?

Probably not, but I think it's a great foundation.

So, while I do expect more state legislation activity, it might be more focused on fairness, and it might be more focused on making sure the rules aren't too restrictive, so that we go back to the dark ages of pre large-scale Telehealth.

>> I think we have seen a tremendous growth in Telehealth, and a lot of that was due to covid, and I think that it has slowed down a little bit and steadied off, and I think you will see more providers getting into Telehealth, because I truly believe patients are going to start asking for it.

You know, we do a lot of digital literacy classes, and we teach folks how to do Telehealth.

We teach them how to go online and look for healthcare providers that provide Telehealth services.

And at some point, the health care providers that are not providing Telehealth, at some point, the patients are going to come to them and say, "Are you providing Telehealth?

If you're not, why are you not?"

And I think what it's going to end up doing is forcing our patients to choose between maybe an existing provider versus going to another local provider that does provide more convenient care.

So I think a lot of the growth of Telehealth is going to revolve around our patients and how vocal they are going to be about their care.

So, we are busier than we used to be, and making care a little bit more convenient is going to be important for us, and I think our healthcare providers are going to be asked the question, "Why are you not doing Telehealth?"

<Dr.

McElligott> Now, I'll just say going forward, I think we've done this really well over the first few years, but as things become more mainstream, I think it'll be important for our state to stay focused on equitable distribution of care.

And I specifically don't say focused on the underserved like we have in the early years, because it is for everyone, and that is in the Telehealth mission statement.

It's for all citizens.

And so I think that's true to serve the underserved, you have to serve everybody, but I do think it's easy for things to become more accessible and less equitable.

And I think that's our challenge going forward, is we have to be really hyper focused on equitable distribution of care.

There was a time where even when we were pushing for the laws to support Telehealth, where legislators asked me, "Can you now access everyone?"

and this was five or six years ago, and I said, "Well, in theory, yes, maybe we can build it and we can get to every one."

And another one said, "How are you going to pay for all of that healthcare being delivered?"

and I have to look back at them and say, "Yes, that's our problem."

Now everyone can be cared for, and so we have a new problem, but don't do it because you can't get to them.

And so I think as we move forward, I do think lowering the cost is essential, and I do think not doing too much in person or comprehensive care when it's not needed and figuring this out but still doing no harm is really important for us to figure this out over the next, really, three to five years to get really moving in that direction, equitable distribution, cost effective distribution.

So, we've built such a wonderful thing.

Now, it's sort of as those legislators debated in session: Now, you put your money where your mouth is.

Now you can do it.

How are you going to do it?

But it has to be done.

[applause] ♪