A Tennessee provider is working to break down barriers to palliative care for rural cancer patients in their home state.
For cancer patients in rural areas, accessing palliative care services can be a burden due to the distance needed to travel to a clinic or for an in-home provider to come to them. Tennessee Oncology, one of the largest community-based cancer care specialists in the United States, has launched a pilot telehealth program to help relieve some of this burden for prostate cancer and breast cancer patients in seven rural Tennessee counties.
The program will cover an umbrella of supportive services, including palliative care, integrative oncology and psychology. Integrative oncology is a whole-person model of care that focuses on nutrition, lifestyle and complementary interventions to improve the quality of life for cancer patients alongside their cancer treatment.
The COVID effect
When the COVID-19 pandemic shut down the world, health care practices had to pivot to telehealth to continue their routine patient care. Tennessee Oncology was no exception.
“We found we can actually reach a lot more people with these supportive services,” Dr. Sandhya Mudumbi said, a palliative care physician who is leading the project. “With telemedicine, we get to see people in their homes, they don’t have to come into the clinic on a different day.”
Mudumbi and others with the practice noticed disparities in telehealth usage with their rural and underserved patients.
“You get an hour outside [the city] and we see a lot of issues with internet connection, cellular signal and people don’t have smart devices,” she said. “Even the engagement with technology is much lower. So, that’s the basis for this project, to enhance access to supportive oncology services through telehealth for rural and underserved communities.”
The main goal of the program is to address this gap in technology services in rural Tennessee, Mudumbi said. Health care technology has exploded since the pandemic, but rural patients aren’t able to access a lot of the tools.
“I have found in cancer care, there’s just so many patient-facing apps and digital health interventions; it’s just growng at an exponential rate,” Mudumbi said. “And then I always go back and think about how my rural community patients are not going to be able to engage with an application because some don’t even have a smartphone. We’re really trying to on some level get people more engaged and familiar with digital health and technology for their health care.”
Improving access
Tennessee Oncology tries to treat people where they are, Mudumbi said. The practice has many satellite clinics across rural Middle Tennessee. These clinics are easier for patients that live in those communities to drive to for their care than coming to metropolitan areas such as Nashville, according to Mudumbi.
To address the issue of limited internet access and cell signal, the pilot program is establishing a telehealth workflow in these satellite clinics so patients can meet with their supportive care teams that may be located elsewhere. This also relieves some burden on city-based providers to travel to their patients.
“While we generally try to get our supportive care providers out to these communities, it’s hard,” Mudumbi said. “That’s why I think this model will be feasible. We have an existing infrastructure of palliative care, integrative oncology and psychology teams. If the patients can drive [to a satellite office] and have all the technology set up so they can meet with a provider that is housed downtown or in one of our suburban clinics … We can leverage the existing infrastructure and service and providers to increase access for those in our rural communities.”
The company is doing something else innovative with the telehealth pilot: involving the people they treat in the project’s design.
“People who develop programs, researchers, have a hypothesis. We have an idea that we want to test,” Mudumbi said. “But a lot of times people don’t necessarily incorporate the people the program will serve in the development. That’s what’s unique about our project — we’re starting with that first. We’re getting people to the table, and they are going to be the ones that inform and develop and give us feedback on the project.”
The community advisory board will be made up of cancer patients, caregivers, cancer survivors and community organizations that advocate for cancer patients, Mudumbi said. She hopes the community boards will also help to eliminate some of the stigma around palliative care, where patients relate it to hospice and dying.
Regulatory challenges
The pandemic saw many flexibilities enacted around reimbursement for telehealth services to improve and protect access to telehealth for vulnerable populations. These flexibilities are expected to sunset at the end of 2024, though there are efforts to prevent that.
Mudumbi said part of the pilot’s goal is to demonstrate the value of telehealth so reimbursement for these services can remain, especially in rural and underserved communities.
“It does worry me,” Mudumbi said of the planned sunset. “But it also motivates me. We are really hoping to add a lot of evidence about the value of telehealth for rural communities to access vital supportive services for their quality of life as they go through serious illness.”
Also sunsetting this year is the federal Affordable Connectivity Program, which provided subsidies to low-income households to offset the cost of broadband internet. The program is expected to run out of money as early as April or May, according to the Federal Communications Commission. Congress has not yet authorized additional funds.
Mudumbi said that in her region of Tennessee, high speed internet access is still limited. With the Tennessee Oncology program, patients don’t necessarily need a device or internet connection, since they can access the services at a satellite clinic.
“There’s still such a disparity [between rural and urban users],” she said. “I really hope that it does go in the opposite direction, but it really saddens me because, as things get more and more advanced, the gap just keeps getting wider and wider. That’s why it was important to make sure we didn’t rely on people having access to these things we can’t control and why we decided to house it in our clinics.”
