Introduction
Rural areas often face disparities in healthcare across the United States. Some of the healthcare gaps are related to fewer resources and higher poverty rates. To be able to support access to health care and resources would help to contribute to improved health outcomes in addition to a better quality of life among rural diabetic patients served by the Alexandria VA Medical Center. Currently, the Alexandria Medical Center and outlying outpatient clinics utilize primary care physician appointments to manage patients with diabetes. The medical center and outlying clinics are in rural areas.
The location of Alexandria Medical Center’s diabetic clinic in a rural setting creates a challenge with regard to patient access to primary care. It is vital to note that as a result of limited access to primary care services, some of the patients experience poor outcomes. The inefficient glycemic control resulting from the missed clinical appointments, ineffective self-management, and infrequent medical assessments manifests as high levels of glycated hemoglobin. In essence, individuals with poorly managed diabetes develop complications that negatively impact their quality of life, seeing as they are required to take more medications, undergo more procedures, and pay more for healthcare services.
Description of Problem
Alexandria VA Medical Center is comprised of the medical center facility located in Alexandria, LA, and also has Community Based Outpatient Clinics in more rural areas of central and southern Louisiana. The facility is categorized as a primary and secondary care institution. It is a teaching health institution that provides a wide variety of primary care services using state-of-the-art technology. The hospital also offers comprehensive acute and long-term health care, which is offered on a primary as well as a secondary basis in areas of psychiatry, medicine, surgery, neurology, physical medicine and rehabilitation, oncology, geriatrics, dentistry, and extended care. The Medical Center serves an estimated veteran population of more than 100,000 veterans and maintains an active patient roster of more than 37,000 individuals (U.S. Department of Veterans Affairs, 2019). Due to COVID19 restrictions, clinic appointments have been decreased to limit patient and staff exposure to symptomatic patients. Prior to COVID19 restrictions, the facility struggled with consistent follow-up appointments for diabetic patients.
Implementing interventions intended to facilitate the improvement of health outcomes among diabetic patients at the Alexandria Medical Center is critical. Evidence-based finding on diabetes indicates that individuals who do not access primary acre services experience high levels of glycated hemoglobin. According to McLendon (2017), a research study identified glaring disparities in diabetes care between rural and urban patients. The cross-sectional analysis of findings from the 2006 Behavioral Risk Factor Surveillance System and patient responses from individuals older than eighteen years with a diagnosis of diabetes yielded the aforementioned results (McLendon, 2017). The researchers noted that individuals living in the rural areas reported infrequent foot and dilated eye exams. In addition, the rural patients reported a higher incidence of diabetic retinopathy and foot ulcers. The study further noted that rural residents seldom participated in diabetes self-management education sessions (McLendon, 2017). The disparity in diabetic education access was further highlighted by the 2007 Medical Expenditure Panel Survey, which revealed that approximately 63.7% of individuals in rural areas with type 2 diabetes did not receive any form of diabetes education (McLendon, 2017). Telemedicine remains the most viable option to consider when addressing challenges associated with access to care.
The clinic setting at the Alexandria VA Medical Center utilizes primary care physician appointments to follow patients with diabetes. These patients are seen at varying intervals ranging from 90-180 days. Several of the patients utilize other healthcare and visit the diabetic clinic infrequently. It is critical to point out that there are several patients enrolled in the clinic who are quite far from the facility. As a result, many of them experience compliance issues with regard to return visits. Although the clinic has established registered nurse clinics, the primary providers do not typically utilize registered nurses to follow diabetic patients. The inclusion of non-traditional encounters such as telehealth appointments could be facilitated by the nursing team to increase access to diabetes management for all the patients.
It is vital to note that the current practice at Alexandria VA Medical Center allows for gaps in consistent and effective monitoring of diabetics with elevated HbA1c above 9%. Intermittent and follow-up diabetes management appointments are not conducted by the registered nurse at this time. Separate appointments are made if desired, with a registered dietician or pharmacist for more in-depth education and management of weight, medication adjustment as it relates to diabetes care. The primary care physician conducts all routine follow-up care via telehealth, traditional face-to-face visits, and pharmacy disease management telephone calls for patients with poorly controlled diabetes. The clinic’s performance measures currently indicate that there is an unacceptably high number of patients with elevated glycated hemoglobin levels at the facility. It is vital to note that a decrease in HbA1c can be encouraged by the incorporation of registered nurse-led telemedicine interventions. Therefore, changes in nursing practice must be instituted to positively impact glucose control of diabetic patients registered at the clinic.
Explanation of Causes
There are marked differences in the physical health outcomes and mortality rates between people who reside in rural settings and those who live in urban areas. Americans in rural locales tend to experience higher rates of illness and less access to healthcare services (Dearinger, 2020). These differences have been highlighted by the Covid-19 pandemic meaning health institutions must be innovative to reach sections of the population without the capacity to access healthcare services. The advent of the Covid-19 pandemic has necessitated the implementation of measures designed to limit the spread of the illness. Some of the measures include limited in-person visits and social distancing measures which have limited contact between clinicians and their patients. The measures are particularly stringent when dealing with elderly individuals who stand a higher risk of contracting the disease. The need for a solution capable of ensuring that patients maintain access to essential healthcare services prompted the development of telehealth options. Remote access to healthcare professionals ensures that patients adhere to their medications, nutritional programs, and lifestyle routines.
Patients who live far from the Alexandria VA Medical Center face a variety of challenges that limit their ability to attend clinic regularly, thus negatively impacting their glycated hemoglobin levels. The high cost of travel, accommodation, food, childcare, and parking often discourage diabetic patients from attending clinics (McLendon, 2017). The geographical barriers are often an inconvenience in view of the fact that patients are forced to spend time away from home. In addition, spending time away from work may have significant economic implications. It is worth noting that many of the clinic’s patients are elderly. Therefore, a significant number of these individuals have mobility challenges that may limit their compliance with clinical visits. In addition, in the event they do not have someone to accompany them to the hospital, they may miss vital appointments. Poor attendance inevitably leads to poor glycemic control, which often impeded effective management by increasing the frequency of complications.
Specific industry and demographic factors have created the need for the adoption of telehealth services. Healthcare services in the United States are evolving from fee-for-service systems to fee-for-performance systems which consider outcomes rather than volumes (King, 2018). The increased emphasis on value and results has created incentives for the adoption of alternative approaches to service delivery. The technological advancements witnessed in America and the increasing recognition of patients as healthcare consumers have created a demand for convenient care modalities such as telehealth (King, 2018). Therefore, telehealth is considered a cost-effective alternative when compared to emergency rooms which are characterized by long waiting times and expensive services.
It is vital to note that the demographic composition in the United States supports the adoption of remote access technologies for the delivery of healthcare services. It is expected that as the aging population increases, the growing awareness of chronic conditions will spur the demand for healthcare services. Projections indicate that by 2030, the U.S. population will exceed 359 million, and one in five individuals will be over 65 years old (King, 2018). Diseases such as diabetes and its associated complications affect a significant portion of the American population. It is vital to note that despite the increase in population, the number of clinicians is unlikely to rise, meaning that the current deficit will only get worse. It is projected that by 2025, the physician deficit will stand at 100,000 (King, 2018). The severity of the healthcare worker deficit has prompted the adoption of effective modalities designed to ensure patients have uninterrupted access to essential primary care services.
Identification of Stakeholders
The clinic’s stakeholders are focused on ensuring that all the patients receive the highest quality of care possible. The main stakeholders are the patients, primary care physicians, registered nurses, and the organization’s administrators. It is vital to note that the stakeholders were identified with the aid of the course instructor, who further discussed the merits of implementing a telemedicine program at the clinic to facilitate the management of diabetic patients.
Table 1: The Clinic Stakeholders
Discussion of Stakeholders
The organization’s administrators are interested in policy changes that are likely to improve patient experiences. In addition, they are focused on the potential for improved service delivery as well as the project’s potential cost-saving capacity. Administrators have the power to authorize the implementation of proposed changes and determine the number of resources allocated to the project. In addition, they have the power to persuade interested parties to support the project. It is vital to note that administrators can influence each step of the project by including specific requirements. In addition, they can influence the clinic’s staff to support various aspects of the project’s development.
The nursing staff is interested in the implementation of telehealth because it is likely to improve the patients’ access to essential services. In addition, the proposed intervention has the potential to improve glycemic control and reduce the incidence of complications. Nurses have the power to serve as patient advocates at the clinic. Nurses also have the power to recruit other nurses to support the project in addition to reviewing the project’s target population and providing comprehensive demographic data. It is vital to note that nurses are the first point of contact which means they can influence all stakeholders at the clinic.
The primary care physicians have an interest in the project in light of its potential to increase positive patient outcomes at the clinic. In addition, their desire to participate in the project is spurred by its potential to improve access to essential services. The primary care physicians have the power to highlight the project’s importance and clinical relevance to the organization’s administrators. They can also ensure that the nurses comply with the project’s requirements. It is critical to point out that the primary care physicians can influence important implementation decisions and inspire other stakeholders to participate in the project’s development.
Patients are an essential aspect of the healthcare system’s functioning. Patients would be interested in the project because it facilitates access to essential healthcare services and reduces the overall cost of healthcare. It is vital to note that patients have the power to recruit other members of society willing to get involved in the project. Patients have the ability to influence the project by giving feedback during clinic visits. Survey scores play a critical role in determining financial reimbursement from the government. It is vital to consider the fact that patients can impact the clinic’s success by choosing to use its services.
Explanation of Project
The proposed plan outlines how the clinic can implement a telemedicine protocol designed to improve outcomes for patients diagnosed with diabetes. Implementing a telemedicine program at the clinic could potentially improve patient adherence to treatment and facilitate the improvement of overall patient outcomes. Evidence-based research indicates that a telemedicine program has the potential to reduce the incidence of diabetes-associated complications. The proposed project stipulates the steps that will be taken to implement a telemedicine program capable of benefiting the clinic’s patients who often encounter challenges accessing services. It leverages evidence-based scientific research that supports the use of telemedicine to improve patient outcomes.
The clinic offers services to patients diagnosed with diabetes using a system that utilizes primary care physician appointments. The patients are seen at varying intervals depending on the severity of their illness and the degree of glycemic control. It is vital to note that a number of patients who frequent the clinic live more than 40 miles from the facility. The long distances significantly influence their compliance to clinical visits. While the clinic has established registered nurse clinics, primary providers seldom utilize these clinics for the management of diabetic patients. Therefore, the proposed plan, which advocated for the implementation of non-traditional encounters such as telemedicine, could increase access to diabetes management for the clinic’s patients.
Proposed Solution
The project’s proposed solution will identify an intervention aimed at improving compliance and outcomes among diabetic patients at the Alexandria VA Medical Center diabetic clinic. It will feature a step-by-step plan for the implementation of a telemedicine program at the facility. The course instructor will play an instrumental role in guiding the completion of an evidence-based literature review to identify the most effective way of ensuring patient compliance to clinic visits is improved. The nurses at the facility have access to the institution’s patient almanac database. It features a comprehensive list of diabetic patients enrolled at the clinic. It is vital to note that the registered nurses utilize the database to review current HbA1c values, medications, and clinic appointments. The project proposes a plan where the registered nurses use the information from the database to contact the patients and offer various telemedicine interventions over the phone, secure email, or videoconferencing. The utilization of telemedicine technology will facilitate the review of follow-up visits, the sharing of decision-making goals as well as patient education.
It is essential to highlight the benefits of implementing a telemedicine program to the clinic’s administrators. This is because the implementation of the program would improve outcomes, increase patient satisfaction and reduce the incidence of diabetes-associated complications. In addition, positive patient survey results are likely to increase government funding for the clinic. It is critical to stress to the clinic’s staff that implementing the project will improve compliance to clinic visits and improve access to essential health services. As a result, patient satisfaction will increase, given that the clinic’s clients will receive quality services.
Evidence Summary
There are few studies focused on evaluating the effectiveness of using telemedicine programs to facilitate self-management and the monitoring of hemoglobin A1c levels in diabetic patients. Diabetes is a growing health concern in several parts of the world, many of which have limited access to specialized health services. It is estimated that the diseases affected approximately 463 million adults globally in 2019, with type 2 diabetes representing 90% of the cases (Sim & Lee, 2021). It is also worth noting that the disease accounted for approximately 5 million deaths in 2015 (Correia et al., 2021). It is estimated that by 2030, the estimated annual medical costs for the management of type 1 and 2 diabetes in the United States will reach 622 billion dollars (Correia et al., 2021). Therefore, it is critical to identify alternative methods to reduce the impact of the illness and minimize the severity of complications. Alternatives such as telehealth are beneficial for primary care teams, diabetic patients, and healthcare institutions.
A systematic review and network meta-analysis of telemedicine interventions in 2017 evaluated the effectiveness of a variety of telemedicine strategies on type 2 diabetes. Telemedicine refers to the transmission of medical information between different locations through electronic means to facilitate the improvement of patient outcomes (Lee et al., 2017). The modalities evaluated included telementoring, telemonitoring, teleconsultation, and Tele-education. The researchers’ findings indicated that there was a significant decline in HbA1c when a variety of telemedicine strategies were incorporated into patient care routines compared to standard care, except for telecase-management and telementoring. The researchers noted that telemedicine had the potential to provide services to patients in rural and underserved areas (Lee et al., 2017). All the aforementioned advantages coupled with a reduction in HbA1c levels could result in reduced healthcare costs.
It is vital to note that shifts in baseline HbA1c levels among diabetic patients who benefitted from telemedicine services were a primary outcome during the study. The researchers surmised that telemedicine services in combination with conventional healthcare services resulted in improved glycemic control among diabetic patients. These findings support the Healthy People 2020 diabetes goal, which was to reduce the incidence of diabetes and its economic burden while improving the quality of life of individuals afflicted by the illness (McLendon, 2017). Telemedicine positively impacted HbA1c levels when used to communicate with patients and facilitate medication adjustment. It is worth noting that interactive interventions such as text messaging by healthcare providers had a significantly positive effect on patient HbA1c levels (Faruque et al., 2017). The noted improvement significantly improved patient outcomes with regard to the management of diabetes.
Some researchers have demonstrated the effectiveness of telemedicine with regard to glycemic control. It is vital to note that while self-care is inextricably linked to improved glycemic control, a number of patients with diabetes are unable to implement the required changes. Most of them are impeded by geographical barriers, poor self-efficacy, and the lack of social support. Sim & Lee (2021) sought to understand user feelings and attitudes towards telehealth and its impact on their lifestyles. Understanding patient perceptions facilitates the customization of programs to meet user needs which is essential for improved outcomes. Sim & Lee (2021) found that patient preferences for face-to-face communication necessitated the creation of two-way communication telehealth systems to allow real-time interaction with healthcare providers. This is because studies demonstrate that telehealth consultations that included a clinician were the most effective at reducing glycated hemoglobin levels (Sim & Lee, 2021). It is vital to note that for individuals diagnosed with type 2 diabetes, patient education was a key determinant of satisfaction. It is evident that telehealth services have the ability to significantly impact disease management among patients with diabetes.
Telemedicine has numerous advantages with regard to the benefits it confers to diabetic patients. Ray et al. (2017) propose that mobile technologies can be used as central nodes in a network to link rural individuals with information that can improve their overall health. For instance, video conferencing eliminates the geographical barriers to care while facilitating the continuity of care and access for individuals with disabilities (Newbould et al., 2020). In addition, it improves access to a range of services, including those offered in primary care. It is vital to note that telemedicine can be adapted to meet the target population’s health needs and facilitates the delivery of support twenty-four hours a day (Newbould et al., 2020). The full adoption of telemedicine has the potential to improve access and reduce healthcare costs (King, 2018). Telehealth programs also facilitate the improvement of administrative efficiency while solving the perennial provider shortage that has plagued the health system for years (Saeed & Pastis, 2018). Improving efficiency and access to healthcare services is a vital step in improving the management of diabetes.
It is vital to note that the application of telehealth services may face certain challenges. For instance, regions with poor internet connectivity may face access challenges which may render the program ineffective (Liddy et al., 2017). However, most of the challenges associated with the implementation of telehealth services can be overcome provided contextual factors are considered. These factors include facilitators and potential barriers to implementation.
It is vital to note that developing a multidisciplinary telehealth team could support patients by allowing them to be actively involved in the management of their health conditions. This significantly reduces pressure on the health system and facilitates the delivery of quality services (Gall et al., 2020). In addition, evidence suggests that individuals who have frequent follow-up visits have much lower mortality rates compared to individuals with limited access to health services (Hawley et al., 2020). Developments linked to telehealth in diabetes include the use of applications that can be connected to systems capable of monitoring glucose levels and transmitting the information to a clinician, who will then advise on the necessary medical, dietary, and lifestyle modifications remotely (Chehade et al., 2020). Telehealth is relevant because the emergence of SARS-CoV-2 has highlighted the need for medical professionals to offer services to patients remotely (Dearinger, 2020). Health institutions have reduced the frequency of in-person health visits in an attempt to curb the spread of the disease.
Communities living in rural areas face a variety of health disparities. In a study conducted by Batsis et al. (2020), an mHealth obesity wellness intervention program was developed to facilitate the provision of care to elderly obese individuals. The program featured a self-monitoring and adaptable device in addition to exercise and nutrition sessions. The study results indicated that the program allowed patients to overcome barriers associated with the delivery of care, such as distance, time, and weather (Batsis et al., 2020). In addition, the program improved health outcomes by creating an accountability structure given the ease with which it could be adapted to local contexts. Therefore, a remote telehealth program could be adapted for the management of diabetic patients who faces challenges accessing the clinic.
Plan of Action
A comprehensive literature review was discussed with the course instructor to determine the most effective telehealth options to implement at the clinic. The formulated plan of action includes a set of interventions designed to improve access to consultation services and improve outcomes among diabetic patients. The complete telehealth plan would then be presented to the clinic’s leaders for implementation. The plan involves using the access registered nurses have to the almanac database to implement specific telehealth services. The database contains a list of all the type 1, and 2 diabetes patients enrolled at the primary care clinic. Traditionally, registered nurses use the data to review patient medications, assess HbA1c results and evaluate the list of scheduled appointments.
The proposed plan includes measures designed to allow registered nurses to use the information in the database to contact patients and offer a variety of telemedicine interventions geared towards improving the management of diabetes. The services include telephone interventions, secure email messaging, and videoconferencing sessions. The main intention of engaging patients through telehealth programs is to remind them about appointments, educate them on varied aspects of their illness and offer encouragement. In addition, it is essential to review shared decision-making goals and make recommendations based on the patient’s progress.
Timeline
Table 2: Plan of Action Timetable
The first week will be reserved for getting permission to conduct the project, engage the course instructor and discuss how to identify various healthcare problems. The meeting will also be used to evaluate potential solutions. After approval is granted, the next step will be to conduct a comprehensive literature review with the instructor’s assistance during the second week. It is vital to note that the information and studies that will be included in the review will all be from the past five years. In addition, only peer-reviewed, evidence-based resources will be utilized in the process.
The third week will be reserved for discussions with the course instructor to determine the most appropriate intervention for increasing access to consultation services for diabetic patients who face challenges accessing the clinic. The information from the literature review will be utilized to develop a first draft of the proposed plan. During the fourth week, the proposed plan will be assessed with the course instructor, who will offer guidance on how to deliver and present critical findings. Areas that require revisions will be outlined and the appropriate changes made. The fifth week will be reserved for the creation of the final proposal and the making of preparations for the plan presentation. Finally, during the sixth week, a presentation of the final proposed plan will be made to the course instructor.
Required Resources and Personnel
It is vital to note that meeting with the Alexandria VA Medical Center administrators and stakeholders is impossible given the government’s directives on avoiding gatherings as a measure to limit the spread of Covid-19. The permitted alternative is to conduct weekly meetings with the course instructor to discuss the project’s development. The university library and Google Scholar will be instrumental in the formulation of a comprehensive literature review. The resources used in the literature review must meet specific criteria. They must demonstrate the use of evidence-based material, must have been published in the last five years, and must be peer-reviewed. It is vital to note that access to the Alexandria VA Medical Center’s almanac database is critical. This is because the proposed solution involves using the database to implement specific interventions.
Proposed Change Theory
The most effective best practice change model to apply to the proposed changes for incorporating registered nurse-led telemedicine at the Alexandria VA Medical Center diabetic clinic is Kotter and Cohen’s Model of Change. This is because the change model appeals to people’s feelings. The proposed practice change addresses the issue of improving the lives of the clinic’s diabetic patients. It is worth noting that patient health involves all the clinic’s personnel both directly and indirectly, involves all clinic personnel. By appealing to their emotions towards wanting our diabetic patients to succeed in lowering their HbA1c and thus potentially decreasing other health risk factors, the registered nurses will feel a sense of accomplishment and the need to continue supporting the practice change.
Continuous medical education and reviews of clinical outcomes data which are displayed in the Alexandria VA Medical Center’s primary care area will help to increase the sense of urgency or need to change. The information on display highlights the percentage of diabetic patients with an HbA1c level greater than 9%. Given that the center’s primary care clinic setting comprises only three teams, needs and ideas for improvement are discussed weekly. These meetings are attended by all registered nurses, meaning that the team leaders can guide the change while working together. A strategy will be developed based on knowledge of the patient population, and the plan will then be communicated to other stakeholders. Primary stakeholders will include the patients, primary care providers, nursing staff, and the organization’s leaders.
Once the vision and strategy have been communicated, implementation of the use of telemedicine interventions by the registered nurses to improve the HbA1c readings of the clinic’s diabetic patients can begin. The registered nurses will utilize designated scheduled and unscheduled appointment availability to offer access to diabetic patients via usual care, video on demand, as well as telephone visits. Registered nurses will be encouraged to offer telemedicine intervention to diabetics while reassuring patients of primary provider consultation. Scheduling clerks will be educated on the need to confer with registered nurses to prevent utilization of registered nurse telemedicine appointments for other care or until said access is readily available within three days of the requested appointment.
Kotter and Cohen’s model posits that in the short term, the number of people resistant to the change will decrease. After continued progression and implementation of the proposed vision, resistance will decline further. With the implementation of the new behavior of utilizing telemedicine registered nurse interventions to positively impact HgbA1c levels of Alexandria VA Medical Center’s diabetic patients, the change will last. The change model will influence the effectiveness with which the proposed intervention is implemented.
Barriers to Implementation
With any proposed practice change, there are some possible barriers to successful implementation. The largest obstacle the Alexandria VA Medical Center faces is the buy-in from its patients. The center’s patient population is majority elderly clientele that often voices their lack of technical knowledge. The clinic staff is tasked with encouraging them and offering a hands-on demonstration of the use of videoconferencing via their smartphone, computer, or tablet. The patients must also have an active email account for the clinic’s staff to send a link to join the videoconference. Once the knowledge is shared, demonstrations are given, and primary care providers promote the idea, the patients will be more open to the use of telemedicine.
Another barrier to successful implementation is the procurement of equipment needed to provide registered nurse-led telemedicine services. However, the Alexandria VA Medical Center believes in the benefit and has supported the project. It is vital to note that all the registered nurses were furnished with a webcam, software, and education on how to use videoconferencing equipment. Additionally, all nursing staff has access to the patient database for their respective teams and access to secure email messaging for patients who have opted in to use that service.
The most prominent ethical implication that may arise while implementing the use of registered nurse-led telemedicine is ensuring patient privacy. Patients would have to be aware of the need to have a secure wireless internet connection and be in a secure location such as home or other places that no one will have access to their protected health information unless the patient has requested to have company in the room.
It is vital to note that the patient will need to be aware that the organization is not responsible for any data use payment to their cable, cellular, or internet provider. This is an important barrier in view of the fact that the additional costs are likely to discourage patient participation. Patients who chose to opt into telemedicine can sign a waiver or other such document prior to the use of services to acknowledge being informed of their responsibilities as a telemedicine patient. Furthermore, each registered nurse has their own office from which to conduct telemedicine visits. The offices have doors and volume controls on the computers that are used for videoconferencing. Therefore, the benefits of RN telemedicine will far exceed possible barriers to care implementation.
References
Batsis, J. A., Dokko, R., Naslund, J. A., Alexandra, B., Kotz, D., Bartels, S. J., & Carpenter-, E. (2020). Opportunities to improve a mobile obesity wellness intervention for rural older adults with obesity. Journal of Community Health, 45(1), 194–200. Web.
Chehade, M. J., Yadav, L., Jayatilaka, A., Gill, T. K., & Palmer, E. (2020). Personal digital health hubs for multiple conditions. Bulletin of the World Health Organization, 98(8), 569–575. Web.
Correia, J. C., Meraj, H., Teoh, S. H., Waqas, A., Ahmad, M., Lapão, L. V., Pataky, Z., & Golay, A. (2021). Telemedicine to deliver diabetes care in low-and middle-income countries: A systematic review and meta-analysis. Bulletin of the World Health Organization, 99(3), 209-219B. Web.
Dearinger, A. T. (2020). Covid-19 reveals emerging opportunities for rural public health. American Journal of Public Health, 110(9), 1277–1278. Web.
Faruque, L. I., Wiebe, N., Ehteshami-Afshar, A., Liu, Y., Dianati-Maleki, N., Hemmelgarn, B. R., Manns, B. J., & Tonelli, M. (2017). Effect of telemedicine on glycated hemoglobin in diabetes: A systematic review and meta-analysis of randomized trials. Cmaj, 189(9), E341–E364. Web.
Gall, A., Bradford, N., & Finnane, A. (2020). of lymphoedema :Clinicians’ and patients’ perspectives. Journal of Lymphoedema, 15(1), 29–35. Web.
Hawley, C. E., Genovese, N., Owsiany, M. T., Triantafylidis, L. K., Moo, L. R., Linsky, A. M., Sullivan, J. L., & Paik, J. M. (2020). Rapid integration of home telehealth visits amidst COVID-19: What do older adults need to succeed? Journal of the American Geriatrics Society, 68(11), 2431–2439. Web.
King, M. W. (2018). Telemedicine: Game changer or costly gimmick? Denver Law Review, 95(2), 289–328. Web.
Lee, S. W. H., Chan, C. K. Y., Chua, S. S., Chaiyakunapruk, N. (2017). Comparative effectiveness of telemedicine strategies on type 2 diabetes management: A systematic review and network meta-analysis. Scientific Reports, 12680(7), 1-11. Web.
Liddy, C., McKellips, F., Armstrong, C. D., Afkham, A., Fraser-Roberts, L., & Keely, E. (2017). Improving access to specialists in remote communities: A cross-sectional study and cost analysis of the use of eConsult in Nunavut. International Journal of Circumpolar Health, 76(1), 1–7. Web.
McLendon, S. F. (2017). Interactive video telehealth models to improve access to diabetes specialty care and education in the rural setting: A systematic review. Diabetes Spectrum, 30(2), 124–136. Web.
Newbould, L., Ariss, S., Mountain, G., & Hawley, M. S. (2021). Exploring factors that affect the uptake and sustainability of videoconferencing for healthcare provision for older adults in care homes: A realist evaluation. BMC Medical Informatics and Decision Making, 21(13), 1-13. Web.
Ray, R., Sewell, A. A., Gilbert, K. L., & Roberts, J. D. (2017). Missed opportunity? Leveraging mobile technology to reduce racial health disparities. Journal of Health Politics, Policy and Law, 42(5), 901–924. Web.
Saeed, S. A., & Pastis, I. (2018). Using telehealth to enhance access to evidence-based care. Psychiatric Times, 35(6), 9–10. Web.
Sim, R., & Lee, S. W. H. (2021). Patient preference and satisfaction with the use of telemedicine for glycemic control in patients with type 2 diabetes: A review. Patient Preference and Adherence, 15, 283–298. Web.
U.S. Department of Veterans Affairs. (2019). Alexandria VA health care system. Web.