The Rural Tribal COVID-19 Response grant is complementing the Skokomish Tribe’s ongoing efforts to implement a telehealth program. Specifically, the Skokomish Tribe is purchasing mobile units to be outfitted as COVID-19 mobile clinics, providing temporary housing for members needing to quarantine, and securing remote monitoring equipment to improve access and expand whole-person care to the community.

The Georgia Health Policy Center recently spoke to Deb Dunithan, the grants and contracts specialist for the Skokomish Tribe, about participation in the Rural Tribal COVID-19 Response Grant program.  Click here to hear the interview.

What is an early accomplishment as part of your participation in the Rural Tribal COVID-19 Response Grant program?   

Our biggest accomplishment so far is the fact that we are at the very final stages of getting a very comprehensive telehealth care delivery system in our small, rural tribal clinic. If we have a patient that needs to see a specialist, it can take anywhere between 40 and 400 miles and anywhere between an hour to seven hours, and often it is not just the patient, but it is either one of our community health representatives or other family members that are transporting them. There is also a lot of disjointedness if we send someone to a cardiologist, do we get all the information back to coordinate care? With our new telehealth system, we are also in the middle of transitioning to a whole-person health care delivery system, making it a lot more effective.  

With our HRSA grant funds, we have been able to purchase six very comprehensive carts that can do EKGs and all different things. We are going to have one in each exam room, so the process will be the same whether the patient is seeing a provider onsite or if they are seeing a telehealth provider. The system is going to be totally integrated with our electronic health record system as well.  

With our HRSA funds, we are also going to purchase remote patient monitoring devices and three mobile units, two of which will be used for isolation and quarantine purposes, and one will be used as a mobile clinic for COVID screening and vaccinations. But after COVID, we can actually move this unit around and take it to the community center for flu shots or some type of screening. The other cool thing about these is they are totally self-contained, and they can be in the middle of a lot, or you can hook them to power septic, sewer, all that. Plus, they are cute — look like the little cabins with the porches.  

What is an early learning that you would share with a tribe launching a similar program?  

I think the most important thing to keep in mind when you are launching a telehealth system is the cost. As we started looking into telehealth equipment and the different systems, we found out how expensive it is because everything is proprietary equipment and proprietary software. I kept asking the question, and through all this and with dogged persistence, we were finally able to find a way to provide our telehealth services with non-proprietary software and hardware. 

So, we now have a really well-equipped cart costing $5,000, as opposed to $30,000 with either the exact equipment or equipment that’s very similar and user costs per year from $180 for a Zoom for Health Care, which is totally HIPPA compliant, to $99 per provider per month. We were also super lucky to find WithHealth, a provider that has experience providing care to tribal communities. This has really been a true partnership — not client and vendor, and we have been working with them for about three months getting their system to integrate with our electronic health records. 

So, it is really important to do your homework, be persistent, and compare apples to apples and oranges to oranges. Once we have it all figured out, we would be happy to share how we built our system with non-proprietary equipment with other tribal and other rural small clinics in order to make this affordable for everyone. My other advice is to work with your billing staff or billing service in advance to let them know what is going on so they can do the homework they need to do to make sure that they have the right coding and the right processes in place. You have to be able to capture that revenue because that is what keeps the doors open. 

How do you see participation in the Federal Office of Rural Health Policy’s Rural Tribal COVID-19 Response Grant program impacting your broader health improvement efforts?  

Telehealth was on our horizon as part of a big Medicaid transformation project that we were working on, but not right up there at the top. We thought maybe we would get around to it in 2021 or 2022. But, with every disaster does come a little silver lining, and with this funding, this need went from ‘yeah, that would be cool’ to how are we going to continue to see patients and ensure that they get the care that they need during COVID? Needs and capabilities have all come together. This funding has taken this far-out-on-the-horizon project to being able to access it now when we really need it.  

What will your tribe be doing differently in the future as a result of lessons learned from COVID-19? 

We have learned that we are usually slow about thinking about or embracing different ways of doing things. This was one of the things we were really concerned about when we were initially thinking about our telehealth program. Our program is a way to bring additional care to the reservation, as opposed to having our providers providing care to our patients, using telehealth. It used to take a really long time to make change, and now it is happening before people even notice it. People don’t have time to think about all the reasons why we can’t do this but have shifted to “Thank goodness we can still keep the doors open and can still provide services.” 
One of the projects we are having our telehealth consultant work on is a clinic continuity plan. It is not just about COVID lockdowns, but the Skokomish Reservation is located in an area that floods and sometimes gets snowed in. This plan will allow us to flip that switch back and forth between telehealth, which for me is just epic. Everything will be entered into our electronic health record, and we will be seeing people just like at the clinic.  
I think one of the things that we kind of bumbled into was the remote patient monitoring, and we found a really neat device that has to be prescribed by the provider, but it is smaller than a cell phone, and it can do O2 saturation, Holter monitoring, temperature, heart rate, and blood pressure. So, if a provider has a patient who is frail or they are concerned about them, the provider can prescribe this monitoring, provide the patient with the training, and then the provider can log into the portal and see all their data there to get a good idea of what’s going on. And the training, the unit, and the monitoring are all billable services. So, this is another way that we are able to offer more. 

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