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UKnowledge > College of Public Health > Journal of Appalachian Health > Vol. 7 (2025) > Iss. 3

 

Corresponding Author

Jessica Thayer, MD: jlthayer@hsc.wvu.edu

Author Affiliations

  1. Jessica Thayer, MD: Assistant Professor, School of Medicine, West Virginia University (Morgantown, WV); E-mail: jlthayer@hsc.wvu.edu; ORCiD: https://orcid.org/0000-0002-7475-728X
  2. Brett Miller, MD: Resident Physician, School of Medicine , West Virginia University
  3. Marcelino Mederos Liriano, MD: Resident Physician, School of Medicine, West Virginia University; ORCiD: https://orcid.org/0009-0003-3323-6482
  4. Kathryn Hoffman, CHSE, : Interprofessional Education Project Manager and Simulation Training and Education for Patient Safety Research Coordinator, Office of Interprofessional Education, West Virginia University; ORCiD: https://orcid.org/0009-0005-6199-5755
  5. Gina Baugh, PharmD: Clinical Professor, School of Pharmacy, West Virginia University ; ORCiD: https://orcid.org/0000-0002-5419-0001
  6. Jenna Sizemore, MD: Associate Professor, School of Medicine, West Virginia University; ORCiD: https://orcid.org/0000-0002-3142-5672

Author Area of Expertise

1. Jessica Thayer, General Internal Medicine, Rural Health

2. Brett Miller, General Internal Medicine

3. Marcelino Mederos Liriano, General Internal Medicine

4. Kathryn Hoffman, Interprofessional Education

5. Gina Baugh, Pharmacist, Interprofessional Education

6. Jenna Sizemore, General Internal Medicine, Rural Health

Abstract

Introduction: Hospital discharge is a complex process plagued with medical errors and poor coordination. Disjointed discharges are detrimental to Appalachian patients with access barriers and multiple chronic diseases. Telehealth is a tool used to improve access within rural Appalachia. To address this high-risk transition period, an interprofessional team deployed telemedicine to improve post-hospital care for Appalachian patients.

Purpose: Patients with uncontrolled chronic medical conditions were enrolled into the Intensive Telemedicine Transition of Care Clinic (I-TTC) with a primary outcome of 30-day Emergency Department (ED) presentations and hospital readmissions. Secondary outcomes included improved control of chronic conditions and patient cost savings.

Methods: Patients with uncontrolled chronic conditions were given home-monitoring devices and enrolled in the I-TTC post-hospitalization. Telehealth visits were conducted with an interprofessional team comprised of graduate health science students under the supervision of I-TTC physicians. Hospital readmissions, emergency department (ED) presentations, and chronic disease specific measurements were analyzed through retrospective review.

Results: Sixteen adult patients participated in the I-TTC pilot study from 2021-2022. At baseline all patients with hypertension were uncontrolled. The average HbA1C of patients with uncontrolled diabetes was 11%. Post-enrollment, 12.5% of patients had a 30-day ED presentation or hospital re-admission. The average HbA1c for those with uncontrolled diabetes was 8.1% after I-TTC intervention. Of the ten patients with uncontrolled blood pressure, six were controlled post-enrollment. The average cohort total cost savings was $3,144.35.

Implications: The I-TTC suggests feasibility for an interprofessional team utilizing telemedicine in achieving control of chronic medical conditions through improved access to ambulatory healthcare.

DOI

https://doi.org/10.13023/jah.0703.07

Creative Commons License

Creative Commons Attribution 4.0 License
This work is licensed under a Creative Commons Attribution 4.0 License.

Recommended Citation

Thayer J, Miller B, Mederos Liriano M, Hoffman K, Baugh G, Sizemore J. Intensive telemedicine transitions of care clinic: a prospective feasibility study of a novel ambulatory model serving Appalachian patients. J Appalach Health 2025;7(2/3):95-104. DOI: https://doi.org/10.13023/jah.0703.07

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