He added that engaging leaders at the national level is key to expanding models to other locations. Manson agreed, stating that generating an early series of small but effective models can inform other advocacy levels. For example, Manson and Shore discussed the role of the VA in supporting the development and further adoption of local models of care that were based on existing tribal relationships. Darkins stated that population health is really the driver for the development of telehealth. Perhaps there will be collaborations at the state level to allow for telecommunications resources to be pooled and used in different ways to serve multiple organizations. However, he said, there are many complexities, including privacy and confidentiality, to making this happen.

One participant asked how to get CMS to accept the work and data of the VA and IHS as evidence for coverage decisions. Carroll answered that the IHS has been working with CMS on these issues. He noted that the IHS also has tremendous data to share on outcomes, process, and costs related to the use of telehealth for national coverage determinations for telehealth. Carroll noted that a U.S. Senate bill had previously been proposed to authorize Medicare telehealth reimbursement for community health centers and Indian health sites. Darkins stated that CMS has been actively supporting telehealth development with many pilot programs. He added that telehealth is not being carried out in a standardized way across the United States, and that creating standardized systems for telehealth within the VA is a key to success. Darkins stated that CMS bases investment decisions on effectiveness, and they will determine if and when there is sufficient evidence to support the development of larger telehealth networks, and which, if any, of the models they believe can be transferred.

Cultural Competency

One participant raised the issue of the importance of cultural competency to the patient-provider relationship. Shore responded that in each community he and his team have served, they have tried to establish either a formal or an informal network with traditional healers. He said they have had ceremonies and blessings for the use of videoconferencing. They also will refer patients interested in traditional healers for sweat lodges to help with posttraumatic stress disorder, and that occasionally, those healers (with the patient’s permission) will come in to discuss the patient’s treatment. Shore stressed that this demonstrates to the individual patient that his or her perspective on health care and treatment is being considered, and it is an indication to the community that the individual provider and the larger health care organization are considering the community needs. Shore further asserted that demonstration of collaboration and partnership at the community level is critical to relationships.

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