BackgroundThe growing prevalence of obesity is paralleling a rise in the older adult population creating an increased risk of functional impairment, nursing home placement and early mortality. The Centers for Medicare and Medicaid recognized the importance of treating obesity and instituted a benefit in primary care settings to encourage intensive behavioral therapy in beneficiaries by primary care clinicians. This benefit covers frequent, brief, clinic visits designed to address older adult obesity.DiscussionWe describe the challenges in the implementation and delivery into real-world settings. The challenges in rural settings that have the fastest growing elderly population, high obesity rates, but also workforce shortages and lack of specialized services are emphasized. The use of Telemedicine has successfully been implemented in other specialties and could be a useful modality in delivering much needed intensive behavioral therapy, particularly in distant, under-resourced environments. This review outlines some of the challenges with the current benefit and proposed solutions in overcoming rural primary care barriers to implementation, including changes in staffing models.ConclusionsRecommendations to extend the benefit’s coverage to be more inclusive of non-physician team members is needed but also for improvement in reimbursement for telemedicine services for older adults with obesity.

Transfer of patients from rural emergency departments to tertiary centers can improve outcomes. The transfer process is complex and often ad hoc, inefficient, duplicative, and frustrating to both patients and providers. Suboptimal transfer undermines quality of care, raises costs, and delays services. Unfortunately, the same barriers that make transfer necessary (limited resources, geographic isolation) also hamper effective review. In this article, we describe a Web-based, interactive morbidity and mortality conference series in which providers reviewed cases transferred from rural emergency departments to a tertiary center. Six case-review conferences were conducted over 8 months. Each involved an average of 20 providers representing a total of 7 hospitals. Learning resources (ie, care protocols, best practice reviews, literature reviews) were developed collaboratively and disseminated among participating hospitals following the case-review conferences. Participant responses were highly favorable: 100% found the case reviews "very useful" or "useful" and 100% strongly agreed that the reviews would improve quality of patient care. We conclude that Web-based technology can efficiently facilitate review of transfers and has the potential to positively impact patient care. Future studies should utilize standard validated survey instruments of a larger number of participants to better understand the impact of this intervention.