Discussions of utilizing Telehealth to reduce readmission rates for Home Health Patients. Presented at the NC Home Health and Hospice convention in 2014
lharris_healthcare_presentation
Strategies for successful implementation of telemonitoring in
the home setting to reduce hospitalizations
Troy Rudeseal RN, BSN
Cardiac Specialist
Keeping Them Home
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Introduction
I may mention different products during this presentation but, I
am not here to endorse any particular company and do not benefit in
any way from this discussion.
I have been a nurse for 9 years mostly in the Step-down and ICU
environment. For the last 2 years I have been working to improve
outcomes in chronically ill patients through the use of
telehealth.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
I found when starting there were few resources to help guide
agencies.
This is very informal. I dont have all the answers and just want
to bring up some of the things that I have learned along the. Way.
It is a process and we are always looking to improve how we manage
our program. All of the topics are issues we have dealt with. Some
we have improved and some are still a work in progress. Please feel
free to ask questions as we go.
OBJECTIVES
This session will address:
What is telehealth?
Why implementation often fails
Improving Staff buy-in and Collaboration with physicians
Understanding how to make telehealth work without reimbursement
from CMS
Reducing hospitalizations in chronically ill patients.
Utilizing a self-management model in regards to patient
education.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
A show of hands. How many of you are currently utilizing
telehealth?
Have you found the implementation frustrating? Thats why we are
here today.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
WHY Telehealth????? I get asked by people all the time what the
benefit is putting telehealth in for a 60 day episode when they
have a lifelong chronic disease process.
INTRODUCTION
Telehealth has been utilized in the Home health setting for over
a decade and promises decreased hospitalizations, better management
of chronic disease processes, as well as decreased Skilled Nursing
visits and cost savings to organizations.
A new report from InMedica, a subsidiary of IMS Research
predicts that the use of telehealth will increase 6 fold by
2017.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
WHAT IS TELEHEALTH?
Telehealth is a means of monitoring chronically ill patients
remotely. Equipment is installed in the home and patients are
taught to take their own vitals. The system guides patients through
an interactive Health Check that collects information regarding
symptoms, care plan compliance, and vital signs such as weight,
blood pressure, oxygen saturation and heart rate.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Fow those who do not use telehealth, here is a basic description
of how the process works.
WHAT IS TELEHEALTH?
The information is immediately transmitted over a standard phone
line or a cellular signal to a nurse for review. This process
provides patients with daily monitoring from qualified healthcare
professionals without having to leave their homes.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
WHAT IS TELEHEALTH?
Home telehealth also has a direct impact on the need for skilled
nursing staff to make patient visits, offering valuable flexibility
in the assignment of personnel. Rather than establishing a set
number of visits per week to assess the patients condition,
clinicians can routinely monitor the patient remotely and visit the
patients home when the patients condition warrants. These more
focused visits provide the right care at the right time and are
more cost efficient.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
WHAT IS TELEHEALTH?
The success of home telehealth is rooted in its use as a
clinical tool with patient-specific parameters, intervention
triggers, established medical standing orders, readily available
intervention medications and, most importantly, the expertise of
clinicians in skilled assessment, monitoring use and protocols.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Common Barriers to successful telehealth implementation
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Lack of clear best practice guidelines at Implementation
Technical difficulties
Inability to get Nurses Buy-in
Inability to obtain patient consent
Lack of collaboration with Physicians
Lack of reimbursement
Ineffective patient education
Unclear guidelines for target population
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
We will touch base on each of these briefly
12
Many Vendors selling telehealth recommend cost-saving measures
that may not benefit the program in the long run.
Using HHA rather than the RN to set up equipment and guide
patients in proper use
No Physician order needed to initiate telehealth
Often unclear best-practice guidelines
Equipment that may not meet needs (lease vs. purchase)
COMMON EARLY PITFALLS
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Remember at the end of the day companies are trying to sell
telehealth and some of the inherent problems arent always fully
addressed on the front side.
Inability to obtain patient consent on admission.
Educate nurses how to present telehealth as part of
treatment.
Treat participation as mandatory for certain diagnoses.
Patients attitude toward technology and inability to use the
equipment has presented problems but new technologies are making
telehealth more user friendly for patients and caregivers and
cellular capabilities are allowing patients without landlines the
ability to be monitored.
COMMON PITFALLS
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Creating a telehealth culture within the organization.
Success depends on all members of the team recognizing the
benefits and having senior management champion the adoption of a
telehealth program from the inception.
COMMON EARLY PITFALLS
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
All levels must be invested. Liasions for referrals through
intake department and nursing staff.
Facilitating Staff buy-in
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Many nurses find it difficult to allow the
technology to work for them and feel that they must be "present"
in person to have a benefit. The idea must be embraced that we are
increasing our presence through "virtual visits" every day rather
than the traditional face-to-face visits which may only make
contact 1-3 times a week or less. This increased gap between visits
can let subtle changes escape detection.
Nurses may also avoid telehealth because of perceived additional
paperwork/charting.
Visits equal money and decreasing frequency can be a bitter
pill.
BARRIERS TO STAFF BUY-IN
I have found that most nurses change their attitude once they
have a patient whom has clearly avoided an exacerbation through the
use of daily monitoring
Sharing success stories is crucial.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Some nurses avoid TL due to incresed charting demands (phone
calls, using equipment in the home, calling for parameters) One
remedy- Make refusing consent harder than obtaining consent.
Utilization of telehealth teams can be beneficial by identifying
those nurses who are comfortable with technology and enjoy the
educational component that is so important to facilitate the
self-management model.
Develop a telehealth audit tool to assess staff for compliance
and identify additional teaching opportunities.
Nurses responsible for install and utilizing equipment on every
visit to troubleshoot and monitor pnt compliance.
Staff buy-in
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Hiring nurses specific to telehealth allows the flexibility to
train and educate to be proficient at helping pnts self manage. And
to not force nurses with an aversion to technology to use. We
looked at this option but the new unit we are using has made a
tremendous difference in the buy-in of staff and their willingness
incorporate telehealth.
When developing a telehealth program it is important to develop
admission criteria to meet your needs.
Flag ALL patients on referral who have CHF, COPD, HTN to be
assessed for telehealth on admission.
Pilot using SHP data to flag ALL patients at high risk for
hospitalization regardless of diagnoses.
TARGETING the right Population
SHP- Strategic Healthcare partners
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
We started in 2010 with a target of flagging pnts with CHF,
COPD, HTN and DIABETES. Limitations on the first model we had
regarding Diabetes monitoring led us to drop that diagnoses.
We are now looking to pilot pnts who are flagged HIGH RISK
regaedless of diagnoses.
Collaboration with physicians
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Most referrals do not come from the Physician. The Agency
Identifies all patients at intake with the diagnoses of CHF
(Congestive Heart failure), COPD (Chronic Obstructive Pulmonary
Disease) and HTN (Hypertension) and assess for telehealth
eligibility.
Obtaining vital signs call parameters from Physicians on
admission and informing them of patients enrollment per agency
protocol to reduce hospitalizations.
Partnering with Physicians to create Standing orders and
protocols for chronic processes such as CHF, COPD, HTN.
Sharing of telehealth reports
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
In this new age of collaboration, it is getting easier to get
Physicians to work together to reduce hospitalizations.
I have felt in the past obtaining PRN orders was difficult d/t
not understanding the scope of home health nursing. We are expected
to take care of increasingly sicker populations and keep them out
of the hospital. To do this we need the right tools to make timely
interventions.
Physician approved Standing orders
Diuretic protocol for CHF
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Telehealth is only one component. If we see trends, but cannot
act on them rapidly, we have not been successful.
Reducing hospitalizations
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
We know there Is no down side to being able to monitor our
patients every day and see symptom and v.s trends. This daily
contact alone will help decrease hospitalizations. When coupled
with other tools it can have a dramatic effect.
23
How to Reduce hospitalizations?
Daily monitoring of vitals and symptoms
Patient education in self- management
Use of standing orders / protocols
Enough telehealth units in use to affect overall agency
rate.
Timely initiation of install. 48hours from referral.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Reducing hospitalizations
FOR THE PAST 12 YEARS, THE U.S. DEPARTMENT OF VETERAN AFFAIRS
(VA) HAS BEEN HELPING VETERANSTHROUGH ITS CARE COORDINATION/HOME
TELEHEALTH(CCHT)PROGRAM.
THE VA TELEHEALTH PROGRAM HAS ALSO CUT PATIENT BED DAYS BY AN
IMPRESSIVE 58% AND PATIENT READMISSION BY 38%.
THE VA BEGAN ITSTELEHEALTH PROGRAM IN 2000 WITH A PILOT PROGRAM
OF 800 PATIENTS, CCHT USED SIMPLE HOME TELEHEALTH TECHNOLOGY THAT
MAINLY HELPED PATIENTS MONITOR THEIR MEDICATION. SINCE THEN THE VA
HAS CONTINUED TO EXPAND WITH OVER 500,000 PATIENTS RECEIVING HEALTH
CARE THROUGH TELEHEALTH PROGRAMS IN 2012. OF THOSE, 119,000
RECEIVED TELEHEALTH CARE RIGHT IN THEIR HOMES AND 76,000 HAD
TELEMENTAL HEALTH CONSULTATIONS, WHICH ACCOUNTS FOR 35% OF ALL
MENTAL HEALTH CONSULTATIONS IN THE PAST YEAR.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Most telehealth data thus far is provided by agencies with small
samples and can be very anecdotal. The biggest proponent of TL to
date is the VA.
HOSPITALIZATIONS 2013
2013 AVERAGES
WELLCARE TELEHEALTH HOSPITALIZATION RATE 7.78% (Observed)
WELLCARE AGENCY TOTAL RATE 20.46% (Observed) 22.95% (RAO)
SHP STATE (NC) 22.06%
SHP NATIONAL 23.53%
SHP- Strategic Healthcare partners
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Our organization has seen dramatic effects.
This is an improvement over 2012 with a rate of 16.9% for pnts
on telehealth and 22.8% agencywide.
HOSPITALIZATIONS 2014
2014 AVERAGES
WELLCARE TELEHEALTH HOSPITALIZATION RATE 6.30% (Observed)
WELLCARE AGENCY TOTAL RATE 22.21% (Observed) 24.51% (RAO)
SHP STATE (NC) 21.98 %
SHP NATIONAL 24.16 %
SHP- Strategic Healthcare partners
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Our organization has seen dramatic effects.
This is an improvement over 2012 with a rate of 16.9% for pnts
on telehealth and 22.8% agencywide.
Utilizing a self-management model in regards to patient
education
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
We are all aware of the teaching tools that we should be using
to educate pnts on disease. Some are easier to implement than
others. With telehealth one major focus is helping pnts recognize
changes to make early interventions.
28
SELF-MANAGEMENT
interventions
Provide a disease specific self-learning booklet on admission.
including medication profile and vitals signs logging sheets.
Materials are illustrated and geared to a 6th grade reading
level.
Inform patients there is an expectation that they obtain their
own low cost monitoring equipment during the episode (we will
provide assistance to those who cannot). Once the patient is able
to self monitor, we remove telehealth and begin monitoring their
ability to log vitals independently and have them teach-back signs
and symptoms to call their provider.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Remove on week 6 for those who are monitoring independently so
that the last weeks of the episode can be used to observe for
compliance and understanding.
To facilitate this, we have implemented 4 educational phone
visits by the case manager throughout the episode to reinforce
teaching.
The focus of education is rooted in teaching patients when to
recognize symptoms so they can call the Physician or agency before
an emergent exacerbation.
SELF-MANAGEMENT
CALL ME FIRST
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Pnts know when to call 911 because they can breathe. They must
learn the yellow symptoms to provide interventions. If we are
successful in no other area but this, we have one a major
battle.
how to make telehealth work without reimbursement from CMS
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
SHOW ME THE MONEY?
CMS Currently does not reimburse in North Carolina for
telehealth services.
Agencies must bear the financial burden
Develop a standard frequency to allow less scheduled visits and
a greater number of PRN. This allows need to drive the visit and
reduces cost of unwarranted nursing visits.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
There are some s codes.
What is the cost of telehealth? What frequency will provide the
appropriate care and still make the cost viable.
Let need drive the visit.
SAMPLE FREQUENCIES
Skilled Nurse Frequency:
Keep visits below 8 an episode
2 Week 1
1 every other week 9
2 PRN
(Frequency assessed on a case by case basis to allow for wounds,
labs and MD orders that may supersede the standing protocol)
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Have heard of other agencies using 3 wk 1, 2 wk 2, prn as needed
for exacerbation.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Notice that we have both reduced Frequency of Nursing visits AND
Hospitalization which lets us know we are making an impact.
35
SHOW ME THE MONEY?
Private pay tele-monitoring
Technology bundles
Med minders
Emergency Fall alerts
Telehealth monitoring
Monthly nursing visits
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
This can make a big difference for pnts and families who are
avoiding the SNFs but feel unsafe in the home.
A La Carte to fit needs $300 month for all.
If private pay can be utilized enough it can provide a buffer
for the non-reimbursed program
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Reimbursement will eventually be available.
37
WHAT IS COMING?
In July 2013, the American Telemedicine Association (ATA)
released
a report titled State Medicaid Best Practice: Report
Patient Monitoring and Home Video Visits (the Report). For the
Report, ATA surveyed state telehealth policies,
and analyzed four best practice models, including those
of Colorado, Kansas, New York, and Washington State.
17 states currently have some
form of Medicaid telehealth program
Alabama, Alaska, Arizona, Colorado, Indiana,
Kansas, Kentucky, Minnesota, New Mexico, New York,
Pennsylvania, South Carolina, South Dakota, Texas, Utah,
Washington State, and Wisconsin.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
STATEREIMBURSEMENTOUTCOMESColoradoagencies $50 per patient for
a one-time installation, and $9.45 per unit/day each month for
telehealth services, for amaximum of 31 units/days per
month.sampled over 12 months and involved 200 patients,showed 62%
reduction in 30-day re-hospitalizations for several conditions,
lower re-hospitalization as comparedwith patients receiving
traditional home care, and a decrease in emergency department
visits from 283 to 21Kansasagencies a maximum $70 per patient for
installation and training, for no more than two per patient per
calendar year, and $6 per unit/day each month. Medicaid will also
reimburse for medication reminder services at $15.91 per unit per
patient. Medication reminder services will not be reimbursed for
adult care homes.data was collected over a period of three years
for chronically ill Medicaid patients. Twenty-five of the patients
did not utilize any healthcare costs from 2007-2008, at a total
savings of $1.4 million. In 2009, annual cost savings were $26,300
per patient with a reduction of hospitalizations of 38%.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Colorado- $292.95 month +$50 install
Kansas- $186 month+ $70 install
39
STATEREIMBURSEMENTOUTCOMESWashingtonMedicaid reimburses home
telehealth services at $77 a visit, compared to $87 for an in
person visit. Medicaid does not reimburse equipment costs and costs
relating to its operation.Over 12 months, a demonstration in
Washington State saw $1.7 million in savings from reduced hospital
admissions and $86,000 in savings in reduced emergency care.
The Councils Take
The Council supports the growing utilization of remote
patient monitoring in Medicaid home care. As the Report
demonstrates, such programs are both cost-effective
and contribute to greater outcomes.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Telehealth implementation is a journey
Have clear agency goals prior to implementation
Allow ample time to see if processes are working but dont be
afraid to make changes.
Take the time to meet with many vendors and talk with references
to make sure the equipment you choose will fit your needs.
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
Track progress through utilization reports. Avg nursing visits,
hospitalization rate vs. agency, state and national benchmarks,
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
P: 555.123.4568 F: 555.123.4567
123 West Main Street, New York,
NY 10001
www.rightcare.com
|
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
JanFebMarAprMayJunJulyAugSeptOctNovDec
Hospitalizations
Telehealth
Patients only
Hospitalization
rate agency wide
SHP State (NC)
SHP National
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
JanFebMarApr
Hospitalizations
Telehealth
Patients only
Hospitalization
rate agency wide
SHP State (NC)
SHP National
