lharris_healthcare_presentation

Strategies for successful implementation of telemonitoring in the home setting to reduce hospitalizations

Keeping Them HomeP: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|IntroductionI 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: 555.123.4567123 West Main Street, New York, NY 10001www.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 failsImproving Staff buy-in and Collaboration with physiciansUnderstanding 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: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com| TELEHEALTH ?

P: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.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.

WHY TELEHEALTH ?

P: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|Common Barriers to successful telehealth implementation

P: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|11Lack of clear best practice guidelines at ImplementationTechnical difficultiesInability to get Nurses Buy-inInability to obtain patient consentLack of collaboration with Physicians Lack of reimbursementIneffective patient educationUnclear guidelines for target populationP: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|We will touch base on each of these briefly12Many 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 useNo Physician order needed to initiate telehealthOften unclear best-practice guidelinesEquipment that may not meet needs (lease vs. purchase)

COMMON EARLY PITFALLS

P: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|All levels must be invested. Liasions for referrals through intake department and nursing staff.

Facilitating Staff buy-inP: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|The nurse Gate keeper16Many 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: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.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 partnersP: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|20Most 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: 555.123.4567123 West Main Street, New York, NY 10001www.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 CHFP: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.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.23How 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: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|Reducing hospitalizationsFOR 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: 555.123.4567123 West Main Street, New York, NY 10001www.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 20132013 AVERAGESWELLCARE 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 partnersP: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.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 20142014 AVERAGESWELLCARE 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 partnersP: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.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 FIRSTP: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.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: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|31SHOW 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: 555.123.4567123 West Main Street, New York, NY 10001www.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 FREQUENCIESSkilled Nurse Frequency:Keep visits below 8 an episode

2 Week 11 every other week 92 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: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|Have heard of other agencies using 3 wk 1, 2 wk 2, prn as needed for exacerbation.SHOW ME THE MONEY?

Private pay tele-monitoringTechnology bundles Med mindersEmergency Fall alertsTelehealth monitoringMonthly nursing visitsP: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.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

WHAT IS COMING?P: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|Reimbursement will eventually be available.35WHAT IS COMING?In July 2013, the American Telemedicine Association (ATA) releaseda report titled State Medicaid Best Practice: ReportPatient Monitoring and Home Video Visits (the Report). For the Report, ATA surveyed state telehealth policies,and analyzed four best practice models, including thoseof Colorado, Kansas, New York, and Washington State.

17 states currently have someform of Medicaid telehealth programAlabama, 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: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|36

STATEREIMBURSEMENTOUTCOMES

Coloradoagencies $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: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|Colorado- $292.95 month +$50 installKansas- $186 month+ $70 install37

STATEREIMBURSEMENTOUTCOMES

WashingtonMedicaid 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 TakeThe Council supports the growing utilization of remotepatient monitoring in Medicaid home care. As the Reportdemonstrates, such programs are both cost-effectiveand contribute to greater outcomes. P: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|38Telehealth implementation is a journeyHave 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: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|Track progress through utilization reports. Avg nursing visits, hospitalization rate vs. agency, state and national benchmarks, QUESTIONS?

P: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|THANK YOU

P: 555.123.4568 F: 555.123.4567123 West Main Street, New York, NY 10001www.rightcare.com|