telehealth for hospice and palliative care – realities and challenges deborah a. randall, jd &...
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Telehealth for Hospice and Palliative Care – Realities and Challenges
Deborah A. Randall, JD & Consultant
202-257-7073
www.deborahrandallconsulting.com
Today in Telehealth at “Home”
Market?? reaching a half billion dollars in USA in five years in telemonitoring.
Remote monitoring currently in use in Western Europe and UK, and growing in Asia. VA has >62,000 homecare.
Sensoring : movement analysis, falls detection, behavior tracking, dementia safety, communication to family
Scope and Payers
Home-based telehealth mostly chronic care management => avoid ER & re-hospitalizations. Provider funded; grants; within global fee for diagnosis.
Medicaid pays some telehealth visits. Home as “originating site” NOT
reimbursed by Medicare. Skilled nursing home= live consultations in (rural or medically underserved) area
PPACA Promising Sections
Post-hospitalization bundling pilot Independence at Home demonstration Innovation Center at DHHS ACOs Medical Home-Medicaid and Pilots Face2face HHA provision w
telehealth;hospice provision silent
Telehealth and chronic illness
St. Vincent Health System's Visiting Nurse Association [Arkansas] has used telehealth computers to monitor patients in their homes for several years, and in its 11 county region had only about 4.5% of heart attack patients re-hospitalized compared with a national rate of 37%. [National Assn for Home Care report]
Telehealth and Aging in Place
University of Missouri :sensors, computers and communication systems, along with supportive health care services monitor the health of older adults who are living at home.
Motion sensor networks installed in seniors’ homes can detect changes in behavior and physical activity, including walking and sleeping patterns. Early identification of these changes can prompt health care interventions that can delay or prevent serious health events.
Blue Cross/Blue Shield WNY
Blue Cross/Blue Shield Western New York in May 2010 initiated online physician-patient communication as a compensated service; encouraging telehealth communications and webcam visits; measuring quality of care and patient compliance factors
EVP expresses interest in home eCare
HMSA: Ambulatory MD/Home
Hawai’i Medical Services Ass’n Jan 09 Online Care connects, 24/7, patients
and physicians via the Internet or telephone;1st in the nation.
$10/45 for 10 minutes interaction Physicians can be “anywhere”; service
is across all islands
Telehealth: Dementia Patients
Residential facilities designed to allow movement of individuals through facility and grounds; Families can track on computer/internet based systems
Sensoring systems; Intel research; TRILL; diagnostic sensoring for fall prevention yielding data on Alzheimer specific movement differentials
Home Care Association of New York State 10
Home Telehealth - NY State
93 home health only providers approved to bill Daily rates as of 1/1/2010 Tier I – 62 $8.88/day/patient Tier II – 31 $10.20/day/patient Tier III – to be tied to regional connectivity Medicaid Managed Care covered service
Electronic Medical Records Approximately 50% - 60% utilization – generally
medium & large sized agencies Multiple other “pieces”
Referral software, physician portals, med management hardware etc.
Home Care Association of New York State 11
DHisease Management
American Telemedicine Assn
Home telehealth and remote monitoring practice group
Working group exploring opportunity for, and prevalence of telehospice; I chair this group.
www.americantelemed.org
MD Acceptance - CCCP
What are the New Directions?
Tele-rehabilitation; Falls prevention Tele-mental and behavioral health Continuous monitoring: diabetes;
cardiac Impaired; Alzheimer’s & dementias
Telehealth and Rehabilitation
Distanced assessments Robots in SNFs Telestroke => telerehab Wii units in senior living facilities Remote monitoring for falls anticipation Traumatic brain injury;wounded warrior
Behavioral & Mental telehealth
On-going research Post traumatic stress disorder Tele-psychiatry Distanced mental health services
under new Medicare reimbursement provisions for community mental health centers
Telehealth and “High Touch”
Does Telehealth work with the history of palliative care and hospice care as intensely “high touch /high sensitivity”?
Is some Touch better than no Touch; better than Touch which comes with travel, delay, fear, understaffing? Is it not all about ACCESS?
Is mHealth’s immediacy = palliative?
“Seeing” Patient Need
Will telehealth have accuracy and reliability for Palliative and Hospice?
Can the clinician make a palliative care decision from the distance?
If the patient is the “center of care”, where more so than end of life; pain management; suffering whether physical, psychological or spiritual?
National Association for Home Care and Hospice (NAHC)
Interest in telemonitoring for home care and hospice. www.nahc.org July 2009 Caring journal devoted to
telemonitoring – some mention of hospice NAHC Division for telehomecare
Center for the Advancement of Palliative Care [CAPC] www.capc.org
National Hospice and Palliative Care Organization
Grants to hospices working in conjunction with VA locations
Not formally looking at telehealth Current Concern: PPACA requires
“visit” by MD/NP at 180 days of care— televisit not included in regulations
American Academy of Hospice and Palliative Medicine
Hospice Care
Terminally ill or end-of-life situation Team delivery of non-curative care Generally, family as the unit of care Physical, mental, psychological and
spiritual care of holistic model Generally, home-based care but some
in-patient, “hospice home” and respite
Palliative Care
Pain and symptom management Outreach and crisis management Triage without transporting to facility Psychological pain and suffering Diagnostic opportunities; family
interactions Ethical principles= autonomy enhanced
Telehealth and Palliative Care
Telehealth and pain management TeleHospice care
•bringing patient and family into the interdisciplinary group [IDG]
•counseling patients and family when social workers are scarce resources
·recorded care videos; on-call nurse
Prevalence of Telehospice
Informal survey with CIMIT Grant done in 2009
Methodology and Findings Follow-on data gathering still on-going
and informal. Professional associations are interested.
Advanced Illness –Is there a Role for Palliative Telehealth
Using an existing model of advanced illness coordination which included health counseling
Congestive heart failure, end-stage pulmonary disease, end-stage renal disease, and cancer as handled in various care settings.
Expanding a model, cont’d.
Goals for improved communication about discomfort, support for decision making;problem resolution; attention to caregiver needs.
Outcomes measurements expanded from the curent: >% DNR or intubate orders; <inpatient admissions with no difference in survival.
Opportunities and Challenges
Medical Director and other physicians Demonstrating cost savings, &/or
quality of care/life improvements- to justify expense of equipment and staff
Training and staffing. Maintenance of depth of field/bench so turnover is not a problem. Need for a "champion".
Leading nurses to embrace technology
Telehealth: Impediments
Reimbursement under Medicare Medicaid Outcomes, cost savings and care
management concerns Licensure and interstate barriers Unlawful incentives in collaboration Standards lacking: Interoperability
among devices/software/infrastructure
Attention to Legal Concerns
Licensure of palliative care provider
Liability and Consent
Privacy and confidentiality
Security of Communication
Thank You!
Deborah Randall, JD
Health Law Attorney
Telehealth Consultant
202-257-7073
www.deborahrandallconsulting.com