REMOTE MONITORING AND HOME-BASED TELEHEALTH – Realities and Challenges

1. REMOTE MONITORING AND HOME-BASED TELEHEALTH – Realities and Challenges Deborah A. Randall, JD & Consultant www.deborahrandallconsulting.com Kathy Duckett, RN,BSN, Director Clinical Services Partners Homecare

2. Moving Towards Electronically Enabled Care Delivery@Home • HIT = Health Information Technology • HIE = Health Information Exchange • EHR = Electronic Health Record • EMR = Electronic Medical Record • PHR = Personal Health Record • ONC = Office of the National Coordinator for HIT [DHHS]

3. Survey 2010: eHealth Initiative • 61% of respondents agree or strongly agree that significant progress has been made in the successful adoption and use of HIT since 2007. BUT 54.9% disagree or strongly disagree the value of HIE is clearly understood & 66.6% disagree or strongly disagree outreach on value of EHR/HIE is effective

4. 55.5% of respondents disagree or strongly disagree that differences between federal and state privacy laws are not a barrier to consumer’s rights to healthcare privacy. • 56% agree or strongly agree that HIT and HIE have had a positive effects on care delivery.

5. Evolving Definitions • Telemedicine vs. telehealth • Doctor to doctor d2d • Doctor to patient d2p • Distance learning • Remote monitoring • eCare eHealth • “Smart” homes

6. Developments & Trends • New Medicare Reimbursement Possibilities: SNFs; kidney, nutritional, diabetes self-management; mental health services • Devices as diagnosis-enhancers • Infrastructure for Telemedicine and Telehealth • Legislation

7. LEGISLATION 2009-2010 HITECH ACT 2009- Stimulus Bill HIT Policy Committee of ONC Infrastructure got first funding Aging Services Technology Study PPACA – Health Reform Act 2010 Independence@Home; Medicaid Medical Home; Chronic Care; Innovation Cntr

8. TELEHEALTH IMPACT A. $2 billion in direct funding for health IT efforts, channeled through the Office of the National Coordinator [ONC] – $300 million reserved for supporting regional health information exchange efforts and the state-based “extension centers" – $20 million reserved for NIST for work on health care information enterprise integration - BEACON GRANTS B. Incentives Medicare and Medicaid to providers and hospitals adopt and use health IT systems =AND THESE PHYSICIANS CAN BE WORKING WITH HHAs and HOSPICES

9. HIGHTECH, cont. – $85 million for the Indian Health Service to use on health IT – $1.5 billion for community health centers, a sum that can be used toward health IT acquisition – $500 million for the Social Security Administration for processing disability and retirement workloads, of which up to $40 million may be used for health IT research and adoption – $1.1 billion to AHRQ, HHS, and the NIH for comparative effectiveness research

10. BEACON: $16+Million Buffalo • Western NY Info.Exchange, Buffalo • clinical decision support –registries ;point-of-care alerts/reminders • innovative telemedicine =improve primary/specialty care for diabetics, ↓preventable ER visits, hospitalizations re-admissions for diabetes, CHF, pneumonia; ↑immunization of diabetics

11. Patient Protection and Accountable Care Act of 2010 • “PPACA” --This is where the expansion will continue to be. • PPACA drives the process towards management of chronic disease. • Health information technology is finally showing, with reliable data, that telehealth can integrate with traditional care and use staffing innovations.

12. PPACA Promises? Promises! • Post-hospitalization bundling pilot • Independence at Home demonstration • Innovation Center at DHHS; chief policy person in place;telehealth focus • ACOs • Medical Home-Medicaid and Pilots • Face2face HHA provision w telehealth

13. 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

14. Technology-enabled Care: Where are we now? • Satellite health facilities • In situ care w medical devices • Remote monitoring and sensors • Awareness and acceptance • European efforts in ambient care • The VA system –the Vanguard

15. Where is Telehealth in Use • Care coordination and Chronic Disease • Patient self-management • Ambulatory care and safety • Palliative care • Rehabilitative services • Behavioral & mental health services

16. VA Chronic Care Coordination via Telehealth Study CONDITION # % DECREASE UTILIZATION Diabetes 8,954 20.4 Hypertension 7,447 30.3 CHF 4,089 25.9 [congestive heart failure] COPD 1,963 20.7 [chronic pulmonary obstruction]

17. VA Chronic Care Coordination via Telehealth Study • Posttraumatic stress disorder 45.1% • Depression 56.4% • Other mental health condition 40.9% • Single condition 10,885 patients;24.8% • Multiple “ “ 6,140 patients;26.0% • Interventions “just in time”; “air traffic control”

18. VA Chronic Care Coordination via Telehealth Study The cost ($1,600.24 pp/yr compares favorably) • direct cost of VHA’s home-based primary care services of $13,121.25 per annum and • market nursing home care rates that average $77,745.26 per patient per annum”. Conclusion: a flexible and cost-effective adjunct to VHA’s existing services. Darkins et al., Telemedicine & EHealth, 12/2008.

19. 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]

20. 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.

21. HMSA: Ambulatory MD/Home • Hawai’i Medical Service 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

22. 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

23. Telehealth:Dementia Patients • AlarmTouch GPS is a personal safety phone with GPS location in Europe. The telecare device includes a ‘Geofencing’ feature, enabling accurate location of users in need. When the wearer wanders outside a specified zone – such as home or school area - the system can send a short message (SMS) alert to a monitoring centre or to a relative or caregiver.

24. Home Telehealth - NY State • 93 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

25. Home Care Association of New York State

26. CURRENT TECHNOLOGY UTILIZATION # Providers Home Care Association of New York State

27. Disease Management Home Care Association of New York State

28. Ambient Assisted Living Programme - EU 23 EU member states with support of European Community [EC] -Enhance quality of life of older people -Strengthen industrial base by use of Information and Communication Technologies [ICT] -Aging well at home, community and work -Coherent framework for research into solutions which are compatible with varying social preferences www.aal-europe.eu

29. 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

30. Partners Home Care Stats and Facts 175 Towns and Cities 2,500Average Daily Census 24,000Admissions Annually 360,000Visits/Year 46% of Admissions are from non-Partners Healthcare System Sources 4 Hospitals: Massachusetts General Hospital, Brigham and Women’s Hospital, North Shore Medical Center, Newton Wellesley Hospital are the core hospitals for PHS Clinicians and Staff 700Full, Part-time, Per-visit 244Registered Nurses 25 Licensed Practical Nurses 131Therapists: physical, occupational, speech 7Social Workers 61Home Health Aides 32Liaisons 11Intake Nurses 4Nutritionists 185Other managers, clinical, admin Technology 383Clinicians on POC 305Telemonitoring devices – remote monitoring 3800Personal Emergency Response units

31. 9 Essential Steps for Sustainability Set Program Goals Gain Insight of Stakeholders Get Buy-in Patient Selection – choose wisely Care Coordination – 5 “Ws” 1 “H” Establish Clinical Standards Equipment Management – DME matters IS Infrastructure - IS is your friend Quality Improvement – implement soon, evaluate often Success Follows

32. 1. Set Program Goals • What is the problem you want to solve? • Set goals based on measureable outcomes • Why telemedicine? • Improved care • decrease number of emergency room visits • decrease number of hospital re-admissions • Increase patient involvement in care • Decrease home visits • Improved outcome and access/decreased costs You’ve decided to choose to start a telemedicine program What’s Next?

33. Recognize the Nature of a Paradigm Shift • Telemonitoring changes traditional notions of care delivery • Incredible opportunity to improve care and increase access • It builds careers and new skill-sets and improves peoples lives …..BUT…… • People resist change • Doing it “right” requires set up and perseverance • The 1st time takes longer than one would think

34. 2. Gain Insight of Stakeholders Nurses & Allied Health Senior Leadership Physicians Patient Operations Quality & Compliance Finance Information Systems

35. 3. Get Buy – In • 4 Main Groups • Senior Organizational Leadership • CEO  Field Staff • Patient • Getting equipment in • MD/nurse confidence • Clinicians/Allied Health Professionals • Champions • Touch and Play sessions • Manager accountability/feedback loop • Prizes • Physicians • Education • “Just in time” reports • Promised decreased calls from patients d/t triage by TM staff

36. 4. Patient Selection – Choose Wisely • Determine Patient Population • Based on program goals • Partners Telemonitoring criteria: • Moderate to high risk for re-hospitalization • Will benefit from telemonitoring • Can be managed with decreased nursing visit frequency • Patient or caregiver is able/willing to assume responsibility for monitoring • Working phone line in patient’s home • Home is safe environment for equipment

37. 5. Care Coordination – 5Ws, 1H Determine process flow • SN evaluations for program admission • By Whom? • Referrals • Who refers? • Where do referrals go? • Who processes them? • Telemonitoring of patients • Centralized – requires dedicated TM staff • Decentralized – integrated into primary clinician work flow • Reporting – Why? • Who • What • When • Where • How

38. 6. Establish Clinical Standards • Best practice, evidence based standards • Must be able to individualize standards • Use clinical experts that clinicians will accept to set standards • Educate clinicians regarding standards • Give clinicians autonomy to modify standards as they deem necessary • Give clinicians algorithms/guidelines for further autonomy in practice

39. 7. Equipment Management – DME Matters • Rent vs. purchase • Identify who will manage • Establish responsibility and accountability for • electronic inventory control • system set- up and provisioning • installation/testing/break-fix • equipment recovery, sanitizing, storage and redeployment • Training, retraining, written protocols • Begin with decentralized process (greater buy-in at local level), migrate to centralized process (efficiency & consistency) over time, selecting best of breed processes • Cultivate leadership

40. 9. Quality Improvement • Implement Soon – Evaluate Often • Establish QI program at beginning of process • Establish planned review periods • Initially weekly • Include stakeholders as appropriate • Include all 8 essential elements as part of formal QI program • Establish database for statistics at start of program • If you think you might need it, get it • Build mechanisms for gathering data if not inherent in EMR program • Excel, Access databases

41. Telemonitoring at PHC • PHC Telemonitoring Program - 2006 • Patient Selection Criteria • Available for Medicare pts currently receiving PHC • Connected Cardiac Care Program - 2007 • 4 month home telemonitoring program • Patient Criteria • Strong educational component – • 1 Nurse visit to establish clinical status and knowledge deficits, then no further nursing • Bi-weekly telephonic educational phone calls • Encourage direct patient/PCP relationship • Patient Choice Program • Private Pay • Hospice • Telehospice Pilot • CMS Pilot program

42. Positive Patient Outcomes • > 2100 patients cared for 2006- present • Average LOS 70 days • Average LOS with no rehospitalizations – 53 days • Average LOS with > 1 hospitalzation – 103 days • Average rehospitalization • PHC program – 25% • CCCP – 30% decrease year over year • 1.3% - 1st 30 days • 3% -program completion

43. MD Acceptance - CCCP

44. Clinician Response • Decrease average SNV to 10 visits/episode with improved outcomes for rehospitalization • Consistent referrals to programs • Clinician comments: • “I love it. I feel like I have a better handle on my fragile heart failure patients using telemonitoring – they look at them every day and let me know if there is a problem I need to be aware of.” • “I think it’s great – it’s made a huge difference for my patients.”

45. What are the New Directions? • Tele-rehabilitation; Falls prevention • Tele-mental and behavioral health • Continuous monitoring: diabetes; cardiac • Impaired; Alzheimer’s & dementias • “Wellness”

46. 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

47. 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

48. Telehealth and Palliative Care • Telehealth and pain management • TeleHospice care •bringing patient and family into the interdisciplinary group [IDG] •counseling to patients and family when social workers are scarce resources

49. 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

50. Prevalence of Telehospice • Informal survey • CIMIT Grant to review • Methodology • Findings • Follow-on research • Canadian telehealth research in palliative area