Telehealth and Medicine Today: Technologies and Tactics Transforming Long-Term Care

Long-term care providers left behind. In the last decade, most of the work digitalizing healthcare has focused on hospitals and physician clinics. Incentives for adopting digital systems and tools bypassed nursing homes and home care providers, leaving them without a way to easily share data with hospitals and physicians. In spite of this, requirements to work more closely with hospitals and physicians increased even while reimbursement was reduced. To safely care for their patients, home care agencies and nursing homes were often asked to digitally integrate with several clinics and hospitals – something difficult and expensive to do. As a result, the fax continues to be the technology of choice to exchange health information. Accountable Care Organizations (ACOs) encounter these barriers that make sharing data with community based organizations difficult, making outcomes more difficult to measure and improve.

Highlights from Technologies and Tactics Transforming Long-term Care Conference. In spite of these challenges, there are innovative projects taking place, with some community providers developing novel healthcare homes to enable data sharing with medical providers. Tracey Moorhead, President of ElevatingHome, a new organization representing profit and non-profit home based care organizations, provided some insights. She recommends that a population predicted to deliver savings be targeted and concentrate these efforts while documenting the savings. She also recommends working with ACOs to make sure reimbursement is distributed to community based organizations so their efforts are rewarded for their telehealth investments.

Chronic Care Management – how are patients, payers and providers getting value? Bryan Arkwright from Schumacher Clinical Partners recommended measuring VOI (value on investment) rather than ROI (return on investment). The risk of not doing care management may outweigh the cost involved. For example, to maximize impact of in-person home visits, one hospital flagged dual eligible patients at hospital admission for post-discharge in-person assessment carried out by partner home care professionals. After initiating a program, look at your program metrics to make sure you are meeting your objectives, and make adjustments if needed to reach your goals.

Business cases for digital transformation of non-acute care. Scaling technologies has begun as new products and services are able to leverage what other organizations have done. In other words, digital services need to integrate with other platforms so they aren’t stand-alone. More and more, individuals are paying for their own care via American Well and other direct-to-consumer medical services. Chronic care services are going the same way, with “Telehealth 2.0” for chronic conditions integrating data from EHRs and scheduling into their platforms. And for those patients unable to pay for their care, systems are beginning to use telehealth to reduce the cost of the uncompensated care they are already doing, anyway.

Other payment sources can also be tapped. In Texas, Medicaid is reimbursing medical providers when school nurses enable telehealth visits for students with parents also connected, facilitating more convenient care and better communication for all involved. And in rural areas, eICU care is facilitated in rural hospitals and skilled nursing facilities when specialty physicians are not on site, making fewer patient transfers necessary and keeping smaller rural hospitals in business.

Some specific examples of demonstrated value. The following examples of telehealth pioneers in long-term care have already proven their efficiency and effectiveness, bringing value to patients and their organizations.

  1. MaineHealth Care At Home. This Portland, Maine, health system started targeting specific chronic diseases in 2001 and expanding digital capabilities in the following years. They now give patients tablets loaded with connections to monitoring devices and education videos. They use Vidyo secure face time for virtual visits that can also bring in medical providers to allow all members of the healthcare team to collaborate. They have developed a Home Diuretic Protocol and demonstrated cost savings by avoiding ED visits and hospitalizations. By 2016, they had a high adherence rate with a 0.7% 30 day readmission rate and no ED visits after this protocol was implemented. Because of their reimbursement constraints, their program can only be used when patients qualify for home care, but patients can continue to use it for $5/day after no longer qualifying for home care.
  2. Genoa Telepsychiatry. This national company is expanding into 1 state every month and into an additional pharmacy every week. They create a hub in a community health organization or a long-term care facility from which their psychiatrists can provide telehealth visits in partner clinic settings. Genoa provides a web-based “lite EHR" with eprescribing built in, and then provide medications via their pharmacies. They are now the 6th largest chain pharmacy in the country. For Michigan Medicaid Managed Care, they have demonstrated a higher medication compliance because the pharmacist is integrated into the care team and they also send reminders to pick up prescriptions and schedule follow up visits. They work with medical clinic partners who have come to value their “care huddles” to give additional insights into their patients’ care.
  3. Kaiser Permanente Northwest (KPNW) Home Health Virtual Visit Program. This Oregon and Washington agency had a large number of patients with chronic non-healing wounds and only 1 wound care nurse. When limited to in-person visits, this nurse could do less than 25 visits per month because of long distances between patients. She now uses Telmedx on nurses’ smart phones so she can examine remotely by video or picture images ported to her desktop. The agency is now able to provide twice as many visits, some still in person, and have added home visiting and nursing home physicians. They have developed wound and ostomy care protocols to streamline their efforts. Their wound healing outcomes have improved. They have also enabled better care when vulnerable patients with fragile wounds can be seen remotely at home or the nursing home by plastic surgeons and dermatologists, reducing risk of infection for patients and for healthcare organizations.

There are still barriers to overcome. As these services come from many different directions, creating an infrastructure to allow adequate and timely coordination, data sharing and integration into useful data management and analytics systems is needed. A recent Direct Exchange Workshop sponsored by ONC explored ways that patients could aggregate and share their own health data among their various clinicians and service providers, including their own patient-generated data. This helps overcome patient identity and matching problems and allows patients to vet their own data for errors.

Payment for services also remains a problem as insurers, government, providers, advocacy organizations and consumers are all in the mix as potential revenue sources. As systems become more adept at facilitating several payment models at once, patients can add and subtract care team members as their needs change. Provider organizations such as hospitals and clinics may change and adapt how they deliver services to more closely meet patient needs, and new products and services will emerge to support patients and caregivers in the environments they prefer. As less expensive services become more available, patients will be able to avoid expensive and more restrictive living environments and live the life they want to live as long as they can. The future of remote healthcare is only beginning.