Telehealth Program Strategies and

Business Plans Revealed

March 4, 2016
Rob Marchuk, VP of Ancillary Services, Adventist Health
Nannette Spurrier, Sr. Telehealth Management Consultant, Blue Cirrus Consulting
Conflict of Interest
Rob Marchuk, MPH, MBA, FACHE
Has no real or apparent conflicts of interest to report.

Nannette Spurrier, MS
Has no real or apparent conflicts of interest to report.
Agenda
• Adventist Health’s Telehealth Initiative
• Telehealth Market Landscape
• Telehealth Strategy and Business Plan
• Telehealth Program Implementation

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Learning Objectives
• Analyze the telehealth market and discuss the changing landscape of
telehealth including traditional and emerging market solutions

• Define the components of a telehealth strategy and business plan

including staffing models, market analysis, technology solutions, 1,3,5 year
planning, financial models and creating the telehealth ‘Building Blocks’ for a
mature clinical program

• Describe how to implement the plan successfully including leadership

communication plans, internal and external marketing and creating a
measured plan for success

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 Realizing the Value of Telehealth

Patient
Patient
Costs Extended
Satisfaction
Reduction in clinical reach
Access to
travel costs Reduction in
specialists from
missed Reduction in
rural locations
appointments unnecessary
admissions or
Physicians
readmissions
Costs
Costs related to Patient
Improved
missed Accountability
Outcomes
appointments
Physician Patient
Timely Patient
Education
Satisfaction
Physician Care
Consults with
Satisfaction
Specialists when Access to
Consults with
needed Avoidance
Specialists when Specialists
Outcomes of
needed Regardless of
Improved unnecessary
location
Coordinated transfers
Patient Care

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Adventist Health’s Telehealth Initiative

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About Adventist Health
• Faith-based, not-for-profit, integrated health care delivery system
headquartered in Roseville, California providing care throughout California,
Hawaii, Oregon and Washington
• Entities include:
– 20 hospitals with more than 2,875 beds
– More than 275 hospital-based, rural health, and physician clinics
– 14 home care agencies and seven hospice agencies
– Four joint-venture retirement centers
– Workforce of 31,000 includes more than 22,350 employees; 4,800
medical staff physicians; and 3,850 volunteers
• With a focus on whole-person health Adventist Health not only strives to
promote healthy individuals and families but also healthy communities

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Adventist
Health
CA
Locations

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Adventist
Health
Northwest
Region
Locations

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Adventist Health’s Rural Landscape

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Telehealth at Adventist Health
• Telehealth is not a new concept to Adventist Health
• Various telehealth models have been implemented across the
system over the last decade
• Rapid increase in need and demand for telehealth services in recent
years drove the necessity for system-wide standardization
• In 2013 partnered with Blue Shield of California on an outpatient
telehealth initiative focused on rural communities
• In 2014 telehealth became a corporate initiative

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Telehealth Market Landscape
• Learning Objective 1

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Telehealth Industry
• Drivers
– Aging Population
– Consumer Demand
– Enhanced Reimbursement
– Eroding Hospital Margins
– Provider Shortages
– Outcome Based Reimbursement
– Readmission Penalties
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• Barriers
– Access To Broadband
– Cost
– Licensure
– Limited Reimbursement
– Network Speed
– Privacy And Security
– Resistance To Change
Changing Landscape of Telehealth
• Most Rapidly Growing Sector In The Healthcare Industry
– Venture Capital Market
– Increase In Retail Clinics And Employer Onsite Health Centers
• Expanding Reimbursement
– Medicare Telehealth-Based Chronic Care Management
– Continued Push At The State Level
• Expanding Payment Options
• More ACOs Using Technology To Improve Care And Cut Costs

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Telehealth Market Solutions

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Telehealth Strategy and Business Plan
• Learning Objective 2

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 Why Strategy is Important
Telehealth Vision Clear Communication
– Where We Want To Go – Internal Marketing
– Direction On How To Get There – External Marketing
Strategic Alignment Across Enterprise Focus on Specific Clinical Problems
– Rural Health Strategy – Access to Care
– Payment Options in CA – Program Expansion
Leadership Buy-in Success Metrics
– Multiple CEOs & Leaders – Consistent Criteria
– Unique Physician Relationships – Comparable Data
– Competing Internal Initiatives

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Adventist Health Telehealth Vision

Support the mission, vision, and

values of AH by creating enhanced
and expanded access to care for the
patients and populations we serve
both in existing and expanded
markets.
Access between patients and
providers will be delivered through
innovative, efficient, reliable, and cost
effective technologies.

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Developing the Telehealth Business Plan

Set telehealth goals

Review telehealth situation

Determine why goals are attainable

Plan for reaching those goals

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 Identifying the Telehealth goals

Reviewing
the
telehealth
situation

Reaching
those
Telehealth Business
goals Plan & Strategy

Determining why the goals

20 are attainable
Needs and Readiness Assessment
• Goal
– Align needs and readiness
• Objectives
– Identify factors that could impact
success of telehealth program
• Approach
– Staff interviews
– Self-Assessment
– On-site and phone interviews
– Conducted over the course of 3
days
– Developed SWOT analysis
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• Sample size
– Approximately 30 individuals
interviewed from all three regions in
CA
• Corporate Executives
• Corporate Directors
• Clinical Directors & Staff
• IT Directors & Staff
• Interview feedback was documented
along with associated risks and
recommended action plan
• Gained clear understanding of telehealth
acceptance and challenges with existing
programs
Telehealth Services Review
• Assess the clinical services operations and determine where
telehealth services will be delivered.
• Objectives
– Gain consensus around value proposition and Adventist Health market
– Review current clinical services operations
– Review current state of technology and infrastructure
– Assess technical needs at each site
• Framework created to add structure to the telehealth service options
• Telehealth services identified
• Staffing model to support the implementation and ongoing
program

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 Telehealth Value Proposition
Primary Care
Patients Communities Specialists
Providers
• Accessibility: care • Keeps patients local • Promotes • Extends broader
when and where they whenever possible coordinated care reach to patients
need it
• Promotes rapid • Maintains primary • Increases patient
• Affordability: diagnosis and relationship with volume and revenue
reduces travel time, treatment linked to patient and maximizes time
expense and time improved patient and efficiency
away from work outcomes • Establishes
credibility with patient • Reduces
• Timeliness: reduces • Improves outcomes documentation
wait time to access and therefore • Promotes greater redundancy by using
specialists improve health of patient satisfaction common EMR
population platform with PCPs
• Integrated and • Generates revenue –
coordinated care visit reimbursement • Promotes
coordinated care

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Functional Staffing Model

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Regulatory & Policy Review
• Goal
– Ensure regulatory impact on
telehealth is clearly understood
and monitored
• Objectives
– Telehealth credentialing and
privileging process
– Research state licensure for
telehealth
• Considerations for plan
- Standardize credentialing and
privileging process
- Utilize credentialing by Proxy
- Understand cross state
requirements
• Reimbursement
– Payers

– Security and Privacy • Medicare

– Telehealth Service Level • Medicaid

Agreements • Commercial Payers
– Reimbursement policies – Rural Facilities

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 Federal Telehealth Reimbursement
Payer Telehealth Delivery Federal Regulations
Model
Medicare Live Video Medicare reimburses on the specific services identified by
Current Procedural Terminology (CPT)
Store & Forward Prohibited

Remote Patient Reimburses for remote patient monitoring of chronic

Monitoring (RPM) conditions

Rural approved originating sites:

• Offices of physicians/practitioners • Federally Qualified Health Centers (FQHC)

• Hospitals • Hospital based or
• Critical Access Hospitals (CAH) CAH-based Renal Dialysis Centers
• Rural Health Clinics (RHC) • Skilled Nursing Facilities
• Community Mental Health Centers

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3-5 Year Rollout
Strategy

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 Financial Models

• Access To Specialty Care in Rural Settings

• Remote Access To Primary Care Physicians
• Remote Patient Monitoring
– ICU
– Home care

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Access to Specialty Care in Rural Settings
• Projected Revenue
– Grants
– Leaked Opportunities (referrals out of network)
– Rural Health Clinic Reimbursement
• Projected Costs
– Operational Staff
– One-time Professional Fees
– One-time Equipment Costs
– Hardware & Software Maintenance
– Equipment Depreciation
– Travel & Training

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Challenges Addressed
• Existing operational telehealth programs - owned and supported
by various organizations
• Telehealth projects - being implemented at the same time the
business plan was being developed
• Other initiatives - priority
• Resource constraints – same people on all projects
• System-wide communication of plan - was difficult due to size of
health system and number of regions
• Telehealth reimbursement - commercial payer coverage was
inconsistent

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Telehealth Business Plan Implementation
• Learning Objective 3

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Critical Success Factors
• Ensure Leadership Engagement
• Establish Governance
• Identify Program Champions
• Build Consensus (Internal Marketing)
• Educate Patients & Community (External Marketing)
• Assign Implementation Team
• Develop Detailed Project Plan Based On Rollout Plan
– Standardize Implementation And Support Processes
– Integrate Telehealth Services Into Standard Of Care Workflow
– Provide Effective Training
• Monitor, Measure, And Communicate Success

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Governance Telehealth
Care
Coordination
Center
(TCCC)
Clinical
Services Physician
Integration

Adventist Health
Outreach Telehealth Service Line
Business
Development Governing Development

Board

Finance
Technology
Performance
Group
Measures

Contracting
Providers/
Clinics

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 High Level Rollout Plan
Telehealth Services
Outpatient Specialty Services
Emergency Services
Inpatient Consultations
Primary Care Services
Ancillary Services
Home Care
Adventist Health: In-Network
Activity 2015 2016 2017 2018 2019 2020
Blue Shield Initiative: Pilot to select locations
Expand Outpatient Specialty Services to all HPSAs, RHC, FQHC, & CAHs
Expand Outpatient Specialty Service lines
Telestroke: pilot to select locations
Pediatric telehealth: pilot to select locations
Expand telestoke service across health system
Expand pediatric telehealth across health system
Cardiology: pilot to select locations
Expand inpatient consultations across health system
Pilot other inpatient consultation services lines
Expand inpatient consultation services lines across health system.
Pilot Small ICU monitoring project
Pilot remote physician visits (w/ PC & Tablet)
Expand remote physician visits across health system
Pilot remote clinic visits (w/PC & Tablet)
Expand remote clinic visits across health system
Pilot patient education
Expand patient education across health system
Expand telepharmacy across health system
Pilot diagnostic services
Expand Diagnostic services across health system
Pilot/study home monitoring
Expand home monitoring services
Pilot care coordination
Expand care coodination services
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Telehealth Maturity Model
Governance Vision/Strategy People Technology Clinical Value
Blue Cirrus ©

Best in Class Integration, Patient, Provider, Facility

Integrated Model for quick Periodic Review of Long Recognized Expert Population Health Driving
Stage 8 Innovation and and Community Recognition
Operational

decisions Term Vision Telehealth Team Clinical Practice Standards

Excellence
Implementation of Excellence

Multi-disciplinary Well Established Roles and Cost Reduction, Cost

Evaluation of new/emerging Telehealth best practices
Stage 7
steering/oversight
Implemented Refined Model Original Vision Achieved Responsibilities for a multi-
service program
technology implemented
Avoidance and Revenue
Generation

committee
Stage 6
Evaluation of Governance Evaluation of Strategy to Operational Support Model
… Recognition of
IT Integration strategy for
Clinical Workflows Refined to
Achieve Clinical Outcome
CQI - measurable patient
experience improvement,
Model Fully Achieve vision and Team in Place long term support clinical outcome data,
excellence
Improvement
Performance

Goals
provider satisfaction data

Clearly Defined Clinical and Integrate, Order, Build and Identify and Implement Internal/External Community
Enterprise Program Executing a Developed
Stage 5 Management Executive Vision/Strategy
IT Implementation Team Test Telehealth Clinical workflow and Engagement with the
Members Infrastructure provider changes needed Telehealth Vision

Enterprise strategy aligned

Multi Disciplinary Recommended infrastructure
with quality initiatives and Coordinated clinical and Enterprise recognition of
Stage 4 Steering/Oversight design to support the Identifying Clinical Priorities
Awareness

corporate goals/unity and technical effort telehealth business model

Committee program
shared purpose
Individual
Stage 3
telehealth
Executive Sponsor
Enterprise vision
developing/aligning with
Multiple service groups
interconnected/early
No unified platform but
investigating multi
Clinical outcomes supported Enterprise identification of
by data potential telehealth market
clinical needs adopters use/expansion
pioneer(s)
No unified platform and
Stage 2
No overall telehealth
governance may have Reactive sporadic services
Interested group or local Infrastructure design
diffused technology which
Protocol driven
Patient access to
Isolated Explorers

leader for siloed service may associated with a care/unexpected benefits

clinical champion
specialty
to support program
No integration and point to Pockets of Service/Workflow
Individual telehealth Meeting a specific
Stage 1 Knowledge void No vision
pioneer(s)
point for a specific changes adhoc and
provider/patient need
service/technology sometimes documented

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Success Metrics
Utilization User Satisfaction

• Frequency telehealth services • Satisfaction level of users

are used with telehealth services (i.e.,
• EMR Reports providers, patients, and
community)
• Surveys

Clinical Outcomes Profitability

• Disease specific outcome • Speed at which organization

measures of telehealth will realize a return on its
services compared to telehealth investment
traditional services • Cost savings, additional
• Clinical Reporting revenue

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 Alignment to Triple Aim Objectives

Measurement Categories Measurement Categories

• Staying Healthy • Access to Care
• Managing Health Risks • Coordination Of Care
• Living With Illness • Patient Satisfaction
• Optimal Care • Provider Satisfaction
• Community Health

Measurement Categories
• Total Cost of Care
• ED Utilization Rate
• Readmission Rate

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Current State of Telehealth at Adventist
• Currently implementing into rural facilities
• Partnering with specialty physician groups to provide coverage
• Focus on finding more behavioral healthcare professionals
• Data is being gathered for metrics
 early wins satisfaction scores and utilization

Outpatient Telehealth Inpatient Telehealth

• Blue Shield Initiative – 25 • Stroke Services – 4 sites

rural sites • Peds ED/Critical care – 6
• USDA Grant – 11 sites sites
• 2016 Psychiatry: Northern CA • Cardiology – 2 sites. ED &
Initiative rounding

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 Realizing the Value of Telehealth

Patient Engagement
Satisfaction Treatment/
&
Clinical
Population Management
27%
increase in
Outpatients utilization
27% Added 5
Scored 4.85 2014->2015
increase in telehealth
on scale of utilization services lines
0 to 5 2014->2015 2014-2015

Physician
2014-2015 Time to
Physicians
Satisfaction
Largest increase Access Stroke
Scored
Consults with 4.63
Specialists in utilization – Neurologist –
onwhen
scale of
needed currently within 5
0 to 5 correctional
min. of page
facilities

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Questions?

Rob Marchuk Nannette Spurrier

VP, Ancillary Services Sr. Telehealth Management Consultant
Adventist Health Blue Cirrus Consulting
MarchuRT@ah.org nannette.spurrier@blue-cirrus.com
916-865-1997 1-800-380-8155

@bcirrus

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