Keeping

Them Home
Strategies

for successful
implementation of telemonitoring
in the home setting to reduce

hospitalizations

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Introduction
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.
I 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.

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OBJECTIVES
This session will address:
What is telehealth?
Why implementation often fails
Improving Staff buy-in and Collaboration with physicians
Understanding 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.

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TELEHEALTH ?
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WHY
TELEHEALTH ?

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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.

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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.

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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.

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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.

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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.

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Common Barriers to
successful telehealth
implementation

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 Lack of clear best practice guidelines

at Implementation
Technical difficulties
Inability to get Nurses Buy-in
Inability to obtain patient consent
Lack of collaboration with Physicians
Lack of reimbursement
Ineffective patient education
Unclear guidelines for target population
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COMMON EARLY PITFALLS

Many Vendors selling
telehealth recommend costsaving 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 use
No Physician order needed to
initiate telehealth
Often unclear best-practice
guidelines
Equipment that may not meet
needs (lease vs. purchase)

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COMMON PITFALLS
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.

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COMMON EARLY PITFALLS

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.
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Facilitating Staff buy-in

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BARRIERS TO STAFF BUY-IN

Many 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.

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.

Visits equal money and decreasing

frequency can be a bitter pill.
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Staff buy-in
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.
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TARGETING the right Population

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.
SHPStrategic
Healthcare partners
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Collaboration with
physicians

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 Most 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
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Physician approved Standing orders

Diuretic
protocol for CHF
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Reducing hospitalizations

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How 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.
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Reducing hospitalizations
FOR THE PAST 12 YEARS, THE U.S. DEPARTMENT OF VETERAN AFFAIRS
(VA) HAS BEEN HELPING VETERANS THROUGH 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 ITS TELEHEALTH 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.
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HOSPITALIZATIONS

2013

2013 AVERAGES
WELLCARE TELEHEALTH HOSPITALIZATION RATE 7.78% (Observed)
WELLCARE AGENCY TOTAL RATE 20.46% (Observed) 22.95% (RAO)
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SHP STATE (NC) 22.06%
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SHP NATIONAL 23.53%
SHP- Strategic Healthcare partners

HOSPITALIZATIONS

2014

2014 AVERAGES
WELLCARE TELEHEALTH HOSPITALIZATION RATE 6.30% (Observed)
WELLCARE AGENCY TOTAL RATE 22.21% (Observed) 24.51% (RAO)
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SHP STATE (NC) 21.98 %
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SHP NATIONAL 24.16 %
SHP- Strategic Healthcare partners

Utilizing a self-management
model in regards to patient
education

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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.
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SELF-MANAGEMENT
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.

E
M
L
CAL T
FIRS
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how to make telehealth work

without reimbursement from
CMS

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SHOW 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.

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SAMPLE FREQUENCIES

Skilled Nurse Frequency:

Keep visits below 8 an episode

2 Week 1
1 every other week 9
2 PRN
(Frequency assessed on a case by case basis to allow for wounds, labs and
MD orders that may supersede the standing protocol)
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SHOW ME THE MONEY?

Private pay tele-monitoring

Technology bundles
Med minders
Emergency Fall alerts
Telehealth monitoring
Monthly nursing visits

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WHAT IS COMING?

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WHAT IS COMING?
In July 2013, the American Telemedicine Association (ATA) released
a report titled State Medicaid Best Practice: Report
Patient Monitoring and Home Video Visits (the Report). For the
Report, ATA surveyed state telehealth policies,
and analyzed four best practice models, including those
of Colorado, Kansas, New York, and Washington State.

17 states currently have some

form of Medicaid telehealth program
Alabama, Alaska, Arizona, Colorado, Indiana,
Kansas, Kentucky, Minnesota, New Mexico, New York,
Pennsylvania, South Carolina, South Dakota, Texas, Utah,
Washington State, and Wisconsin.
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STATE

REIMBURSEMEN
T

OUTCOMES

Colorad
o

agencies $50 per patient for a

one-time installation, and $9.45
per unit/day each month for
telehealth services, for a
maximum of 31 units/days per
month.

sampled over 12 months and

involved 200 patients,
showed 62% reduction in 30day re-hospitalizations for
several conditions, lower rehospitalization as compared
with patients receiving
traditional home care, and a
decrease in emergency
department visits from 283 to
21

Kansas

agencies 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 20072008, at a total savings of
$1.4 million. In 2009, annual
cost
savings
were $26,300
per
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hospitalizations of 38%.

STATE

REIMBURSEMEN OUTCOMES
T

Washingt
on

Medicaid 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 Take

The Council supports the growing utilization of remote
patient monitoring in Medicaid home care. As the Report
demonstrates, such programs are both cost-effective
and contribute to greater outcomes.
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Telehealth implementation is
a journey
Have 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.

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QUESTIONS?
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THANK YOU
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