Electronic Health Reporter

Guest post by Richard Kimball, Jr., CEO,  HEXL.

Here are some selected FAQs about telehealth service delivery that focus most particularly on the home healthcare arena, which is most probably the health service sector most unaffected by new technology introduction and use until recent decades. Strictly hands-on, or ‘high touch” care service delivery was the order of the day throughout the 20^th century. Yet home healthcare is likely to become a very critical component for achieving the much broader and longer term view of patient care delivery after patients’ discharge from hospital. It is then and at home that patients will receive subsequent services through their continuum of care that will keep them well over a long term.

Can I get reimbursed for providing telehealth?  

The answer is yes, usually, for providing home telehealth services but not in the usual billing scenarios most home healthcare organizations are used to for submitting bills to Medicare or other insurers. As of now, mid-2015, changes in Medicare and Medicaid fee for services are just coming on-board affecting home telehealth service delivery. There is still a long way to go until Medicare will not very much require face-to-face home healthcare visits during a patient’s admission period—this is the same insurer who absolutely required specific documentation about every portion of nurses’ contact with patients and let the home health agencies (HHAs) know that to CMS, if something was not documented [e.g., a telephone call between nurse and patient about wellness directives] , it didn’t happen [and the bill would therefore not be paid]. Today there are many insurers beyond Medicare that are paying for home telehealthcare (e.g., Aetna, United Healthcare), but it’s very early on—we need to return to this question later this year.

How will I develop a home telehealth service capability? How will I develop a strategic and operating plan for this new delivery channel? Where will I get the technology? What type of training will be required of my people and what will the cost of training be and how many employee hours need to be dedicated to this training?

It’s best to keep in mind that, although the technology is new, you’re not beginning with a blank slate for running a healthcare service delivery business. While all of these questions about telehealth tool acquisition and use are important, the very first question to ask, not mentioned in this list of questions is, hands down, who are my HHA’s most costly patients? An agency-wide chart review would reveal that these are the patients that require the most visits, and additional training in self-management skills and routines.

Once identified, and these are usually patients living with specific chronic diseases and conditions, such as congestive heart failure (CHF) and non-healing wounds, then the subsequent questions can be addressed. In earlier days of home telehealth service delivery (ca. mid-1990s), a full-scale workstation was typically available that could be assigned to any home healthcare patient and came fitted with telecommunications-ready vital sign measuring peripheral devices such as a blood pressure cuff and pulse oximeter, as well as glucometer for measuring diabetic patients’ blood sugar levels even though some patients didn’t have diabetes. These were kind of a one-size-fits-all system, though these proved to be too costly for HHAs and too complicated for patients to use regularly and correctly. More common now is to order and assign only needed and stand-alone telecommunications-ready peripherals devices for patients to perform daily measurements and transmit them to their clinicians.

Next, once the prevalent chronic disease and conditions are identified, research has to be undertaken into telehealth equipment companies that have developed tools to manage care of patients living with these diseases and conditions and have a track record of success stories with piloted programs by HHAs. Some specialize in services for people living with heart conditions, others with COPD, among other focuses. A list of potential companies to contract with has to be developed, with some time spent beforehand identifying features of their systems, stated costs, vendor assistance [as in a Help Desk 24/7 offering], etc. Assistance from the American Telemedicine Association should be sought out for names of home telehealth companies and contact information.

Once a list of potential telehealth vendors is compiled, all of them will be only too happy to arrange an in-person demo and preliminary training session. Once a decision on vendor is made, the telehealth equipment company routinely delivers demonstration sessions to the HHA offices and sets up training sessions for HHA staff. As to the amount of staff training time that’s required, this really varies, but it usually takes place within one day, particularly the clinical aspect of training. In that case, most of the tools are the peripherals with which every nurse is familiar and uses regularly on in-person home health visits—now she has to learn and use (and teach her patients how to learn and use) the devices’ telecommunications capability. This usually involves affixing a plug on the telecare-ready device into a telephone jack and then pushing a “Send” button, then learning online charting capabilities.

At first, throughout the 1990s, there had been some reservations voiced by nurses about using home telehealth. They frequently noted that it doesn’t feel as hands-on, as home healthcare is known for, but eventually, many warmed to the idea of how much more information they can glean about a patient’s daily routine, even when the nurses are off-site. Implacable negative feelings toward home telehealth still exist among home hospice nurses. Not everyone is convinced of the value of more frequent contact by telephone or video, but at least some hospice nurses, who are known for delivering the highest touch, lowest tech delivery of all, have expressed learning to value this different kind of “touch” made possible with home telehealth.

What types of patient issues can be handled with telehealth? Will there be any diminished quality by using telehealth?

The most important issue that can be developed via telehealth contact with patients is: obtaining improved patient health outcomes. These can be achieved via nurses’ providing more and customized patient education materials, tools, and directives (about eating, exercising, taking medications, etc.) leading to more patient self-management (and less costs, fewer re-hospitalizations). These improved and more frequent contacts [on a daily basis, usually for limited time periods — like, 10 to 15 minutes or less — compared to hour-long but fewer weekly in-home visits] are especially more productive and ultimately cost saving with chronic disease patients such as the very large ranks living with congestive heart failure (CHF).

Diminished quality? Hands down, patients and nurses feel the frequent contact actually improves the quality of care. Patients who use a multi-faceted workstation that includes needed peripheral devices such as blood pressure cuff and pulse oximeter with telecommunications capabilities report feeling assured that the nurse is “always there” if there is any problem with their vital sign readings. Nurses, too, although they are not really “always there” physically, report satisfaction about knowing their patients “better” by having very regular telehealth transmissions about their vital sign readings and daily reports about diet than they could be by undertaking 2 in-home, in-person visits per week.

What are the risks if I don’t develop a telehealth capability?

There are many risks of not developing an in-agency home telehealthcare program today. Here are a few:

1. Losing regular business to competition which does have such a program [i.e., other home health agencies that have telehealthcare programs]. Hospitals are now partnering with Accountable Care Organizations (ACOs), for instance, and the ACOs themselves, will want to partner with home health agencies (HHAs) that can provide the most innovative and cost effective care to patients in subacute care settings and so help the ACOs to provide all care needed during the patients’ in- and outpatient continuum of care cycles.
2. Losing business by providing only conventional in-person care visits when there is a smaller but important word-of-mouth business atmosphere peopled by aging Baby Boomers who were able to opt for telehealth services from HHAs that offer innovative tools. Many of these tools [such as wearable devices] can help patients follow their healthcare routines when and where they choose [that is, within some reasonable parameters based on their own care plans and scheduled healthcare activities]. The seniors’ choice of a more innovative HHA that routinely assigns telehealth tools to their clients might be linked to their preference for being more independent seniors who choose to age well in place with the assistance of new technologies.

Conclusions:

Many changes are imminent among the burgeoning senior population in this country, many of them now simply aging Baby Boomers. Today, there are many new technologies to help them stay more well (for instance, wearables to track their walking progress and/or dietary needs; and very portable ECG units in the shape of a credit card carried in their wallets and used, as needed, to check their heart rates).

Today, we may very easily note the very popular depictions of seniors on bicycles, each carrying a backpack (no doubt toting their meds, water bottle, cell phone or PERS unit and wearable devices for vital sign tracking). And so, there should soon be an outcry to be expected among this seemingly more well and active population to remove the restriction that receiving Medicare healthcare services is only for the “homebound” population. Indeed, this mobile generation wants (and physically is able to get) care when and where they need it thanks to home telehealthcare developments.

After graduating from Yale with a B.A. in Economics, Richard Kimball Jr. spent more than two-and-a-half decades advising healthcare organizations on strategy and capital structure and leading and building both early stage and more established businesses. Kimball started at Morgan Stanley and rose to managing director. More recently he was chief strategy and growth officer at Accretive Health. He is a trustee of The Brookings Institution, a fellow in Stanford University’s Distinguished Careers Institute and a member of the World President’s Organization. He is currently CEO of HEXL, a population health management startup.