Visiting nurses are valued for their caring and compassionate nature. Their valuable skillset makes a difference in the well-being of their patients and the lives of patients’ families. However, they face unique challenges amid the coronavirus as patients and staff are concerned about receiving in-home care during this time. Bringing healthcare to the home is no easy task.
As NAHC President William A. Dombi stated, “Home care and hospice nurses, therapists, aides, and other providers who choose to use their lives to serve our country’s aged, disabled, and dying. This noble work deserves our recognition and praise.”
Home health agencies are on the front line amid the coronavirus pandemic. A recent Home Care Association of New York State (HCA-NYS) survey found that nearly half of agencies in the survey said they have experienced patients or family members refusing entry of home care personnel. “Different states and regions are at different stages in surveillance and monitoring,” Roger Noyes, director of communications at HCA-NYS, told Home Health Care News.
“This speaks to some very important educational and outreach needs to reassure patients and to ensure that vital care can be delivered,” Noyes said. In addition to patients’ hesitation to let nurses into their homes for in-person visits, many patients are already quarantined, sheltering in place, or social distancing. And, some patients are denying service because they appreciate their nurses so much that they do not want to risk getting their nurse sick in-person. Concurrently, the nurses themselves might also be wary of conducting in-person visits as they might not have sufficient protective gear and/or fear the risk of infection.
Agencies are implementing telehealth/virtual care to preserve their patients, their staff and their limited supplies. Technology can help agencies’ staff continue what they do – provide compassionate and critical care – and “be present” with their patients as much as possible. With technology, agencies can safely continue the delivery of care during this time and quickly communicate critical updates as needed. The technology helps home healthcare agencies:
Conduct virtual visits with patients to safely ensure continuity of care
Send out critical COVID-19 updates and self-care tips
Send condition-specific messages to improve ongoing adherence
Provide virtual access to their staff which helps nurses address patients’ emerging concerns and also alleviate patients’ loneliness while being socially isolated
With virtual visits, agencies are kept abreast of the realities of the patient’s home environment and their available resources (financial, food, social, etc.). Staff can continue to monitor their patients’ day-to-day situation and individualize the care (and conversation) to the “new normal” for the at-home patient.
Home health agencies need to be able to access and share PHI while they are on-the-go – often while using their smartphones or tablets. It’s critical that these types of communication are both fast and secure. However, many home health agencies allow staff to use text messaging when sharing patient data with each other, colleagues, or the patients themselves.
Text isn’t always best despite its popularity for convenient communications. Agencies might be more at risk than they think if staff members are texting each other information about patients. And, free consumer group messaging apps utilize vulnerable platforms which are unable to address health care-specific needs in terms of security and compliance.
An agency places itself and its patients at risk when sending ePHI via unencrypted text messaging. Traditional texting may not meet security or compliance requirements set forth under HIPAA. The HIPAA Journal indicates that the fine for a single breach of HIPAA can be anything up to $50,000 per day the vulnerability responsible for the breach is not attended to. Organizations which text in violation of HIPAA can also face civil charges from the patients whose data has been exposed if the breach results in identity theft or other fraud.
Immediacy, privacy and trust are key when communicating PHI among agency clinicians and the broader care team (e.g., the referring physician, a specialist, a pharmacist, etc.). For example, the patient or the field nurse can snap a picture of a patient’s wound and then send it securely to the wound care specialist for his/her recommendation. A wound care specialist can make a decision remotely – saving drive time and expenses – and immediately provide assistance to the field nurse.
Decision-making is accelerated, helping patients receive timely care and assistance. Staff productivity is optimized, helping the agencies better leverage specialists across a larger number of cases. ER visits and re-admissions are reduced, helping enhance patient satisfaction and outcomes.
With secure messaging functionality, home health staff members can easily and securely communicate and collaborate with colleagues, their patients and family caregivers, and with other care team members such as the referring physician or another specialist. HIPAA-compliant secure messaging is critical to securing ePHI in staff-to-staff and staff-to-patient communications.
The statistics related to chronic disease management are staggering. According to the US National Center for Health Statistics, 40 percent of the US population have chronic conditions and almost one-third of this patient population has multiple chronic conditions. It’s a struggle to manage and engage these patients and keep the “sickest of the sick” at home, receiving care, vs. returning to the hospital or another facility. These high-risk members are also the most expensive. The treatment of patients with chronic conditions accounts for three-quarters of the $2.2 trillion in healthcare spending, with roughly 96 cents per dollar spent in Medicare and 83 cents per dollar in Medicaid, according to the CDC.
Unfortunately, these patients may be “frequent fliers” in a health system; they typically need more attention between care appointments and often rely on emergency medical services and/or the emergency room to answer questions and provide care in non-critical situations. Significant opportunities exist for technology and touchpoints to bring ongoing care and support closer to these patients. Virtual care technology can improve care coordination and increase patient access to convenient care 24/7. Frequent touchpoints can continually engage chronic care patients, resulting in better disease management, improved outcomes and reduced costs.
Post-acute care organizations are embracing the use of a virtual care communication platform to engage chronic care patients and optimize their agency’s available resources. Using a combination of a video-based platform and readily available smartphones, tablets and PCs, home health clinicians can quickly connect, communicate and collaborate with patients – and colleagues — to ensure patients are actively monitored and motivated in their care without a series of in-home visits.
Ongoing messages and a series of virtual visits can augment – and even replace – many traditional in-person visits, effectively reducing the costs and liabilities associated with nurses driving to each patient’s home. The virtual visit can also include a clinician, a pharmacist and even an interpreter, depending on the patient’s needs. During virtual visits, home health providers can use video to detect potential patient issues before an in-person consult is needed and deliver preventive care during the call, minimizing the need for an immediate in-person intervention.
Care transitions, such as pre- and post-admissions and pre- and post-surgery, are pivotal points for ensuring adherence to the care plan and improved outcomes. However, organizations have historically struggled to keep patient engaged and compliant with the care plan during these transitions – leading to costly re-admissions and poor satisfaction. Virtual care can be applied in these settings to provide an efficient and convenient way to keep the lines of communication open during these pivotal transitions, leading to increased adherence and better outcomes.
Importance of transitional care
A carefully considered transition of care strategy is critical to enabling the safe and timely movement of patients throughout the care continuum. Each transition stage should include the communication of a comprehensive care plan that ensures continuity and coordination of care across points and providers of care. Points of care include hospitals, rehab centers, skilled nursing facilities, long-term care facilities, and even the patient’s own home. Providers of care include clinicians, specialists, nurses, home health workers, in addition to pharmacists, nutritionists, interpreters and transportation assistants.
According to the Joint Commission Center for Transforming Healthcare, sub-standard transitions may result in delay of treatment, inappropriate treatment, adverse events, omission of care, increased hospital length of stay, avoidable readmissions, increased costs, inefficiency from rework and other minor or major patient harm. According to JAMA, failures of care coordination can increase costs by $25 billion to $45 billion annually.
Rural healthcare organizations and their patients are up against a myriad of challenges, from minimal funding and resources to limited access to care, social determinants of health, and more barriers that stand in the way of effective care delivery. Unfortunately, nearly half of rural hospitals operate at a negative margin and are struggling to survive, according to iVantage’s 2017 Rural Relevance Study.
The number of rural hospital closures has risen to 87 in the last eight years, according to the National Rural Health Association (NRHA). The closures create a large gap in healthcare resources available in rural communities, as the residents cannot always drive or fly great distances to access needed care. Virtual care technology can address gaps in care and help rural providers continue to deliver care for the vast populations and geographies they support.
Increased re-admission rates amongst rural patients are driven by inadequate care and support after the patient returns home. Home health organizations now play a critical role in helping hospitals reduce these rates by providing care to rural patients, especially during the initial thirty days after discharge. Home health organizations are actively implementing virtual care platforms to automate the post-discharge follow-up with a rural patient by sending reminders to schedule appointments for post-discharge virtual visits via the communication channel of the patient’s choice – e.g., text, SMS, email or even a phone call. Follow-up care can be provided in a cost-effective video call (for home health providers and patients) which optimizes the caregiver’s productivity by minimizing excessive transportation time, travel costs and related liabilities typically associated with driving to/from patient homes.
To help home health agencies, there has been a longstanding Medicare rural add-on for home health services. Federal add-on payments through the Center for Medicare and Medicaid Services (CMS) have been crucial to these agencies operating in rural regions of the country. The 3 percent payment modifier to reimbursements for services provided in rural and underserved areas helps these agencies which face higher overhead expenses through factors such as increased travel time between patient visits and demands for extra staff. This payment modifier is imperative so that rural agencies will be able to keep their doors open and provide necessary care to home-bound patients.
However, the Centers for Medicare & Medicaid Services (CMS) has proposed payment rules which may impact the delivery of home health care in rural communities. The shift was mandated by the Bipartisan Budget Act of 2018. Under the new methodology, CMS is varying add-on amounts depending on a rural county’s home health utilization, population density and other factors. Unlike the current standard of a 3 percent three percent rural add-on, CMS’s proposed payment rule segments counties into “high utilization,” “low population density” and “all other” categories:
High-utilization counties are “rural counties and equivalent areas in the highest quartile of all counties and equivalent areas based on the number of Medicare home health episodes furnished per 100 individuals who are entitled to, or enrolled for, benefits under part A of Medicare or enrolled for benefits under part B of Medicare only, but not enrolled in a Medicare Advantage plan under part C of Medicare.” Low population-density counties are designated due to their population density of six individuals or fewer per square mile of land. The all-other category includes counties and areas that don’t fit into either definition.
Population growth and aging continue to be the primary driver of increasing demand for healthcare services. According to a March 2018 study by the Association of American Medical College, between 2016 and 2030 the U.S. population is projected to grow by close to 11 percent, from about 324 million to 359 million.
The population aged 65 and over is estimated to increase by 50 percent while growth for the 18 and under age segment is forecasted at only 3 percent. Since seniors have much higher per capita consumption of healthcare than younger segments, the demand for services used by seniors is estimated to far outpace the demand for pediatric care.
Given the expected demand from this demographic shift, the healthcare industry will face growing staffing challenges – with predictions including a shortage of 120,000 doctors by 2030, and a lack of 446,000 home health workers and 95,000 nursing assistants by 2025. Technology – specifically virtual care platforms – can address these expected gaps by allowing providers, care managers, and visiting nurses the ability and flexibility to treat more patients virtually. With virtual care platforms, healthcare organizations can meet the heightened demand for access to care by increasing staff productivity and optimizing workflows, while minimizing costs for all stakeholders.
Increasing Staff Productivity
Virtual care platforms can help administrators optimize their available staff around patient needs. Instead of needing to hire additional team members (or outsource some of the care responsibilities to other healthcare delivery organizations), administrators can review when patients are more likely to seek out care and then match provider scheduling around patients’ preferred timing for virtual visits.
If necessary, staff can also be augmented by remote team members to address an anticipated near-term shortfall of providers. Many health systems – whether rural/remote or urban/suburban locations – struggle with being able to have behavioral health resources on-hand, all the time. Virtual care platforms help remote behavioral health specialists more efficiently provide needed diagnoses and admission/transfer decisions to their onsite colleagues.
Virtual care platforms can be designed to automate existing workflows and can be readily applied across roles, settings, and facilities. This ensures that the use of the technology is complementary – not disruptive – to how providers currently interact with their colleagues and engage with their patients. Greater collaboration will stem from providers being able to more easily access remote specialists for a video consult. The transition of care – including transfers between departments, floors, providers and settings – will be streamlined as all stakeholders (including the patient and family members) are included in the video-based call to align on expectations and next steps.
Minimizing Excess Costs
Technology enables healthcare organizations to leverage staff to care for more patients, around-the-clock. Instead of expending “windshield” time to physically reach at-home patients for an in-person visit, providers can convert “drive time” to “patient time” and effectively see more patients, more often. Virtual care platforms can fill expected workforce gaps by allowing providers/care managers/home health staff the ability to treat three patients virtually in the time it takes for one at-home visit.
Investment in expanding the number and type of staffing resources would not be needed. In addition, transportation costs and related liabilities associated with driving to/from patient homes and conducting in-person appointments are effectively reduced.
Most likely, in one of the few lucid moments you have in your hectic, even chaotic schedule you contemplate healthcare’s greatest problems, its most pressing questions that must be solved, obstacles and the most important hurdles that must be overcome, and how doing so would alleviate many of your woes. That’s likely an overstatement. The problems are many, some of the obstacles overwhelming.
There are opportunities, of course. But opportunities often come from problems that must be solved. And, as the saying goes, for everyone you ask, you’re likely to receive a different answer to what needs to be first addressed. So, in this series (see part 1 and part 3), we examine some of healthcare’s most pressing challenges, according to some of the sector’s most knowledgeable voices.
Without further delay, the following are some of the problems in need of solutions. Or, in other words, some of healthcare’s greatest opportunities. What is healthcare’s most pressing question, problem, hurdle, obstacle, thing to overcome? And how that can be solved/addressed?
Lynn Carroll, chief of strategy & operations, HSBlox
Preventable medical errors are the third leading cause of death in the U.S., and frequently can be linked to inaccurate patient data, according to a study by Johns Hopkins University. Machine learning should be used to solve patient-matching challenges by analyzing and consolidating patient data from multiple systems, such as EHRs, medical charts, e-prescribing technologies, clinical documentation solutions and revenue cycle management platforms, and by creating longitudinal patient records that can be transparently shared among the patient’s care team, optimizing care coordination. The patient-matching solution is then combined with blockchain to disseminate the relevant patient data to all parties who have permission to view it.
Extending care coordination beyond the hospital walls heavily burdens providers and healthcare administrators. As the industry continues to shift from fee-for-service to value-based care, optimizing care teams to address social determinants of health and drive patient engagement is paramount. Today’s health systems must leverage an agile workforce and intuitive technology to deliver 360-degree patient-centered care.
Dr. Samant Virk, physician, founder and CEO, MediSprout
As a practicing physician for the last 15 years, I had a growing frustration with the fact that more than 70 percent of my time was consumed by administrative tasks that took away from my ability to help patients. The biggest challenge of healthcare right now is that we’ve lost touch with that physician and patient connection. Question: How can we reconnect physicians with patients — tech has driven a wedge between us and it’s time to fix this. Doctors would love to spend more time with the patients that need them the most while getting paid for follow-up care and communications that eats up their day. We believe that technology is the solution here.
Healthcare must shift its focus from viewing patients as “customers” and instead consider patients as “partners” within the broader healthcare ecosystem. All of the exciting innovation underway (including the increased adoption of virtual care and telehealth) should reflect what is required for the patient/partner to better manage his/her healthcare throughout the care continuum. To solve for healthcare that is truly consumer-centric, the broader healthcare ecosystem needs to identify the best investments to make which will drive quicker and better outcomes for the individual consumer (e.g., the patient/partner), overall population health, healthcare professionals, and healthcare organizations.
Price transparency for the Employers and the patient. The explanation of benefits (EOB) does not contain real financial payments between the payer and the provider. The real numbers are considered proprietary. A patient nor employer benefit plan cannot control their healthcare costs if they do not know how much was paid and for what service. At a grocery store, each item is tagged with the name of the product and the price. In healthcare the service and or product is not presented to the patient prior to the receipt of service and the services are not itemized on the bill. What to do? Make is illegal for payers and providers to have proprietary payments on healthcare goods and services.
The most pressing problem for US healthcare is improving quality of care while reducing cost. Intelligently leveraging clinical information — for predictive analytics, precision medicine, population health analytics and other analytic purposes — is critical to solving this problem. The largest impediment to actionable analytics is dirty clinical data entered by more than four million clinicians into more than one hundred certified EHRs resulting in a clear and present need for scalable technology to normalize, de-duplicate and enrich clinical data so that data scientists can spend more time identifying actionable insights from data, and less time fixing clinical data.
I see our shortage of primary care physicians as the biggest challenge the American healthcare system faces over the next 20 years. PCPs are crucial to the patient experience, and preventative care that can help drive value. Tied to this is my concern is the lack of investment/acceleration in technology designed to improve physician experience and utilization. PCPs spend way too much time entering data when there are opportunities like voice assisted scribe or authentication that reduce data entry and allows them to spend more time completely focused on patients providing quality care.
While telehealth has been around for years, virtual care technology is emerging as a powerful tool that goes beyond the traditional telehealth model. What will it take to reach the tipping point of virtual care adoption?
To become the “next generation” of telehealth, virtual care will need to improve access, availability, application, and acceptance considerations. Virtual care is poised to be embraced by the healthcare ecosystem, helping to optimize satisfaction and outcomes for all.
Timing is everything in critical care situations. Providers need instant access to specialists who can make vital diagnoses and decisions on-demand. Virtual care technology enables specialists to provide an immediate consult via video and ensure that patient questions and emerging conditions are addressed. Remote video-based consults allow a specialist to examine and diagnose the patient in real time, regardless of the specialist’s location. Virtual care will move into the mainstream as more providers (whether at a healthcare facility or home health agency) realize they can obtain timely answers, prevent return trips to the ED, and minimize readmissions. Smaller and rural hospitals will be able to strengthen their role in the community by using virtual care to access offsite, specialized staff. The time-to-treatment will be reduced; providers will not need to waste precious minutes attempting to contact available specialists. And, specialists can provide the needed consult via video, without needing to rush to the patient’s bedside.
Many patients fail to follow up with their provider for post-discharge care. No-shows may result when a patient is unable to leave his/her residence due to a medical condition. Some patients are unable to secure reliable, timely, and/or affordable transportation to a follow-up appointment. Virtual care will improve the standard of care by providing patients with more convenient, comfortable, and cost-effective access to follow-up care. Once out of the hospital or nursing facility, a patient can participate in virtual visits on commodity devices such as tablets and smartphones.
Healthcare organizations typically pilot the use of virtual care in one department, with one use-case or for a specific patient population, before rolling out the technology across a facility, health system, and/or health plan’s member base. Organizations may hesitate to expand virtual care across departments if they anticipate the implementation may be disruptive to their current processes. However, virtual care technology is designed to complement (and even automate) current workflows. Providers jump on the virtual care bandwagon when they realize that the application factors in a patient’s choice of communication devices (e.g., tablet, smartphone, and computer) and language. Because the technology features the ability to include interpreters in a video call and also provide messaging in the patient’s primary/preferred language, more healthcare organizations will accelerate the deployment of virtual care as they can now engage all patients in their care and across any level of connectivity.
In urgent care situations, being able to provide timely and quality healthcare is essential to the impact and satisfaction of the ED staff and related EMS team members. Using telehealth, current ED workflows can be enhanced to increase access and make collaboration between onsite providers and offsite colleagues and specialists easier and more timely. Virtual care platforms can rapidly improve the delivery of care, effectively addressing urgent patient needs while reconciling the gap in having available specialists on-hand / in-person for immediate consults. Virtual consults are a viable and valuable solution to helping improve outcomes in emergent care situations.
Providing Critical Care On-Demand in the ED
Seconds and minutes count in the ED. With a virtual care platform, a hospital’s ED staff can quickly access remote specialists and facilitate a virtual consult between offsite specialists and patients. Instead of losing crucial minutes, hours, or even critical days in the ED to call a specialist or wait for an in-person consult, ED staff can quickly reach the first available, designated specialist who can deliver a timely virtual consult and provide guidance as to diagnosis, admission, and/or transfer. With virtual care technology, specialists can provide the needed consult from anywhere and on any device. Key decisions as to whether the patient needs to be admitted, transferred or discharged can be made in minutes (vs. hours or days). The costs involved with keeping a patient in the ED are also contained, and the hours or days which a patient spends in the ED are reduced. As hospitals struggle to have multiple specialists on-hand at any time, virtual consult platforms can empower hospitals to leverage specialists within their networks to support their patient care objectives around-the-clock.
Reducing Waiting Time and Minimizing Leakage in the ED
Virtual care platforms are also being used to reduce waiting times in the ED and deliver routine care to patients with non-emergent conditions. In a recent study published in Telemedicine and e-Health, rural hospitals using telehealth reduced the time between patients entering the ED to receiving physician care, according to University of Iowa researchers.
Virtual care had decreased door-to-provider time by six minutes. The researchers also concluded that the length of stay in the ED of the initial hospital was shorter for patients who were eventually transferred but had initially participated in a virtual care consultation. At New York-Presbyterian/Weill Cornell Medicine, the Express Care program allows patients with minor injuries or non-life-threatening symptoms to be seen virtually by an offsite provider via video. When asked by the Wall Street Journal, “What’s the number one complaint of patients in the emergency room?” Rahul Sharma, the emergency physician-in-chief at Weill Cornell, responded: “Wait time.”
The hospital reported that the Express Care telehealth program has cut the average wait time in the hospital’s ED by more than half; between 35 to 40 minutes. As hospitals struggle to prevent leakage and minimize the chance of patients leaving their ED waiting room for another healthcare setting, virtual consults can help the waiting patients access the diagnoses and care they need in a more timely and convenient manner.
Expanding Impact into the Community
ED staff can also use virtual care platforms to expand their impact within their respective communities. Rural hospitals face some of the biggest deficits in terms of having a range of specialists on staff. Providers in these hospitals can have access to a greater pool of specialists who can support urgent patient care via video when a particular specialist is not already on staff or readily available in-person. Giving ED staff the ability to facilitate virtual consults on-demand improves their impact within their own community – regardless of distance between the ED and the specialist. ED staff can also conduct HIPAA-compliant virtual meetings to drive better collaboration amongst the broader care team across the care continuum. Communication can be maintained with the appropriate care team members (including the patient’s PCP, a pharmacist, a coordinator at the next care facility, etc.) to ensure the patient’s overall health needs are regularly discussed and addressed in the ED and during the transition of care – without requiring care team members to drive to/from meetings at different locations and facilities.