Like so many other technological advances, telehealth services are quickly moving from novelty to convenience, and it won’t be long before they move from convenience to necessity.
According to the Mayo Clinic, “telehealth is the use of digital information and communication technologies, such as computers and mobile devices, to access healthcare services remotely.” The terms “telehealth” and “telemedicine” are sometimes used synonymously, but telemedicine is really a subset or option of telehealth. Telemedicine enables virtual MD “visits” through computers, tablets, or smart phones. Telehealth encompasses the entire broad array of digital devices and technologies that facilitate the remote delivery of health care services.
The Need for Telehealth is Real… and Growing
Approximately 16 percent of the U.S. population today, about 51.7 million people, are aged 65 and older, according to The World Bank. The U.S. Census Bureau projects this senior population will increase by more than 50 percent over the next 15 years, to nearly 78 million. By 2030 the last baby boomer will have reached age 65, and by 2050, seniors will make up more than 22 percent of the U.S. population.
So what does this mean for the home healthcare industry? We know that elderly people today are more likely to suffer from chronic diseases and have greater and more complex healthcare needs; older adults have an almost 70 percent chance of needing some type of support or long term care during their lifetime. Because most older adults would prefer to remain in their homes as they age—as many as 90 percent, according to a 2017 article by the American Association of Retired Persons (AARP), the need for home healthcare will keep expanding.
Add to this the fact that the population of adults aged 25 to 64, representing the majority of the U.S. workforce, is projected to increase by only four percent over the next 15 years. With these numbers in mind, it’s easy to see why the already existing home health workforce shortage will only get worse over the coming decades. If they hope to stay competitive in the years to come, home health agencies (HHAs) must utilize and embrace new technologies in order to cut costs, maximize resources, and enhance productivity and efficiency.
One important way that HHAs can stretch their resources is with telehealth technology, which allows agencies to remotely monitor, record, manage, and share data without the need for face-to-face interaction. Luckily, the population is becoming more technologically savvy as it ages. Receiving health and medical care through a computer, tablet, or smartphone is not as intimidating as might be expected, and some surveys have found that as many as 60 percent of patients actually prefer digital health services.
While older adults are certainly more resistant to new technology than younger patients, today’s adults are tomorrow’s seniors. As tech-savvy adults continue to age, HHAs will face their patients’ ever-increasing demands for the same convenience, affordability, and safety these patients have grown accustomed to as digital age consumers.
Indeed, awareness and availability may be the biggest stumbling blocks for telehealth at this point. In one survey, about 66% of surveyed seniors said they were willing to use telehealth technology, but only 8% reported they already had.
“Health care providers should view this [8% adoption figure] as a profound opportunity and, in some ways, an inherent responsibility to be part of the movement that is [evolving] health care,” said Dr. Peter Antall, Chief Medical Officer for one telehealth provider.
As the home health industry continues to seek more efficient and cost-effective ways to provide care, and as awareness of new telehealth technologies expands, the role of telehealth will continue to grow. “We’re asking how we can simultaneously improve the health of populations, create better care experiences for patients and reduce the per capita cost of health care…” says Dr. Jan Kimpen, chief medical officer and SVP at Philips. “Telehealth is one of the key enablers to make that happen.”
The AARP agrees: “Telehealth strategies offer the potential to improve access to care and the quality of care, while reducing strain on family caregivers…and may help address the challenge of rising costs.”
Reimbursement: The Static on the Line
If availability is a stumbling block, the fault lies not with HHAs but with outdated reimbursement regulations which have failed to keep up with developing healthcare technologies. Reimbursement issues are the static on the line to the future of telehealth.
Up until now, telehealth services have been reimbursed only in rural areas and for extremely limited medical conditions. Reimbursement initiatives are underway, however, for both telemedicine and telemonitoring. Health industry leaders predict that “changes in reimbursement will spur growth in virtual care,” which is likely to significantly impact the bottom line for HHAs.
These initiatives began in February of 2018 with the passage of the Bipartisan Budget Act (BIBA) of 2018, which included provisions from 2017’s bipartisan Creating High-Quality Results and Outcomes Necessary to Improve Chronic [CHRONIC] Care Act. According to the American Telemedicine Association (ATA), the new law provided “the largest boost to Federal telehealth coverage and payment in 17 years.” ATA anticipated the CHRONIC Care Act would “expand telehealth coverage for accountable care organizations (ACOs), improve flexibility for telehealth use under Medicare Advantage plans, and allow nationwide reimbursement for tele stroke care and home dialysis treatment.”
On the heels of that bipartisan legislation, the Centers for Medicare & Medicaid Services (CMS) announced in late 2018 that the rural setting requirement for telehealth reimbursement would be removed, expanding reimbursement for telehealth services without regard to home setting. CMS finalized its policies on April 5th of this year, allowing Medicare Advantage plans to offer additional telehealth benefits to patients at home. According to CMS, the final rule “will strengthen popular Medicare private health insurance plans” and “expand patients’ access to telehealth services… whether they live in rural or urban areas.”
CMS administrator Seema Verma says the new policies represent an historic step: “With these new telehealth benefits, Medicare Advantage enrollees will be able to access the latest technology and have greater access to telehealth. By providing greater flexibility to Medicare Advantage plans, beneficiaries can receive more benefits, at lower costs and better quality.”
Despite restrictive reimbursement regulations, many home care agencies are already offering telemonitoring and other telehealth services to their patients. BIBA allowed remote patient monitoring (RPM) to be reported by home health agencies as allowable costs on the Medicare cost report form, and the HHA industry hopes that RPM reimbursement will not be far behind. The benefits to patients are indisputable and, reimbursement aside, telehealth is a valuable tool for HHAs as they strive to offer the best care possible to their patients.
Telehealth Options for HHAs
Telehealth enables the timely recording and sharing of patient data that keeps both patients and agencies connected: to each other, to clinicians and caregivers, and to other healthcare providers. Telehealth allows caregivers and providers to identify real issues and potential concerns earlier, enabling more timely and efficient intervention. This is of particular consequence to HHAs, with patient populations that are often homebound and at risk.
Telehealth options include:
- Telemedicine through online video conferencing or over the phone: allowing patients to connect with physicians for remote diagnosis, monitoring, and treatment without the need for face-to-face consultations in the home or office
- Tele-education through online video conferencing, for tailored patient education
- Wearable safety and security devices utilizing electronic sensors and cloud-based technologies to monitor activity, alert caregivers, and help keep at-risk individuals safer in their home environments: devices include medication reminders and dispensers, activity monitors and GPS trackers, fall protection belts, “smart” appliances, other remote communications devices
- Mobile health apps–many FDA-approved–for diabetes management, weight control and fitness, cardiac and ophthalmic monitoring, and much more
- Artificial intelligence (AI) used in the practice of virtual care
- Asynchronous “store and forward” technology such as CAT scans, MRIs, X-rays, digital photos and more: store and forward data is recorded, stored and then transmitted to care team clinicians and specialists for evaluation
- Remote patient monitoring: the most used, and perhaps the most important, telehealth option for HHAs
HHAs are Embracing RPM Technology
Telehealth and RPM enable the remote communication between devices and people, whether it be patient-to-clinician interaction or the secure transfer of medical data. Sometimes (and previously) referred to as telemonitoring, RPM technology used to require large, heavy equipment that was hard to transport and cumbersome in a home environment. As is commonplace in our digitalized world today, technological advances have made telemonitoring equipment and devices smaller, less cumbersome, more accurate, and more convenient.
Today, RPM technology comprises a wide range of clinical-grade, often AI-driven, wearable, mobile, or portable devices. Most RPM devices and their supporting software platforms are prescribed by an MD or used in conjunction with medical advice; they are generally FDA approved or certified by other regulatory health authorities.
Telehealth RPM devices help patients and clinicians manage a variety of health conditions in the home, without requiring clinical home, office, or laboratory visits. Patients who can benefit the most from RPM are those suffering from chronic diseases such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), hypertension, diabetes, and emphysema.
How Does RPM Work?
RPM devices can generate, record, monitor, analyze, and report patient health data and connect patients with caregivers or healthcare professionals when necessary.
Telehealth monitors and monitoring frequency are customized to the patient according to the physician care plan. Clinicians can remotely monitor vital signs and cardiac performance, glucose levels and pulse oximetry, weight and sleep patterns. Relevant, real-time data is transmitted to agency clinicians, allowing for earlier detection of real or potential complications for more timely response and intervention. Some devices, such as wearable defibrillators, are autonomously and automatically interventional.
Telehealth RPM devices include:
- blood pressure and glucose monitors
- pulse oximeters and spirometers
- smart scales and thermometers
Why Consider RPM and Telehealth?
With reimbursement minimal or nonexistent, why do, and why should, HHAs offer RPM and other telehealth services? Look at it this way: if you have an important phone call to make, is the static on the line going to stop you?
The ROI (Return on Investment) for telehealth services is multifaceted. Consider:
Quality care delivery includes doing what’s best for the patient, and many HHAs are committed to best practices, with or without appropriate reimbursement.
Clinician/caregiver shortages mean it is necessary to maximize resources and enhance productivity and efficiency. RPM is a way to keep tabs on patients and monitor their condition and safety status without a clinician needing to be in the home.
According to NEJM Catalyst, with RPM “chronic conditions can be more readily and efficiently managed resulting in higher quality care and outcomes as well as reduced costs.”
Telehealth and RPM technologies:
- can reduce costs for both patients and agencies
- can facilitate recovery
- can help reduce ER visits
- may help to reduce unnecessary hospital readmissions
- may reduce patient mortality: one study found that RPM reduced mortality rates for CHF patients, at least during the first six months.
- can improve patient engagement and satisfaction
- can help patients, caregivers, and family members become more involved
Today’s adults are tomorrow’s seniors: as awareness of telehealth continues to grow, tech-savvy HHA patients will increasingly demand the benefits and convenience the technology offers. “Today, many patients are opting for the convenience of telehealth at home,” said Audrey Kinsella in her article Home Telehealth Offers Opportunity to Develop New In-Home Programs, “thanks to decades-long improvements to telecommunications systems, added to the growing accuracy of telemonitoring equipment when transmitting patient health status from afar. In other words, it is working for home healthcare patients.”
The Future of Healthcare
From novelty to convenience; from convenience to necessity: Smart HHAs are banking on their future survival and success by providing the optional services of today that will be the required services of tomorrow.
Telehealth Implementation: Considerations and Strategies
There are necessary and unavoidable hardware and software costs associated with telehealth implementation. In a cost-benefit analysis, RPM may seem like a questionable investment for many HHAs. Obviously, the more widespread the utilization of RPM, the more cost-effective the technology will become; but in the meantime, telehealth implementation strategies can make a significant difference in the bottom line and ROI.
Brenda Yost, Denver group director of cardiology services at Centura Health, says there are ways for HHAs to increase efficiency and cut costs associated with RPM and telehealth. Yost notes that only a subset of agency patients will be using telehealth services at any given time, and agencies should train “only a subset of caregivers” to use the telehealth technologies. Yost says that it is more effective for agencies to have “a smaller cohort of nurses that are responsible for [telehealth] patients.”
If you are considering RPM or telehealth implementation, take a careful look at your agency’s current and prospective reality: review existing resources and operations, ask questions, explore options.
Consider agency operations and staff
- What new policies and procedures will be necessary?
- What staff education will be necessary?
- Clinicians and other staff must be educated on the installation and ongoing use of telehealth technologies: monitoring, reporting, and compliance
- How and when will patient devices be monitored?
- Who will be responsible for monitoring and device management?
- How will alerts be addressed?
- What kind of monitoring coverage is necessary?
- It is important to remember that telehealth should not be an emergency service, therefore 24-hour/day, seven days/week is probably not necessary outside of a hospice environment
- How will staff compliance be monitored?
- How will staff non-compliance be addressed?
Consider patient population and demographics
- What percentage of patients will benefit from RPM and telehealth services?
- Look at CHF, COPD, hypertension, diabetes, and emphysema patients
- Do the majority of agency patients have wifi and/or cell service?
- What patient education will be necessary?
- Patients must be educated on the benefits, requirements, costs, and consent regarding RPM/telehealth
- Patients must be educated on relevant technologies and devices, and must demonstrate use and understanding
- How will the need for ongoing or re-education be determined?
- How will patient compliance be defined and monitored?
- How will patient non-compliance be addressed?
- How will patient satisfaction be monitored?
Consider different telehealth vendors
- Look at the availability of existing and emerging technologies
- Does the vendor ensure HIPAA compliance?
- What is the vendor’s track record in the industry?
- How does the price compare to other vendors with similar offerings?
- Can the vendor system be integrated with your existing or new Electronic Medical Record (EMR)?
Telehealth and Your EMR
RPM or “telemonitoring” can be integrated right into your HHA EMR system. Thornberry Ltd. has several telemonitor vendor integrations with its NDoc® EMR in use today, including Vivify, Philips, Medtronics (Cardiocom), Honeywell, Viterion, and CareTrends. With NDoc, RPM readings can flow seamlessly into the clinical record.
Patients being admitted to NDoc will automatically appear in the telehealth environment, and telehealth readings will flow into NDoc. Agency nurses and other clinicians will see the complete record of vital signs readings, whether entered by agency staff or recorded through RPM. For instance, a patient’s temperature graph will include plot points from both clinician-recorded and RPM entries, for a complete history of patient’s temperature readings.
“We introduced Vivify telemonitoring earlier this year, and the interface of RPM data into the NDoc system has been active since July,” says Melissa Allard, System Director, Home and Community Based Services at St. Joseph’s Health Home Care in Syracuse, NY. “Having the RPM data available right in the patient record means we can more accurately and consistently track patient health and progress. With RPM we are alerted to potential problems much earlier, which in turn allows us to intervene and address any issues much earlier.”
CMS Press Release re Telehealth and Medicare Advantage: https://www.cms.gov/newsroom/press-releases/cms-finalizes-policies-bring-innovative-telehealth-benefit-medicare-advantage
Fact Sheet on the CY 2020 Medicare Advantage and Part D Flexibility Final Rule (CMS-4185-F), please visit: https://www.cms.gov/newsroom/fact-sheets/contract-year-2020-medicare-advantage-and-part-d-flexibility-final-rule-cms-4185-f
Final Rule re Medicare Advantage program (Part C) regulations to implement certain provisions of the Bipartisan Budget Act of 2018: https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-06822.pdf
Telehealth Services for Medicare Booklet – a CMS Medicare Learning Network (MLN) Booklet: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Telehealth-Services-Text-Only.pdf