REMOTE MONITORING AND HOME-BASED TELEHEALTH – Realities and Challenges - PowerPoint PPT Presentation

Loading...

PPT – REMOTE MONITORING AND HOME-BASED TELEHEALTH – Realities and Challenges PowerPoint presentation | free to download - id: 3c7277-NTQwO



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

REMOTE MONITORING AND HOME-BASED TELEHEALTH – Realities and Challenges

Description:

REMOTE MONITORING AND HOME-BASED TELEHEALTH Realities and Challenges Deborah A. Randall, JD & Consultant www.deborahrandallconsulting.com Kathy Duckett, RN,BSN ... – PowerPoint PPT presentation

Number of Views:242
Avg rating:3.0/5.0
Slides: 61
Provided by: deborahran
Learn more at: http://www.deborahrandallconsulting.com
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: REMOTE MONITORING AND HOME-BASED TELEHEALTH – Realities and Challenges


1
REMOTE MONITORING AND HOME-BASED TELEHEALTH
Realities and Challenges
  • Deborah A. Randall, JD Consultant
  • www.deborahrandallconsulting.com
  • Kathy Duckett, RN,BSN, Director
  • Clinical Services Partners Homecare

2
Moving Towards Electronically Enabled Care
Delivery_at_Home
  • HIT Health Information Technology
  • HIE Health Information Exchange
  • EHR Electronic Health Record
  • EMR Electronic Medical Record
  • PHR Personal Health Record
  • ONC Office of the National Coordinator for HIT
    DHHS

3
Survey 2010 eHealth Initiative
  • 61 of respondents agree or strongly agree that
    significant progress has been made in the
    successful adoption and use of HIT since 2007.
  • BUT 54.9 disagree or strongly disagree the value
    of HIE is clearly understood
  • 66.6 disagree or strongly disagree outreach on
    value of EHR/HIE is effective

4
  • 55.5 of respondents disagree or strongly
    disagree that differences between federal and
    state privacy laws are not a barrier to
    consumers rights to healthcare privacy.
  • 56 agree or strongly agree that HIT and HIE have
    had a positive effects on care delivery.

5
Evolving Definitions
  • Telemedicine vs. telehealth
  • Doctor to doctor d2d
  • Doctor to patient d2p
  • Distance learning
  • Remote monitoring
  • eCare eHealth
  • Smart homes

6
Developments Trends
  • New Medicare Reimbursement Possibilities SNFs
    kidney, nutritional, diabetes self-management
    mental health services
  • Devices as diagnosis-enhancers
  • Infrastructure for Telemedicine and Telehealth
  • Legislation

7
LEGISLATION 2009-2010
  • HITECH ACT 2009- Stimulus Bill
  • HIT Policy Committee of ONC
  • Infrastructure got first funding
  • Aging Services Technology Study
  • PPACA Health Reform Act 2010
  • Independence_at_Home Medicaid Medical Home Chronic
    Care Innovation Cntr

8
TELEHEALTH IMPACT
  • A. 2 billion in direct funding for health IT
    efforts, channeled through the Office of the
    National Coordinator ONC
  • 300 million reserved for supporting regional
    health information exchange efforts and the
    state-based extension centers"
  • 20 million reserved for NIST for work on
    health care
  • information enterprise integration
  • - BEACON GRANTS
  • B. Incentives Medicare and Medicaid to providers
    and hospitals adopt and use health IT systems
    AND THESE PHYSICIANS CAN BE WORKING WITH HHAs
    and HOSPICES

9
HIGHTECH, cont.
  • 85 million for the Indian Health Service to
    use on health IT
  • 1.5 billion for community health centers, a
    sum that
  • can be used toward health IT acquisition
  • 500 million for the Social Security
    Administration for
  • processing disability and retirement workloads,
    of which
  • up to 40 million may be used for health IT
    research
  • and adoption
  • 1.1 billion to AHRQ, HHS, and the NIH for
    comparative
  • effectiveness research

10
BEACON 16Million Buffalo
  • Western NY Info.Exchange, Buffalo
  • clinical decision support registries
    point-of-care alerts/reminders
  • innovative telemedicine improve
    primary/specialty care for diabetics,
    ?preventable ER visits, hospitalizations
    re-admissions for diabetes, CHF, pneumonia
    ?immunization of diabetics

11
Patient Protection and Accountable Care Act of
2010
  • PPACA --This is where the expansion will
    continue to be.
  • PPACA drives the process towards management of
    chronic disease.
  • Health information technology is finally showing,
    with reliable data, that telehealth can integrate
    with traditional care and use staffing
    innovations.

12
PPACA Promises? Promises!
  • Post-hospitalization bundling pilot
  • Independence at Home demonstration
  • Innovation Center at DHHS chief policy person
    in placetelehealth focus
  • ACOs
  • Medical Home-Medicaid and Pilots
  • Face2face HHA provision w telehealth

13
Blue Cross/Blue Shield WNY
  • Blue Cross/Blue Shield Western New York in May
    2010 initiated online physician-patient
    communication as a compensated service
    encouraging telehealth communications and webcam
    visits measuring quality of care and patient
    compliance factors

14
Technology-enabled Care Where are we now?
  • Satellite health facilities
  • In situ care w medical devices
  • Remote monitoring and sensors
  • Awareness and acceptance
  • European efforts in ambient care
  • The VA system the Vanguard

15
Where is Telehealth in Use
  • Care coordination and Chronic Disease
  • Patient self-management
  • Ambulatory care and safety
  • Palliative care
  • Rehabilitative services
  • Behavioral mental health services

16
VA Chronic Care Coordination via Telehealth Study
  • CONDITION DECREASE UTILIZATION
  • Diabetes 8,954 20.4
  • Hypertension 7,447 30.3
  • CHF 4,089 25.9
  • congestive heart failure
  • COPD 1,963 20.7
  • chronic pulmonary obstruction

17
VA Chronic Care Coordination via Telehealth Study
  • Posttraumatic stress disorder 45.1
  • Depression 56.4
  • Other mental health condition 40.9
  • Single condition 10,885 patients24.8
  • Multiple 6,140 patients26.0
  • Interventions just in time air traffic
    control

18
VA Chronic Care Coordination via Telehealth Study
  • The cost (1,600.24 pp/yr compares favorably)
  • direct cost of VHAs home-based primary care
    services of 13,121.25 per annum and
  • market nursing home care rates that average
    77,745.26 per patient per annum.
  • Conclusion a flexible and cost-effective adjunct
    to VHAs existing services. Darkins et al.,
    Telemedicine EHealth, 12/2008.

19
Telehealth and chronic illness
  • St. Vincent Health System's Visiting Nurse
    Association Arkansas has used telehealth
    computers to monitor patients in their homes for
    several years, and in its 11 county region had
    only about 4.5 of heart attack patients
    re-hospitalized compared with a national rate of
    37. National Assn for Home Care report

20
Telehealth and Aging in Place
  • University of Missouri sensors, computers and
    communication systems, along with supportive
    health care services monitor the health of older
    adults who are living at home.
  • Motion sensor networks installed in seniors
    homes can detect changes in behavior and physical
    activity, including walking and sleeping
    patterns. Early identification of these changes
    can prompt health care interventions that can
    delay or prevent serious health events.

21
HMSA Ambulatory MD/Home
  • Hawaii Medical Service Assn Jan 09
  • Online Care connects, 24/7, patients and
    physicians via the Internet or telephone1st in
    the nation.
  • 10/45 for 10 minutes interaction
  • Physicians can be anywhere service is across
    all islands

22
Telehealth Dementia Patients
  • Residential facilities designed to allow movement
    of individuals through facility and grounds
    Families can track on computer/internet based
    systems
  • Sensoring systems Intel research TRILL
    diagnostic sensoring for fall prevention yielding
    data on Alzheimer specific movement differentials

23
TelehealthDementia Patients
  • AlarmTouch GPS is a personal safety phone with
    GPS location in Europe. The telecare device
    includes a Geofencing feature, enabling
    accurate location of users in need. When the
    wearer wanders outside a specified zone such as
    home or school area - the system can send a short
    message (SMS) alert to a monitoring centre or to
    a relative or caregiver.

24
Home Telehealth - NY State
  • 93 providers approved to bill
  • Daily rates as of 1/1/2010
  • Tier I 62 8.88/day/patient
  • Tier II 31 10.20/day/patient
  • Tier III to be tied to regional connectivity
  • Medicaid Managed Care covered service
  • Electronic Medical Records
  • Approximately 50 - 60 utilization generally
    medium large sized agencies
  • Multiple other pieces
  • Referral software, physician portals, med
    management hardware etc.

25
(No Transcript)
26
CURRENT TECHNOLOGY UTILIZATION
Providers
27
Disease Management
28
Ambient Assisted Living Programme - EU
  • 23 EU member states with support of European
    Community EC
  • -Enhance quality of life of older people
  • -Strengthen industrial base by use of Information
    and Communication Technologies ICT
  • -Aging well at home, community and work
  • -Coherent framework for research into solutions
    which are compatible with varying social
    preferences
  • www.aal-europe.eu

29
American Telemedicine Assn
  • Home telehealth and remote monitoring practice
    group
  • Working group exploring opportunity for, and
    prevalence of telehospice I chair this group.
  • www.americantelemed.org

30
Partners Home Care
  • Stats and Facts
  • 175 Towns and Cities
  • 2,500 Average Daily Census
  • 24,000 Admissions Annually
  • 360,000 Visits/Year
  • 46 of Admissions are from non-Partners Healthcare
    System Sources
  • 4 Hospitals Massachusetts General Hospital,
    Brigham and Womens Hospital, North Shore Medical
    Center, Newton Wellesley Hospital are the core
    hospitals for PHS

Clinicians and Staff 700 Full, Part-time,
Per-visit 244 Registered Nurses 25
Licensed Practical Nurses 131 Therapists
physical, occupational, speech 7
Social Workers 61 Home Health Aides 32
Liaisons 11 Intake Nurses 4
Nutritionists 185 Other managers, clinical,
admin
Technology 383 Clinicians on POC 305
Telemonitoring devices remote monitoring 3800
Personal Emergency Response units
31
9 Essential Steps for Sustainability
  • Set Program Goals
  • Gain Insight of Stakeholders
  • Get Buy-in
  • Patient Selection choose wisely
  • Care Coordination 5 Ws 1 H
  • Establish Clinical Standards
  • Equipment Management DME matters
  • IS Infrastructure - IS is your friend
  • Quality Improvement implement soon, evaluate
    often
  • Success Follows

32
1. Set Program Goals
  • What is the problem you want to solve?
  • Set goals based on measureable outcomes
  • Why telemedicine?
  • Improved care
  • decrease number of emergency room visits
  • decrease number of hospital re-admissions
  • Increase patient involvement in care
  • Decrease home visits
  • Improved outcome and access/decreased costs
  • Youve decided to choose to start a telemedicine
    program
  • Whats Next?

33
Recognize the Nature of a Paradigm Shift
  • Telemonitoring changes traditional notions of
    care delivery
  • Incredible opportunity to improve care and
    increase access
  • It builds careers and new skill-sets and improves
    peoples lives ..BUT
  • People resist change
  • Doing it right requires set up and perseverance
  • The 1st time takes longer than one would think

34
2. Gain Insight of Stakeholders
Nurses Allied Health
Senior Leadership
Physicians
Patient
Operations
Quality Compliance
Finance
Information Systems
35
3. Get Buy In
  • 4 Main Groups
  • Senior Organizational Leadership
  • CEO ? Field Staff
  • Patient
  • Getting equipment in
  • MD/nurse confidence
  • Clinicians/Allied Health Professionals
  • Champions
  • Touch and Play sessions
  • Manager accountability/feedback loop
  • Prizes
  • Physicians
  • Education
  • Just in time reports
  • Promised decreased calls from patients d/t triage
    by TM staff

36
4. Patient Selection Choose Wisely
  • Determine Patient Population
  • Based on program goals
  • Partners Telemonitoring criteria
  • Moderate to high risk for re-hospitalization
  • Will benefit from telemonitoring
  • Can be managed with decreased nursing visit
    frequency
  • Patient or caregiver is able/willing to assume
    responsibility for monitoring
  • Working phone line in patients home
  • Home is safe environment for equipment

37
5. Care Coordination 5Ws, 1H
  • Determine process flow
  • SN evaluations for program admission
  • By Whom?
  • Referrals
  • Who refers?
  • Where do referrals go?
  • Who processes them?
  • Telemonitoring of patients
  • Centralized requires dedicated TM staff
  • Decentralized integrated into primary clinician
    work flow
  • Reporting Why?
  • Who
  • What
  • When
  • Where
  • How

38
6. Establish Clinical Standards
  • Best practice, evidence based standards
  • Must be able to individualize standards
  • Use clinical experts that clinicians will accept
    to set standards
  • Educate clinicians regarding standards
  • Give clinicians autonomy to modify standards as
    they deem necessary
  • Give clinicians algorithms/guidelines for further
    autonomy in practice

39
7. Equipment Management DME Matters
  • Rent vs. purchase
  • Identify who will manage
  • Establish responsibility and accountability for
  • electronic inventory control
  • system set- up and provisioning
  • installation/testing/break-fix
  • equipment recovery, sanitizing, storage and
    redeployment
  • Training, retraining, written protocols
  • Begin with decentralized process (greater buy-in
    at local level), migrate to centralized process
    (efficiency consistency) over time, selecting
    best of breed processes
  • Cultivate leadership

40
9. Quality Improvement
  • Implement Soon Evaluate Often
  • Establish QI program at beginning of process
  • Establish planned review periods
  • Initially weekly
  • Include stakeholders as appropriate
  • Include all 8 essential elements as part of
    formal QI program
  • Establish database for statistics at start of
    program
  • If you think you might need it, get it
  • Build mechanisms for gathering data if not
    inherent in EMR program
  • Excel, Access databases

41
Telemonitoring at PHC
  • PHC Telemonitoring Program - 2006
  • Patient Selection Criteria
  • Available for Medicare pts currently receiving
    PHC
  • Connected Cardiac Care Program - 2007
  • 4 month home telemonitoring program
  • Patient Criteria
  • Strong educational component
  • 1 Nurse visit to establish clinical status and
    knowledge deficits, then no further nursing
  • Bi-weekly telephonic educational phone calls
  • Encourage direct patient/PCP relationship
  • Patient Choice Program
  • Private Pay
  • Hospice
  • Telehospice Pilot
  • CMS Pilot program

42
Positive Patient Outcomes
  • gt 2100 patients cared for 2006- present
  • Average LOS 70 days
  • Average LOS with no rehospitalizations 53 days
  • Average LOS with gt 1 hospitalzation 103 days
  • Average rehospitalization
  • PHC program 25
  • CCCP 30 decrease year over year
  • 1.3 - 1st 30 days
  • 3 -program completion

43
MD Acceptance - CCCP
44
Clinician Response
  • Decrease average SNV to 10 visits/episode with
    improved outcomes for rehospitalization
  • Consistent referrals to programs
  • Clinician comments
  • I love it. I feel like I have a better handle
    on my fragile heart failure patients using
    telemonitoring they look at them every day and
    let me know if there is a problem I need to be
    aware of.
  • I think its great its made a huge difference
    for my patients.

45
What are the New Directions?
  • Tele-rehabilitation Falls prevention
  • Tele-mental and behavioral health
  • Continuous monitoring diabetes cardiac
  • Impaired Alzheimers dementias
  • Wellness

46
Telehealth and Rehabilitation
  • Distanced assessments
  • Robots in SNFs
  • Telestroke gt telerehab
  • Wii units in senior living facilities
  • Remote monitoring for falls anticipation
  • Traumatic brain injurywounded warrior

47
Behavioral Mental telehealth
  • On-going research
  • Post traumatic stress disorder
  • Tele-psychiatry
  • Distanced mental health services under new
    Medicare reimbursement provisions for community
    mental health centers

48
Telehealth and Palliative Care
  • Telehealth and pain management
  • TeleHospice care
  • bringing patient and family into the
    interdisciplinary group IDG
  • counseling to patients and family when social
    workers are scarce resources

49
Palliative Care
  • Pain and symptom management
  • Outreach and crisis management
  • Triage without transporting to facility
  • Psychological pain and suffering
  • Diagnostic opportunities family interactions
  • Ethical principles autonomy enhanced

50
Prevalence of Telehospice
  • Informal survey
  • CIMIT Grant to review
  • Methodology
  • Findings
  • Follow-on research
  • Canadian telehealth research in palliative area

51
Research on Telehospice
  • Initial research papers
  • Work in Missouri and Washington State
  • Directions
  • IDG involvement patients and families
  • Education and emotional support to caregivers
  • Reactions of patients to use of health
    information technology
  • Preferences of video versus audio only

52
Opportunities and Challenges
  • Medical Director and other physicians
  • Demonstrating cost savings, /or quality of
    care/life improvements- to justify expense of
    equipment and staff
  • Training and staffing. Maintenance of depth of
    field/bench so turnover is not a problem. Need
    for a "champion".
  • Leading nurses to embrace technology

53
Telehealth Government Impediments
  • Reimbursement under Medicare
  • Medicaid
  • Grants
  • Outcomes, cost savings and Disease Management
    concerns
  • Licensure and interstate barriers
  • Standards lackingInteroperability among
    devices/software/infrastructure

54
Legal Barriers and Concerns
  • Licensure
  • Liability
  • Consent
  • Reimbursement
  • Management of the Case
  • Privacy and confidentiality
  • Security of Communication
  • Fraud and Abuse

55
Licensure
  • Many states New York is one--bar physicians from
    practicing via telehealth without a full or
    partial new licensequality control as issues
  • Some states now licensing the entity which
    arranges for and participates in telehealth
    services
  • Nursesnot surprisinglymore sane

56
Liability--Consent--Managment
  • Medical device or simply a conduit of information
  • Manufacturer Software vendors will seek total
    immunity from exposure
  • Patients need to hear from physicians and health
    entity about conditions, errors and backup
    response
  • Insurers reluctant or ignorant

57
Telehealth Privacy Laws and Impediments to Data
Exchange
  • State privacy laws
  • HIPAA
  • Congressional opposition on the HITECH and other
    HIT bills
  • Strong language extending privacy protections
    including business assocs
  • Is ARRA destined to slow eHealth progress

58
Fraud and Abuse
  • Coordination of telehealth services vs.
  • Impermissible incentive to referral source,
    including patient herself
  • and
  • If it is a new service is it subject to
    Stark law concerning physician financial
    interests

59
Discussion Are you involved
  • Audience experience in telehealth
  • Reluctance.and reasons
  • Board reactionshave they been educated
  • Can our society afford not to bring telehealth
    into our long term care situations?

60
Contact Information
  • Deborah A. Randall
  • law_at_deborahrandallconsulting.com
  • www.deborahrandallconsulting.com
  • 202-257-7073
  • Kathy Duckett, RN, BSN, Director
  • Clinical Programs Partners Home Care
  • kduckett_at_partners.org
  • 781-290-4058
About PowerShow.com