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Telehealth for Hospice and Palliative Care


Telehealth for Hospice and Palliative Care Realities and Challenges Deborah A. Randall, JD & Consultant 202-257-7073 – PowerPoint PPT presentation

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Title: Telehealth for Hospice and Palliative Care

Telehealth for Hospice and Palliative Care
Realities and Challenges
  • Deborah A. Randall, JD Consultant
  • 202-257-7073

Today in Telehealth at Home
  • Market?? reaching a half billion dollars in USA
    in five years in telemonitoring.
  • Remote monitoring currently in use in Western
    Europe and UK, and growing in Asia. VA has
    gt62,000 homecare.
  • Sensoring movement analysis, falls detection,
    behavior tracking, dementia safety, communication
    to family

Scope and Payers
  • Home-based telehealth mostly chronic care
    management gt avoid ER re-hospitalizations.
    Provider funded grants within global fee for
  • Medicaid pays some telehealth visits.
  • Home as originating site NOT reimbursed by
    Medicare. Skilled nursing home live
    consultations in (rural or medically underserved)

PPACA Promising Sections
  • Post-hospitalization bundling pilot
  • Independence at Home demonstration
  • Innovation Center at DHHS
  • ACOs
  • Medical Home-Medicaid and Pilots
  • Face2face HHA provision w telehealthhospice
    provision silent

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

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.

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
  • EVP expresses interest in home eCare

HMSA Ambulatory MD/Home
  • Hawaii Medical Services 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

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

Home Telehealth - NY State
  • 93 home health only 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.

DHisease Management
American Telemedicine Assn
  • Home telehealth and remote monitoring practice
  • Working group exploring opportunity for, and
    prevalence of telehospice I chair this group.

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

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

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

Telehealth and High Touch
  • Does Telehealth work with the history of
    palliative care and hospice care as intensely
    high touch /high sensitivity?
  • Is some Touch better than no Touch better than
    Touch which comes with travel, delay, fear,
    understaffing? Is it not all about ACCESS?
  • Is mHealths immediacy palliative?

Seeing Patient Need
  • Will telehealth have accuracy and reliability
    for Palliative and Hospice?
  • Can the clinician make a palliative care decision
    from the distance?
  • If the patient is the center of care, where
    more so than end of life pain management
    suffering whether physical, psychological or

National Association for Home Care and Hospice
  • Interest in telemonitoring for home care and
  • July 2009 Caring journal devoted to
    telemonitoring some mention of hospice
  • NAHC Division for telehomecare
  • Center for the Advancement of Palliative Care

National Hospice and Palliative Care Organization
  • Grants to hospices working in conjunction with VA
  • Not formally looking at telehealth
  • Current Concern PPACA requires visit by MD/NP
    at 180 days of care televisit not included in
  • American Academy of Hospice and Palliative

Hospice Care
  • Terminally ill or end-of-life situation
  • Team delivery of non-curative care
  • Generally, family as the unit of care
  • Physical, mental, psychological and spiritual
    care of holistic model
  • Generally, home-based care but some in-patient,
    hospice home and respite

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

Telehealth and Palliative Care
  • Telehealth and pain management
  • TeleHospice care
  • bringing patient and family into the
    interdisciplinary group IDG
  • counseling patients and family when social
    workers are scarce resources recorded care
    videos on-call nurse

Prevalence of Telehospice
  • Informal survey with CIMIT Grant done in 2009
  • Methodology and Findings
  • Follow-on data gathering still on-going and
    informal. Professional associations are

Advanced Illness Is there a Role for Palliative
  • Using an existing model of advanced illness
    coordination which included health counseling
  • Congestive heart failure, end-stage pulmonary
    disease, end-stage renal disease, and cancer as
    handled in various care settings.

Expanding a model, contd.
  • Goals for improved communication about
    discomfort, support for decision makingproblem
    resolution attention to caregiver needs.
  • Outcomes measurements expanded from the curent
    gt DNR or intubate orders ltinpatient admissions
    with no difference in survival.

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

Telehealth Impediments
  • Reimbursement under Medicare
  • Medicaid
  • Outcomes, cost savings and care management
  • Licensure and interstate barriers
  • Unlawful incentives in collaboration
  • Standards lacking Interoperability among

Attention to Legal Concerns
  • Licensure of palliative care provider
  • Liability and Consent
  • Privacy and confidentiality
  • Security of Communication

Thank You!
  • Deborah Randall, JD
  • Health Law Attorney
  • Telehealth Consultant
  • 202-257-7073