Telehealth - A P4P Tool for Quality Based Reimbursement: Its Impact on Quality Care and Customer Service

As America's population continues to age and as we continue to see chronic health conditions predominate, the challenge to provide continuing care in the home and other non-hospital settings, and with fewer health care workers, is fast becoming a reality. Thus, the importance of establishing systems on a solid business foundation cannot be underestimated.

Technology that improves data accuracy, reduces errors, enables intelligent communications, and improves overall patient care and clinical satisfaction while reducing costs, is the only realistic solution. Against this backdrop, we must not lose perspective on what our mission and work is all about...quality care and outstanding service.

According to health care industry consultant Tim Rowan of Stony Hill Management, the patient-nurse ratio is going to double in the next few years, leaving home care and hospice with little alternative but to automate, and enable nurses to do more using technology. Just as electronic point of care (POC) solutions proliferated over the past decade, new telehealth technology and technologies that link POC and telehealth data are what is next on the planning agenda for home health agencies. These advances will make for more efficacious care of patients, resulting in quality results.

Around the same time as the first baby boomers turn 65 in 2011 and join Medicare, home care agencies will likely also be grappling with federal pay-for-performance (P4P) regulations, and how they are paid. CMS expectations and P4P provide strong incentives to improve clinical outcomes and patient satisfaction; keeping patients out of hospitals and out of the emergency departments will make economic and business sense.

Recent research by the Dartmouth Atlas Project (May 2006), attests that the health care system as a whole, not just CMS, has not developed efficient, effective ways to care for people with severe chronic illnesses. The project is an ongoing review of health care use and resources nationwide, and is conducted by the Center for the Evaluative Clinical Sciences (CECS) at Dartmouth Medical School.
CECS researchers commenting on the report said that it "... speaks clearly to the need to overhaul the way chronic illness is managed - to redirect resources away from acute care, and invest in an infrastructure that can better coordinate and integrate care outside of hospitals, for example home health and hospice care. A major challenge is to develop reimbursement policies that provide a path toward transition. When payment is based solely on utilization, hospitals that reduce stays lose money."

The report calls for a reimbursement system that rewards rather than penalizes provider organizations, which successfully reduces excessive use of services, and develops broader strategies for managing patients with chronic illness

While there is still much debate on exactly what pay for performance will look like, (ie. what will be measured, how agencies will be rewarded for good performance or penalized for poor performance, and when it will be introduced), there is no debate that every home care agency should be preparing now for how they will cope with an increased patient census and a reduced number of health care workers, while meeting the demands of CMS and P4P.

Preparing for Pay for Performance

Planning in the face of uncertainty is never easy but the following constitutes an approach to generate better outcomes:
Outcomes - analysis tools and action plan
Standards - utilization, margins and outcomes
Procedures - case management, training, agency button to institutionalize best practices
Technology - telehealth, clinical monitoring, point of care

Outcomes - Are tools in place to analyze outcomes in the context of resource utilization to develop an understanding of what care delivery patterns and practices parlay into favorable or unfavorable outcomes?
Are you capturing and mining data (of correct type and sufficient quality and quantity) which allows you to identify practice patterns that result in positive (or negative) outcomes, down to the clinician level? Have you created action plans to propagate those practice patterns that produce positive results, and correct or mitigate the impact of those that do not, and train or retrain staff accordingly?
Standards - Once you have an understanding of how resource mixes affect quality and fiscal outcomes, are you prepared to develop standards for resource utilization, fiscal margins and patient outcomes against which current performance can be measured?
Procedures - Have you evaluated new or improved procedures that can: 1) impact fiscal and quality "bottom lines"; 2) provide more vigorous and pre-emptive case management; 3) secure more appropriate levels and frequencies of staff training; and 4) utilize tools to integrate best practice guidelines into point of care software?
Technology - Are you evaluating new opportunities to apply technology to care delivery, monitoring and follow-up? Have you investigated the benefits of an electronic medical record accessible at the point of service? Old habits die hard; once invested in EMR, are you continually looking for new ways to maximize its utilization? Have you evaluated the return on investment and the contribution to quality and patient satisfaction that telehealth and remote clinical monitoring devices can deliver to your organization?

The Promise of Telehealth

Telehealth holds huge promise for delivering and managing patients with chronic illnesses in their homes. To date however, only around 5-10 percent of home health agencies have adopted telehealth. Another 25- 50 percent are thinking about it. The problem, according to Rowan, is that agencies need to understand that telehealth is a clinical service, not a computer device, and they need to start investing. More and more studies are showing compelling results for telehealth such as reduced ER usage, reduced hospitalizations, fewer unscheduled office visits, savings for all payers, improved patient care, and customer satisfaction.

Remote electronic monitoring is the dominant version of what is generically referred to as telehealth, and along with video conferencing, vital sign gathering, and what some refer to as telephone triage, make up the majority of telehealth technologies and techniques in most common use. Physician and patient portals are an associated technology that allows physicians, patients and their families to also view patient data, keep them informed, educated, and in general, more satisfied.

Most recently, a growing number of home health agencies are taking the next step and investing in technology that integrates their POC and telehealth data systems.

Building a Patient Data Tracking and Treatment Care Chain

Twin Tier Home Health of Binghamton, New York, a member organization of home care services provider United Health Services, has been using telehealth monitors from Honeywell HomMed, LLC for the past five years. Since early 2006, they have been successfully using a new interface that links that telehealth data to their POC system (NDoc) from Thornberry Ltd.

The telehealth integration option from Thornberry provides homecare agencies with the ability to capture the most up-to-date patient information possible, and to view that data within the context of the integrated electronic health record (EHR) which resides within the POC system.

Critical information such as blood pressure, oxygen level, pulse and temperature that is gathered by a telehealth monitor in the patient's home is automatically transmitted to Twin Tier's HomMed data repository. The information is then imported into NDoc where it can be accessed by the homecare agency's clinician from any location. Clinicians not only get to see the integrated information at the laptop level, but also all the 'abnormal' readings as defined by the agency for the patient, as well as associated alert and census reports specific to telehealth patients. By integrating clinical data captured by all sources, the telehealth enhancement supports optimum care delivery from the clinician at the patient's residence.

Patient Selection

Patient safety issues and a patient's physical and mental capability have to be taken into account in selecting which patients are most appropriate for telehealth monitoring. Are the patients compliant with their care? Do they have a care giver? Are they able to put on a blood pressure cuff? These are typical questions to consider. Patients must be receptive to telemonitoring for it to work successfully.
Patient condition or diagnosis was also an important factor in enabling the agency to prove the technology by visibly tracking results and outcomes. Twin Tier focused on patients with 'dizzy' symptoms. Cardiac and respiratory patients with the highest risk for re-hospitalization received telehealth monitors. With this clear identifier, they could be more accurately and actively monitored, and helped to best manage the disease process, and the agency could readily measure results.

Outcomes

Twin Tier's Care Manager uses the data to educate patients and to reinforce correct behaviors, asking patients what they ate last night that resulted in elevated sodium levels and high blood pressure the next day. For instance, Telehealth data is reviewed daily at a minimum and often more frequently, depending on the physician's request or a particular issue to do with the patient's condition.

Although the agency employs 20 nurses and anywhere from 20 and 25 therapists, they have found so far that a dedicated Telehealth team of one office-based care coordinator and two case nurses is more efficient. Twin Tier started with 25 telehealth monitors, and based on full utilization and reduced hospitalizations, recently purchased another 10, taking their count to 42.

The agency's goal is to continue to reduce its number of re-hospitalizations through the use of telehealth, to enforce med compliance, and to more actively engage patients in monitoring their own health status and need for clinical assistance.

Prior to adopting a small dedicated team approach for telehealth monitoring, the agency used to require all its case managers to manage the telehealth data. This meant multiple people coming into the agency to review data and making notes on paper.

Not only has the dedicated team approach overcome that issue, but the introduction of POC technology in 2004, and the adoption early in 2006 of interface software that captures the telehealth data and automatically integrates it into the electronic patient record, has meant the data is now available to every NDoc user in the office, and that patient records are complete records. Users no longer have to physically go to the central station to obtain and record patient information.

The interface also allows field clinicians to see historical telehealth data, which is especially useful with those patients who don't keep a log as faithfully as clinicians might like to see, and which was previously kept on paper where no one got to see it.

Users also no longer have to toggle back and forth between an electronic POC system and telehealth data that ultimately lived on paper in a separate record. Now clinicians and therapists can get yesterday's testing overnight on their laptop at home. They can react to data sooner, actively choosing which patients to visit in person first, and reducing re-hospitalization, all of which enhance the concept of putting the customer first.

South Jersey Healthcare HomeCare (SJHCHC) started using telehealth monitoring in early 2005, having adopted NDoc point of care software nine years previously. SJHCHC is part of South Jersey Healthcare Community Services, which in turn is part of South Jersey Healthcare, a charitable, nonprofit health care provider in the Delaware Valley.

They currently have 60-65 units in patients' homes at any given time. The agency is continuing to introduce more monitors, and have another 31 on order to make available to private paying individuals.
Measurements such as heart rate, blood pressure, and pulse oximetry or blood oxygen content captured by HomMed equipment in patient homes is sent electronically every 15 minutes via Skytel satellite or phone line for rural patients, to an agency-based central repository. SJHCHC selected the HomMed monitor because it is small, compact, easy to use, is not as invasive in patient's homes and because various clinical questions can be programmed into the monitor to obtain additional information besides just vital signs, allowing clinicians to triage a patient's condition.

This 'decision-tree' methodology is part of what makes telehealth so valuable and so powerful. Patient vital signs trigger follow-up responses, and patient responses trigger follow-up questions, leading to earlier and often less costly attention.

This year, like Twin Tier, SJHCHC went one-step further and linked telehealth monitoring and POC. The interface software automatically extracts telehealth data and merges it for seamless presentation to nurses and therapists. Clinicians and therapists are now fully equipped at the point of service to make patient care decisions based on all available clinical data, including telehealth.

Nurses at SJHCHC now carry a caseload of up to 40 patients, the majority of whom are on monitors. The champion nurse usually has a caseload of 30-35 cases. Using their laptops, nurses now start their day from home with the entire patient chart at their fingertips, and they can then see and review results with a patient when they are in the patient's home instead of waiting for them to be faxed to them at the end of the day. The new system has also greatly increased patients' involvement in their own health care.

The reaction from nurses and patients has been extremely positive. There is an increased sense of security for patients in knowing they are being watched for subtle changes, and for the nurses as well, who can now respond with early intervention when a change in condition occurs and a patient is having a problem, rather than making a random visit.

It is not just patients and nurses who will benefit from the new electronic integration of telehealth data and clinical POC management software. Less paperwork, printing out and faxing results, the ability to decrease patient visits while at the same time improving patient care and care-planning and reducing re-hospitalizations, has given the agency the ability to improve profit margins while keeping patients satisfied with their level of care.

About the Authors

Paula M. Joyce, RN, is compliance coordinator/clinical systems manager for Twin Tier Home Health, Inc. In her 23 years in the industry, she has served as case manager and compliance oversight and reimbursement coordinator. More recently, Paula has held the lead position for the search and implementation of Twin Tier's POC documentation system while continuing as clinical systems manager. She can be reached at paula_joyce@uhs.org.

Diane Levan, RN, BSN, MSN, is homecare director of SouthJersey Healthcare HomeCare. She has worked in various settings including hospital, long term care, adult day care and home care settings. Levan can be reached at levand@sjhs.com.

Thomas C. Peth, president, Thornberry LTD, is co-founder of the organization, which is a provider of acute care nursing documentation software. He assumed his current position in 1994, and presided over the transition of its product to home health point of care/electronic medical record software. Peth can be reached at tomp@thornberryltd.com.

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