News| Volume 20, ISSUE 5, P18, June 01, 2019

# Telehealth Advances Provide Innovative Solutions to Complex Resident, Facility Needs

The pressure has been mounting for skilled nursing facilities to prevent avoidable hospitalizations, and a statistic from the Centers for Medicare & Medicaid Services (CMS) explains why. According to CMS, among Medicare-Medicaid enrollees in long-term care facilities, 45% of hospital admissions could have been avoided. And these hospitalizations, in addition to increasing expenditures for CMS and SNFs, can have dire consequences for residents.
“We see this happen all the time, where somebody who has been fairly stable gets a small thing like a minor respiratory infection, is sent to the emergency room [ER], and the patient is never again the same — even after just an 8-hour ER visit, for whatever reason. And there is good evidence behind it,” said Karl E. Steinberg, MD, CMD, HMDC, chief medical officer for Mariner Health Central in California, and vice president of AMDA — The Society for Post-Acute and Long-Term Care Medicine. “So a big goal of ours is to treat people in place.”
One way to help accomplish this goal, according to many in the post-acute and long-term care (PALTC) space, is through telehealth, which involves the use of technology to deliver health care services. Telehealth systems typically include bidirectional video conferencing, ancillary devices (e.g., a stethoscope or otoscope), a doctor or other practitioner on the other end of the communication, and an onsite staff member who acts on the doctor’s behalf. Sometimes referred to as telemedicine, which is similar in meaning but entails fewer remote health care services, telehealth offers new ways to address the needs of the PALTC population, potentially benefiting residents and staff alike.
“[Telehealth] allows you to get personal contact and eyes on a patient, which is so important because many acute events in PALTC facilities occur after 5:00 p.m., on the weekends and holidays, and those are times we like to carve out for our families and ourselves,” James E. Lett II, MD, CMD (Ret.), medical director at Avar Consulting, based in Rockville, MD, and past president of the Society told Caring. “It is also almost physically impossible to get to a facility in a timely fashion to deal with an acute problem. You have to decide whether this event is critical [i.e., whether the resident should be sent to the emergency department] or something we can deal with in the facility.”
Dr. Lett explained that telehealth provides residents and their families an added layer of comfort, knowing the decision-making process was not the outcome of a “phone call they didn’t hear with a clinician they didn’t see, but instead came from someone who heard and saw them,” he said. “The nurse is also comfortable because someone is actually hearing, seeing, and, through the nurse’s hands, touching the patient, so the decision is not a frivolous one, but made in consultation with, and after observation and examination of, the patient.”

As with the adoption of most new technologies, the first major roadblock preventing implementation of telehealth in PALTC facilities is cost. Initially, the systems featured large carts that cost several thousand dollars; now, with enhancements in technology, both the cost and footprint of the systems have been reduced.
CMS. “Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents.” https://innovation.cms.gov/initiatives/rahnfr
West Health. “A Practical Guide to Telehealth: Implementing Telehealth in Post-Acute and Long-Term Care Settings (PALTC).” https://www.westhealth.org/resource/telehealth-paltc-guide/
FCC. “Telehealth, Telemedicine and Telecare: What’s What?” https://www.fcc.gov/general/telehealth-telemedicine-and-telecare-whats-what
“Increasingly, we are seeing people use … an iPad [for their telehealth needs],” said Richard Stefanacci, DO, MGH, MBA, CMD, medical director at AtlantiCare/Geisinger in Pennsylvania. Beyond the cost and size reductions, Dr. Stefanacci said, computer tablets also improve the learning curve. “Most certified nursing assistants and nurses in long-term care are familiar with iPads, while the carts would take additional training. With staff turnover, you don’t want a system that is going to require a lot of training.”
For David Chess, MD, internist, geriatrician, and founder and chief medical officer of Tapestry Telehealth, based in Stratford, CT, an additional impediment is integrating physicians into the telehealth system. “Many physicians would rather maintain control than collaborate with others on providing care,” he said. “However, none of us can be available to our patients at all times. [Delivering care] requires a team.”
A lack on reimbursement represents another hurdle to widespread application. To date, Medicare does not reimburse telehealth outside of rural areas. To address this issue, if the bipartisan Reducing Unnecessary Senior Hospitalizations (RUSH) Act of 2018 is passed, it would allow medical professionals at SNFs to provide emergency care through telehealth.
Although supporting the objectives and purpose of the Act, Dr. Steinberg, who is the Society’s former chair of public policy, has raised several concerns he and fellow society members have with the legislation in its current form.
“The requirements stipulate that the doctor be an ER doctor and that the person onsite be somebody like an EMT [emergency medical technician] who has advanced cardiac life support [ACLS] training. That is the last thing our frail geriatric patients need,” he said. “With all due respect to ER doctors, they frequently misdiagnose, overdiagnose dehydration and urinary tract infections ... and are constantly adding drugs to the regimen, whereas we geriatricians are removing drugs that are causing problems.”
As for the EMTs, he said, if an ACLS intervention is needed, the resident will go to the emergency department anyway. “You’re never going to shock them, give them epinephrine, and leave them in the nursing home.” So using EMTs is not going to help prevent hospitalizations.“If we were completely reliant on family practitioners, internists, and geriatricians, there wouldn’t be enough for the nursing homes across the country. So there is definitely a need for [telehealth].”— Richard Stefanacci, DO, MGH, MBA, CMD
Ultimately, for Dr. Steinberg, the best onsite caregivers are those who work with this population on a daily basis, such as geriatric nurses, and the best person on the other end of the transmission should be a geriatrician or PALTC specialist familiar with what can be done in a nursing home.

## Effect on Hospitalizations

One of the foremost concerns for the facilities and insurers who are considering investing in telehealth is whether the systems will have a quantifiable effect on hospitalizations. Multiple studies suggest it will. In one controlled study of 11 nursing homes, switching from on-call to telemedicine physician coverage during off hours decreased hospitalizations and led to cost savings for Medicare greater than the nursing home’s investment in the service among the more fully engaged facilities (Health Aff 2014;33:244–250).
A separate study, conducted in a 365-bed SNF, examined the use of an after-hours telemedicine-enabled coverage service (TripleCare of New York) featuring a physician group specializing in the care of medically frail patients. Among the 313 residents who received telemedicine during the year of service, 83% were treated onsite, including 91 who avoided hospitalizations, according to third-party verification, while 54 were transferred to the hospital. As a result, Medicare and other payers received an estimated $1.55 million in associated cost savings (Am J Manag Care 2018;24:385–388). According to Dr. Chess, who was a coauthor of the 2018 study and is the founder and former chief medical officer of TripleCare, having an onsite doctor made a tremendous impact on residents and their families because they did not have to visit the emergency department and the resident did not have to spend hours lying on a gurney. Furthermore, Dr. Chess and colleagues estimated that the program’s$60,000 annual cost netted the facility $80,000. This$20,000 gain, the authors wrote, came from preventing hospitalizations; helping the facility maintain census, particularly in its short-term rehabilitation unit; decreasing transportation costs; and capturing lost Medicaid days while a patient was hospitalized. In other words, “everyone won,” Dr. Chess said. “The patients won; the families were happy; the attending physicians were happy because they weren’t called at night; and the facility and payer were happy. It really is a service that makes incredible sense.”
Dr. Chess stressed that these outcomes may not be reproducible with other telehealth systems because of what he called “incredible variability” with the clinician on the other side of the screen. “The technology is the easy part,” he said. “[The challenge] is getting clinicians who are going to wake up at night, see the patient, and pay attention ... There were so many doctors who joined [TripleCare] and were asked to leave after 2 days because they didn’t get up at night.”

## The Future of Telehealth

Despite the inherent challenges of incorporating a new technology into practice, the experts who spoke with Caring were optimistic about the prospects of telehealth and were convinced that it will become a necessary part of delivering care. An important reason for this, Dr. Stefanacci said, is the decreasing number of attending providers interested in long-term care.
“Fortunately, we have nurse practitioners and physician assistants, but if we were completely reliant on family practitioners, internists, and geriatricians, there wouldn’t be enough for the 14,000-plus nursing homes across the country. So there is definitely a need [for telehealth],” he said, adding that the systems will allow for expansion into specialty services. “We never get dermatologists to come to a nursing home, and the transportation burden for our older adults is pretty onerous. This expansion is going to make it financially feasible.”
As PALTC facilities continue to wait on the passage of legislation to ease the financial burden, Dr. Stefanacci remains confident that the advantages of telehealth will make it a necessity, even without direct financial reimbursement. “The increased accountability on the part of nursing homes with [emergency department] and hospitalization rates is going to make it pretty much a requirement for most facilities, and the finances will help support it,” he said.
Dr. Lett added that, based on the regulatory demands and the ethical and clinical needs, the question is not whether telehealth will expand. “It’s how much, where and how quickly,” he said.
Brian Ellis is a freelance writer and editor based in NJ.
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