Problem Addressed

• Cycle of hospitalization for chronically ill patients: Many patients with chronic illnesses are rehospitalized for complications associated with their condition. For example, almost one-third of CHF patients are readmitted within 30 days of discharge.¹ Readmissions can occur for a number of reasons, such as deficiencies in patient self-care and lack of appropriate followup after discharge.²
• Leading to significant clinical and economic burden: Chronic illnesses such as CHF, COPD, and diabetes are associated with high health care utilization. For example, CHF is the leading cause of hospitalization among older patients, accounting for an estimated $29.6 billion in costs in 2006.²
• Followup care difficult in areas with low population concentrations: Home care has the potential to decrease readmission rates and costs, but individuals living in rural areas and other remote locations often have limited access to health care providers, including home health nurses.³ For example, access to home health services is limited in New Mexico, a state characterized by a rapidly growing population of individuals over the age of 85 years, a shortage of registered nurses (projected to reach 43 percent by 2020), and a high proportion of patients residing in rural areas.⁴

Description of the Innovative Activity

• Referral for home health services: Patient referrals for home health care services come from a variety of sources, including proactively reviewing lists of new hospital admissions by discharge planners to identify patients with specific diagnoses (e.g., CHF, COPD and diabetes) who may be eligible for telehealth services in home care or hospice, and referrals from home health nurses in the field, intake nurses in the hospital and home health department, and physicians.
• Screening for telemedicine services: All patients referred for home care services are screened to determine eligibility for telemedicine monitoring. Eligible patients must meet three criteria: (1) the patient is either receiving Presbyterian Home Healthcare services or is a member of Presbyterian's health plan, (2) the patient has a telephone landline, and (3) the patient or someone in the home can operate the telemedicine equipment.
• Ongoing in-home visits: A Presbyterian home health nurse conducts two in-home visits during the patient’s first week at home after discharge. The home health nurse provides additional home visits if needed.
• Equipment installation: During the first week after discharge, a telemedicine technician visits the patient to set up the telehealth system and educates the patient about the machine. The patient receives one of three different unit models, depending on his or her needs: a video unit, a nonvideo unit (with a high-resolution stethoscope, a blood pressure monitor, a scale, a glucometer, and a pulse oximeter), or a combination unit. Video units have a high-resolution screen and audio function, allowing the telehealth registered nurse (RN) and the patient to see and hear each other during the visit. Combination units include nonvideo components along with the audio/video functionality.
• Ongoing telehealth visits: The telehealth RN, who is located in the Presbyterian Home Healthcare office, has an introductory “visit” with the patient via video or telephone during the installation visit and then conducts subsequent telehealth visits once or twice weekly, depending on patient need. During these visits, the nurse provides services similar to what a home visit nurse would provide, checking vital signs, providing condition-related education, and ensuring adequate self-care. The nurse also conducts a review of the equipment to make sure it is working properly. Telehealth services typically continue for 6 to 8 weeks; services may continue longer for patients who are officially discharged from home care (and therefore no longer receive in-home visits) but who could benefit from additional monitoring and education.
• Daily assessments: In addition to the telehealth visits, telehealth patients are asked to measure their vital signs, weight, and oxygen saturation levels each day. The telehealth software records these results and prompts patients to answer specific questions (e.g., “Did you take your medications today?”). Data are sent to a Web site for review by the telehealth RN. Care algorithms in the system alert the telehealth RN if a value is outside of the normal range, or if answers to questions indicate a cause for concern. Telehealth RNs call patients when alerted, and if patients do not enter information on a routine basis. For those patients with video units, RNs can perform additional assessments, such as wound examination, in response to the daily assessment data.
• Communication between providers: Telehealth RNs communicate abnormal values and/or other concerning findings to patients’ physicians via phone call or fax. In addition, telehealth RNs can print out vital signs for any period of time the patient has been under care and can forward that information to the physician if requested. Telehealth RNs communicate with in-home home health nurses via an electronic medical record.

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Innovator Disclosures

Results

• Contributing to fewer CHF hospitalizations: The hospitalization rate among CHF patients monitored by telemedicine fell from 19 percent in 2007 to 12.2 percent in first quarter 2008. The telemedicine program was one of several initiatives undertaken by Presbyterian Home Healthcare to improve care for CHF patients, so it is possible that not all of this decline is attributable to the telemedicine services.
• Cost savings: Presbyterian estimates that approximately $4,900 to $8,000 is saved for each CHF hospitalization prevented, given an estimated 3- to 5-day length of stay.
• Assumed return on investment: Although an analysis of the program's return on investment has not been performed, Presbyterian leadership assumes that the return is positive, given that even one avoided hospital admission more than covers the cost of a telehealth unit.
• Increase in RN patient load: The patient load for telehealth RNs is almost twice that of visiting home health nurses (telehealth RNs can conduct six to eight visits a day, versus five for home health nurses), due to the significant time associated with traveling to patient's homes in remote areas.
• High patient satisfaction: Surveys of participating patients indicate satisfaction rates of 96 percent.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Senior management buy-in: The executive director of Presbyterian Home Healthcare championed the adoption of telemedicine for monitoring patients. The executive director convinced senior management to fund the program through a presentation that detailed current resource constraints and offered examples of other home health agencies using telemedicine to increase productivity and improve outcomes.
• Review of telemedicine systems: Staff researched different telemedicine systems and vendors; selection criteria included ease of use by elderly patients, straightforward online access to monitoring data for nurses, and minimal need for troubleshooting of machines when in the patient's home. Nine video units were initially purchased; additional units were purchased over the next several years based on patient demand.
• Training nurses: Telehealth nurses were trained by the telehealth manager over a period of approximately 2 months; training focuses on principles of telehealth, patient eligibility, and how to use the telemedicine equipment. New telehealth RNs first observe visits and then conduct joint visits with a mentor before handling them on their own. With the help of the equipment vendor, the organization also created competency sheets to ensure adequate training.
• Educating referral sources: Staff conducted demonstrations of the equipment for physicians and discharge planners and also provided an overview of the program and its benefits, including patient eligibility criteria and how to refer patients to the program. New physicians receive an overview of the program during orientation activities.
• Program expansion: The program began with 9 telehealth units but by the end of 2007 had expanded to 81 units. In 2011, the program has 172 units.

Resources Used and Skills Needed

• Staffing: The program typically has three telehealth RNs (although one nurse position is currently vacant), with each nurse monitoring a caseload of roughly 40 patients; the program also employs one telemedicine technician. RNs have at least 1 year of home care and disease management experience and excellent computer skills.
• Costs: Telehealth units cost between $3,000 and $7,000 depending on their functionality. Staffing costs for the nurses and technicians run approximately $306,000 a year for 3.8 full-time employees.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Start small: Ensure that machines are fully utilized before purchasing additional ones.
• Do not underestimate the logistics, especially when treating elderly patient populations: Making appointments to set up the machines, hooking them up to cable or telephone lines, maintaining them, and training patients to use them all require time and a dedicated technician who can focus on these issues.
• Ensure vendor support: Select a telemedicine equipment vendor who will provide ongoing, prompt, reliable support.
• Be prepared to work with utility staff: Telephone and cable company employees may need to troubleshoot problems with transmission of telemedicine data.
• Pursue reimbursement: Determine whether private payers will reimburse for telemedicine services. Highlighting the potential for improved clinical outcomes and reduced costs may help convince payers to consider reimbursement.

Sustaining This Innovation

• Ensure some patient contact for telehealth RNs: Telehealth RNs may have low job satisfaction if their caseload is composed solely of patients who are monitored via nonvideo units. Ensure that caseloads are balanced to include both video and nonvideo patients.
• Consider replication of the model to other diseases: Once the program is running well, consider expanding it to patients with other common conditions that can be effectively monitored via telemedicine.

Additional Considerations and Lessons

• Because Presbyterian Home Healthcare is part of an integrated system, the system benefits when hospitalizations are prevented. Freestanding home health agencies can also benefit from providing telemedicine services if they can demonstrate a positive return on investment via decreased hospitalization rates to their clients.
• Adopters cannot bill Medicare specifically for a telemedicine visit. However, Medicare allows telemedicine services to be used to satisfy care delivery obligations under the Home Health Resource Group (the case-mix groups associated with given reimbursement levels) classifications for providing care.