Pulse
Virtual Visits
A few home health care providers are extending their reach by remotely monitoring patients with chronic diseases, but whether more will do so hinges on reimbursement.
Neil Johnson has been watching a wall cloud make its way across the horizon of the home health industry. Fueled by increasing demand for nurses and home health aides, growth in the aging population, escalating health care costs, and more recently by high gas prices that have led some providers to refuse to drive long distances to patients’ homes, it is threatening an industry already struggling to meet the demand for its services. “You could call it the perfect storm for home health care,” says Johnson, director of the Minnesota Home Care Association, a professional association of home health agencies in the state.
Johnson and other experts believe one of the more viable strategies for mitigating the impact of the brewing storm is for agencies to use telemedicine technology to care for patients remotely. Known also as telehealth or telehomecare, it typically requires the patient to have in their home a monitor along with peripheral equipment such as a stethoscope, blood pressure monitor, scale, glucose monitor, or pulse oximeter attached to it. Some units also have videocameras. From their homes, patients can turn on the system, take their vitals by following its audio instructions, and then press a button to transmit the data through a phone line or satellite connection to a central station in the home health agency’s office. The readings then go into an electronic repository that clinicians or home health staff can access. In many cases, a nurse or physician will receive an alert from the monitoring system when a measurement falls outside the normal range for that patient. If that happens, the nurse may schedule a home visit or have the patient seen by his or her doctor, depending on the severity of the situation.
Keeping Tabs on At-Risk Patients
Home health agencies aren’t the only ones looking to telemonitoring technology to care for patients in their homes. In 1999, St. Mary’s Duluth Clinic (SMDC) Heart Center created a telemonitoring program for patients with congestive heart failure (CHF) after having nurses call patients to monitor their conditions proved time-consuming and led to inaccuracies in patients’ self-reported weight measurements. About 200 patients can receive the telemonitoring services at a given time. About a thousand have already participated in the program.
In 2007, SMDC’s six-month rehospitalization rate for CHF patients was 2.5 percent—well below the national average of 40 percent, which results in cost savings for both insurers and the hospital. The hospital currently pays about $50 per patient per month to lease and operate the equipment. (Insurers currently don’t reimburse for this service.) “I think this technology could be the wave of the future,” says Linda Wick, a nurse practitioner who works in the congestive heart failure program. “Given our outcomes, it is hard to justify not paying for this, when an ER visit for heart failure costs $5,000 and a hospitalization for heart failure costs $6,000 to $11,000.”
Stan Finkelstein, Ph.D., director of the University of Minnesota’s Schmitt Center for Home Telehealth and a professor of health informatics, has studied the clinical and financial outcomes of home telemonitoring. Those studies have shown that it reduces overall medical costs for lung transplant patients by decreasing inpatient visits. One study found that the more diligent patients were about using a telemonitoring system, the lower the cost of their care. A statistical model predicted an average savings of 52.4 percent for those patients who adhered to home monitoring 100 percent of the time.
Those findings were so significant that the University of Minnesota Medical
Center-Fairview now offers a home monitoring program for any lung transplant patient who wishes to take part.
Mayo Clinic is exploring the use of telemedicine for patients with chronic medical conditions who are at risk for rehospitalization. “The goal is to have these sicker patients at home but still connected with their physician or primary health provider,” says John Fitz, M.D., an internal medicine physician at Mayo Clinic and director of Mayo’s as-yet-unnamed division for telecare services. “We’re trying to be more proactive about being their doctor at the time they need it—rather than waiting for them to get so sick that they have to schedule an appointment and can’t get in for two weeks and then have no choice but to visit the ER or get hospitalized.”—J.M.
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Patients most likely to benefit from the technology are those with chronic diseases such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), or diabetes, as well as those who have received an organ transplant—in short, patients at high risk for rehospitalization (see “Keeping Tabs on At-Risk Patients”).
A Few Pioneers
Johnson says that only about a dozen or so of the hundreds of home health agencies in Minnesota are currently using telehealth technologies to monitor patients at home. One reason may be the upfront cost. A home health unit can run about $5,000, depending on the peripherals needed and whether additional capabilities such as medication tracking are needed.
Poor reimbursement is another reason why agencies have been slow to adopt the technology. Medicare does not yet reimburse for home telemonitoring services, and Medicare beneficiaries make up the largest population of home health patients. (Minnesota is one of only three states in the country whose Medical Assistance program reimburses at the skilled nursing rate for home visits done using video monitoring.) What’s more, interpreting the daily influx of data from the telemonitoring units can tax a clinical team.
Despite those drawbacks, the agencies that have adopted the technology indicate that it is preventing hospitalizations and allowing staff to work more efficiently. Sunrise Health Services Inc., a home health agency in Stacy, Minnesota, began using telemonitoring in the summer of 2006 as part of a Medicare quality-improvement initiative to decrease hospitalizations. The agency leases five units at a cost of nearly $600 a month. About 15 patients have used the units since the inception of the program. “We’ve definitely seen decreases in hospitalizations; but what we like most about it is that we can detect problems earlier when we can do something about them,” says Sue Anderson, director of nursing at Sunrise. When a patient with congestive heart failure (CHF) gains more than a few pounds over a 24-hour period, the system alerts staff immediately so they can follow up either through phone counseling or a home visit. Although she has not calculated increased productivity among staff as a result of using telemonitoring, Anderson says it does allow them to do more thorough and frequent follow-up and be more judicious about sending nurses out to patients’ homes.
At St. Cloud Hospital Home Care and Hospice, where telemonitoring has been used for about five years, the technology is standard for patients with CHF. Director Gail Olson estimates that the facility has used the system with more than a thousand patients since the program began. (Up to 80 patients can be monitored at a time, and each patient uses the system for an average of 55 days.) “The way we are using it is the way that others are: to look for any indicators that a client’s health is declining,” Olson says. “But we’re also educating patients in the process—showing them that these readings tell us how they are doing and how their dietary and other life choices may be affecting the measurements.” Because the facility’s service area spans a 45-mile radius, telemonitoring has been particularly effective in reducing travel time for daily home care visits. “We have seen a decrease in skilled nursing visits overall for monitored patients versus those without a monitor since the inception of our program five years ago,” she says. “This reduction in visits does allow us to utilize staff more effectively and translates into a reduction in travel time and mileage expenses.”
Ready for Reimbursement
Academic research has substantiated claims about positive outcomes associated with using telemedicine. In 2006, Stan Finkelstein, Ph.D., director of the University of Minnesota’s Schmitt Center for Home Telehealth and a professor of health informatics, published results of a study in Telemedicine Journal and E-Health demonstrating that home telemonitoring improved clinical outcomes in patients with COPD and CHF. Hospitalization or nursing home admission occurred in only 21 percent of those patients enrolled in telemonitoring programs compared with 42 percent of those in a control group, and the cost per patient “visit” was $10 to $15 less with telemonitoring ($48.27 for a face-to-face home visit versus $32.06 to $38.62 for telemonitoring of CHF and COPD patients, respectively). Despite such evidence that shows that telemonitoring can be cost-effective as well as good for home health care patients, there likely won’t be a move toward increased use until there’s better reimbursement for such services.
Bills introduced by Rep. Jim Ramstad (R-Minnesota) and Sen. John Thune (R-South Dakota) authorizing certain home telehealth visits to qualify for Medicare reimbursement have stalled. Finkelstein believes that reimbursement will increase only when more randomized clinical trials make a statistically significant case for the technology. “Hopefully outcomes data will indicate that home tele-care is at least as, if not more, effective than standard care. But in the meantime, what we ought to be convinced of [from studies conducted thus far] is that monitoring can be done by patients—and it actually provides useful medical information upon which action can be taken.”
Without appropriate reimbursement for telemonitoring services, the situation facing the home health industry could turn into the perfect storm Johnson fears. If that happens, he says, family members will ultimately be left to deal with the aftermath. “I think there will be a growing reliance on untrained caregivers or more informal caregivers like family members,” Johnson says. “If agencies do not have the staff or the technology to deliver services to a growing number of people, it will be more difficult to access quality services in a timely manner.”—Jeanne Mettner