Why Every SNF Should Be Offering Telemedicine For Its Residents or Transforming SNF Care Through Telemedicine

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1 PACAH 2018 Spring Conference John Whitman, MBA, NHA The Wharton School Tapestry TeleHealth The TRECS Institute Why Every SNF Should Be Offering Telemedicine For Its Residents or Transforming SNF Care Through Telemedicine April 26, 2018

2 Thank God Spring is Here! off+car+in+snow&&view=detail&mid=7081f9c6e36aba56fd4d7081f 9C6E36ABA56FD4D&rvsmid=2C7912DEC16B B2C7912DEC16B B&FORM=VDQVAP

3 Meet Gertie

4 Congratulations! You are a physician and you are now on call!

5 What Would You do Doctor? It s 2 am and you receive a call from the local SNF Your patient Mrs. Smith is having chest pains what would you like us to do?

6 Send Them To The Emergency Room! What options does a physician really have? Concerns over: May or may not know the resident May or may not know/trust the RN calling Limited ability to effectively intervene on site at the SNF No reimbursement Concerns about litigation potential Both resident and physician want to go back to bed!

7 The Default Factor As a System, we lack the ability to effectively differentiate which nursing home residents need to be sent to the hospital and which residents can and should remain and be cared for in the SNF!

8 The Negative Impact of the Default Factor Retrospective studies confirm that 60% to 70% of all SNF to hospital admissions are unnecessary Average cost per admission = $12,000+ In addition to cost, admitting a vulnerable senior to the hospital when they don t need to go is NOT QUALITY CARE! Over $1 billion dollars a year is wasted!

9 Sending A Vulnerable Senior To The Hospital When They Don t Need To Go Is Anything BUT Quality Care! Increased morbidity Increased confusion Incontinence Skin breakdown More medications Exposed to hospital acquired infections And the added cost of all these well documented risks!

10 Key Challenges For Skilled Nursing Facilities Much sicker patients Lower reimbursement High staff turnover Smaller pool of patients (hospital census is down) Increased regulatory oversight and compliance pressure Clinical outcomes matter STAR ratings and $ penalties Families and patients have increased expectations Clinicians are hard to find and no one wants to work after hours

11 America s Skilled Nursing Facilities 15,452+ SNF s in America 11,110 Urban 4,342 Rural 70% Medicaid Physician presence in SNFs (limited at best) Sporadic day time in most urban 2-3 hours per month in many rural facilities Majority of care decisions made over the phone

12 HOW CAN WE POSITIVELY IMPACT SKILLED NURSING FACILITIES?

13 By offering high quality telemedicine services in our nation s skilled nursing facilities!

14 Telemedicine The practice of medicine when the doctor and patient are widely separated using two-way voice and visual communication Started in the military Today has many different applications: Remote weight and blood pressure checks Blood sugar levels Cardiac monitoring Basic primary care Medication management Rural emergency rooms Ambulances

15 Telemedicine Provides The Ability To Differentiate Resident s Medical Needs Two way video interaction Digitally enhanced stethoscope Zoom camera Otoscope Pillow speaker & privacy phone No log in/key board Multi-hour battery life

16 Cardiac ICU Monitoring For Small & Rural Hospitals

17 Most Insurance Companies Are Now Offering 24/7 Phone Access

18 TeleMedicine At Its Core Improves access to care Cost effective way of focusing advanced and preventive care Early Detection - Monitoring allows the SNF to focus on residents before they require hospitalization Virtual onsite care allows a limited workforce to be virtually present when needed (on demand)

19 Telemedicine The Catalyst For SNF Transformation Moving From a Nursing - Social Model to a Medical Model A Clinical and Financial Paradigm Shift

20 Two Primary SNF Telemedicine Models Urban No reimbursement All out of pocket for SNF Cost for I.T. readiness Cost for Administrative fee/equipment Economics work in SNFs favor due to added net revenue Rural Reimbursement for clinicians (Medicare Part B) Originating Fee ($20 per visit) covers I.T. readiness and equipment costs Economics work because no net cost to SNF

21 Urban Programs Access to face-to-face bedside care from a team of exceptional physicians 113 hours of coverage/week at times when bedside physician care is rarely available Evenings, nights, weekends, holidays Improve clinical outcomes, enhance care, and differentiate facility

22 How Most Urban Services Work The facility nurse calls and connects directly to a telemedicine physician. The physician examines the patient with the nurse through the telemedicine unit and treats in place when possible. Full notes and orders are faxed securely to the nurse to update the patient s record. The physician communicates with the attending on the episode and treatment plan and with the family

23 How Rural TeleMedicine Works Access to Clinicians for primary care and more Primary Care Support: Having a Family Practitioner, Internist, Geriatrician or Nurse Practitioner available daily (Monday through Friday) to see patients for medical issues and acute changes in condition Behavioral/Psych Services: Scheduled and emergency 24/7 care Specialty Consults: Consultative specialists services which could include dermatology, cardiology, pulmonology, nephrology, gastroenterology and endocrinology and more Wound Care & Continence Care

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25 Rural Primary Care Support Available 9 hours a day to see patients on demand (8 am to 5 pm, Monday through Friday) Daily Rounds (5 days per week) with facility s nurses Available on demand to see patients when there is an acute change in condition Communicates with families Assists with Advanced Care Planning Communicates and integrates with the attending Documents visits

26 Rural Behavioral/Psych Services Monthly Behavioral Visits (or as often as clinically required) Residents with: Depression, Bipolar, Schizoaffective disorders Dementia with behavioral manifestations Medication De-escalation and monitoring Behavioral Milieu Management Family Communication and Support Acute change of condition and 24/7 support Staff training and support F Tag response

27 Rural Consultative Specialists Services Providing Consultation via Telemedicine Scheduled and urgent visits Dermatology Cardiology Pulmonology Infectious Disease Physiatry Gastroenterology Endocrinology Urology Neurology Orthopedic Surgery Integrates with the attending Communicates with family Provides consultative note

28 Virtual Evaluations & Treatments Fevers, Infections, Pneumonia, Urinary Tract Infections, Wound Infections, Cellulitis, Sinusitis Lacerations, Skin Tears Fall Evaluations Shortness of Breath CHF, Asthma, COPD, Pneumonia Pain Evaluations - Chest Pain, Musculoskeletal Behavioral Issues - Limiting Psychotropic Medication Usage

29 More Virtual Evaluations & Treatments Change in Mental Status Diabetes Management Gastro-Intestinal Symptoms Medication Monitoring and Reconciliation Weight Loss Urinary Incontinence

30 Clinical and Social Impact Early Treatment of Conditions Reduced Emergency Room Transfer Reduced Hospitalizations State Survey Assistance Medication Stewardship Advanced Care Planning High Nurse Satisfaction Onsite Experiential Nurse Training High Patient and Family Satisfaction High Attending Integration and Satisfaction

31 RUGS Financial Impact Integrate with MDS nurse, Integrating with RTMS software STAR Rating Direct impact on return to hospital Keeps beds filled and helps to grow census Direct Impact on emergency room transfers. Improved nursing staff skills and confidence Significant Market Differentiator Your own medical house staff Makes your SNF more attractive to Hospital Systems, Health Plans, ACOs and Bundled Payment Plans, ISNP (Shared Savings Programs)

32 Financial Impact (continued) CMS 2% Penalty (or bonus) Specialist Office Visit Costs (scheduling, coordination, transportation and CNA time) Pharmaceutical Savings Infection Control - Antibiotic Stewardship Transfer Costs Nurse Satisfaction and Retention Increase Family Satisfaction Resulting in Fewer Complaints and More Referrals

33 Common Telemedicine Episodes Chief Complaints Shortness of breath Fever Change in mental status GI symptoms Chest pain Falls with injuries Behavior changes Common Diagnosis CHF Pneumonia COPD Hypovolemia and/or hypotension Urosepsis

34 Critical Success Factors for a SNF Considering a Telemedicine Service Management support (Corporate, NHA, MD, DON, Nurses) Selecting the right physician group Clinically sound and experienced in SNF care Good communicators Passionate Equipment Stethoscope and Zoom camera Other pieces can be nice but not absolutely needed The equipment enables the visit the quality of the Physician Group is the real key!

35 Common Concerns about Telemedicine Voiced by SNF Physicians Will this impact my billing? Will this increase my liability exposure? What s to keep the virtual physician from stealing my patients?

36 Significant Reduction in Avoidable SNF to Hospital Transfers NYC Study One Year Study in New York City 350 bed facility 91 Avoided admissions in one year $1.3 million dollars savings for Medicare $132,000 additional billing for SNF Better Care for Seniors Lower Costs

37 The Ying Yang Reality in Health Care Using telemedicine in SNFs benefits: Residents The SNF The local hospitals Our health care system Using telemedicine in SNFs hurts:????????????????

38 Some Thoughts to End On. There has never been a better time in health care to improve care & save money! Support from your management team is an absolute necessity for a telemedicine program to be successful Telemedicine is one way to differentiate your facility, reduce readmissions, improve relationships with hospitals, increase net revenue, and position for a shared savings opportunity In the next 3-5 years, every successfully run SNF will be offering telemedicine services to its residents.

39 Thank You! Please feel free to reach out to me if you have any questions about the potential of implementing Telemedicine in your skilled nursing facility! John Whitman, MBA, NHA The Wharton School Tapestry TeleHealth The TRECS Institute

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41 At the end of the day. It for the Gerties of the world!

42 Sometimes the best laid plans

43 Just don t work out!

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