Muskie School of Public Service

Transcription

1 Imprving Access t Care: Use f Telehealth by Critical Access Hspitals Muskie Schl f Public Service Jhn Gale Flex Mnitring Team

2 Muskie Schl f Public Service Cntact Infrmatin Jhn Gale, MS /Flex Mnitring Team Muskie Schl f Public Service University f Suthern Maine jgale@usm.maine.edu Phne:

3 Muskie Schl f Public Service Overview Hw des telehealth fit int the revised prgram area III - Ppulatin Health Management and Emergency Medical Services Integratin? Expanding access t needed lcal services using telehealth technlgy Terminlgy Telehealth technlgies Reimbursement issues Impact f telehealth use Examples frm the field invlving CAHs

4 Muskie Schl f Public Service III. Ppulatin Health Management and Emergency Medical Services Integratin Prgram area III fcuses n wrk t: Imprve the health f rural cmmunities thrugh ppulatin health management Cmmunicatin and cllabratin between different health care prviders Imprving patient experiences when transitining frm ne care setting t anther Building EMS capacity t best serve CAHs and their cmmunities Telehealth falls under the first tw gals Key uses f telehealth: T imprve system functining Prvide crisis supprt fr patients in the emergency department (ED), tele-trauma t supprt ED, telepharmacy t fill gaps in pharmacy cverage, teleradilgy Prvide key needed lcal services Mental health, specialty services, tele-endcrinlgy fr diabetes management

5 Muskie Schl f Public Service Use f Telehealth t Expand Access t Care Telehealth can increase access t and quality f healthcare in rural cmmunities Allws rural patients t see specialists withut leaving their cmmunities, permits lcal prviders t take advantage f distant expertise, and imprves timeliness f care Accrding t the American Hspital Assciatin (AHA), 52% f hspitals used telehealth in Anther 10% were starting the prcess t use telehealth. Delivery f mental health services is a cmmn use In Illinis, small and rural hspitals were mst interested in telepsychiatry, tele-endcrinlgy, teledermatlgy, and teleneurlgy Other clinical services include telestrke, teleradilgy, tele-icu, telepathlgy, cybersurgery, remte mnitring, telepharmacy, and ther specialty cnsultatins and services

6 Muskie Schl f Public Service Terminlgy Originating site: where patient is lcated and seen Physician ffices, skilled nursing facilities, Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Critical Access Hspitals (CAHs) Distant (presenting) site: Where prvider f service is lcated Prvider can include physicians, psychiatrists, clinical psychlgists, clinical nurse specialists, clinical scial wrkers, ther prviders Difference between telemedicine and telehealth Telemedicine refers specifically t remte clinical services The Health Resurces & Services Administratin (HRSA) defines telehealth as the use f electrnic infrmatin and telecmmunicatins technlgies t supprt lng-distance clinical health care, patient and prfessinal health-related educatin, public health and health administratin Telehealth includes videcnferencing, the internet, stre-and-frward imaging, streaming media, and terrestrial and wireless cmmunicatins

7 Muskie Schl f Public Service Telehealth Technlgies Live Videcnferencing (Synchrnus): Live, tw-way interactin using audivisual telecmmunicatins technlgy Stre-and-Frward (Asynchrnus): Transmissin f recrded health histry t a practitiner wh uses the infrmatin t evaluate a case r render a service utside f a live interactin Remte Patient Mnitring: Persnal health/medical data cllected frm a patient via electrnic cmmunicatin technlgies and transmitted t a prvider in a different lcatin fr use in care and related supprt Mbile Health (mhealth): Health care and public health practice and educatin supprted by mbile cmmunicatin devices. Applicatins range frm targeted text messages that prmte healthy behavir t wide-scale alerts abut disease utbreaks.

8 Muskie Schl f Public Service Medicare Reimbursement Issues Originating site must be in a rural health prfessinal shrtage area (HPSA), cunties utside metrplitan statistical areas (MSA), HPSAs lcated in rural census tracts f an MSA Authrized riginating sites: physician/practitiner ffices, CAHs, hspitals, cmmunity mental health centers (CMHC), skilled nursing facilities (SNF), RHCs, FQHCs, hspital-based dialysis center Distant site prviders: physicians, nurse practitiners (NP), physician assistants (PA), clinical nurse specialists (CNS), registered dieticians (RD), certified nurse midwives (CNM), certified registered nurse anesthetists (CRNA), clinical psychlgists, clinical scial wrkers

9 Muskie Schl f Public Service Medicare Reimbursement Issues Originating sites may bill a facility fee Distant sites are reimbursed at the prvider fee schedule Limited t face t face (real time interactins) except in demnstratins in Alaska and Hawaii and FCHIP where stre and frward is allwed fr specified services

10 Muskie Schl f Public Service Medicaid Reimbursement Issues Cverage varies frm state t state Check state cverage plicies Example: Medi-CAL (Califrnia) Must be real time (face t face) fr evaluatin and management services Technlgy must, at minimum, meet prcedural definitin f the cde prvided thrugh telemedicine Distant prvider must be licensed in Califrnia and enrlled in Medi- Cal as a prvider Originating site must btain and dcument ral apprval prir t prviding service via telemedicine Stre and frward limited t phthalmlgy and dermatlgy Telephne cnversatins, faxes, and s are excluded frm the definitin f telemedicine Originating sites can bill a facility fee, distant sites are paid at the current fee schedule

11 Muskie Schl f Public Service Cmmercial Reimbursement Issues Cverage varies frm plan t plan and state t state Check state cverage plicies Sme states such as Gergia require all payers t pay fr services prvided thrugh telehealth (if they pay fr the service delivered in persn) The ability t bill an riginating fee depends n the plan Typical bth riginating and distant sites must be members f the health plan

12 Muskie Schl f Public Service Impact n Access Imprved access t specialty services within the cmmunity Reduced travel barriers t lcal residents Expanded supprt fr hspital specialty services such as strke, trauma, and intensive care services Ptential Impact f Telehealth Use Telehealth/Telemedicine Impact n Medicare Csts and Utilizatin Reduce unnecessary hspitalizatins, readmissins, and emergency department use fr ambulatry and lng term care patients Reduce length f stay in ED and reduced length f hspital stays Reduce high cst patient transfers fr strke and ther emergencies Reduce the need t refer patients t mre expensive urban facilities Reduce delay in receipt f care thereby imprving treatment f care at a less-acute stage f the illness Impact n Quality f Care Imprve timeliness f services Reduce barriers t care Imprve crdinatin f care Imprve access t specialty cnsultatins fr lcal prviders (better partnerships t imprve patient care) Reduce prvider islatin in frntier cmmunities Imprve utcmes due t earlier diagnses and treatment utcmes Imprve supprt fr EDs and ICUs results in reduced mrtality rates, reduced cmplicatins, and reduced hspital stays

13 Muskie Schl f Public Service Facts frm Califrnia Telehealth Resurce Center Mrtality rate drpped frm 13.6% t 11.8% after tele-icu was implemented, and length f stay in the intensive care unit (ICU) fell frm 13.3 days f 9.8. (JAMA 2011) The Veterans Administratin (VA) reprts reductins in utilizatin f between 20% and 56% when care crdinatin and hme mnitring are emplyed. (Department f Veterans Affairs, June 2009) A VA hme telehealth prgram fr vets with chrnic cnditins reduced hspital admissins by 19% and ttal bed days f care by 25%. (Telemedicine and e-health, Dec. 2008) Califrnia prisn fficials prvided rughly 9,000 telehealth cnsultatins in 2004, saving taxpayers mre than $4 millin in transprtatin and escrt csts. (Califrnia HealthCare Fundatin, 2008) Telemnitring reduced hspitalizatins by 75% and ER visits by 83%. (Pennsylvania Hmecare Assciatin) In 2007, Sutter estimated that 425 sepsis related deaths were prevented and the eicu resulted in $2.6 millin in savings (Cmputer Wrld 2007)

14 Muskie Schl f Public Service Wabash Valley Rural Telehealth Netwrk, IN Crisis Services in CAHs Prblems with mental health patients clgging EDs Hub & spke mdel: CMHC prvides crisis services t 6 CAHs Services are prvided CMHC s 24/7 access center using licensed clinical scial wrker (LCSW)/licensed mental health (LMH) staff and psychiatrist Standardized prtcls/algrithms used t assess patients CMHC sees patient using telehealth technlgy and prepares cnsultatin reprt and dispsitin plan ED length f stay (LOS) reduced frm hurs t 240 minutes Hspital pays $125 per cnsult t CMHC Learning pints: Substantial savings (lwer ED LOS), fewer unnecessary hspitalizatins Standardized prtcls and 24/7 access key

15 Muskie Schl f Public Service Nrthern Human Services, NH Rural CMHC Netwrk - Umbrella health rganizatin includes 5 CMHCs and 7 CAHs in nrthern New Hampshire Started with Rural Health Outreach funding Primarily funded thrugh Medicaid and 3 rd party billing Grant funding t secure mre equipment Uses telemental t increase access and shre up the netwrk Cncerns abut sustainability under develping Medicaid managed care prgram Dealing with a number f credentialing related challenges

16 Muskie Schl f Public Service Nrthern Human Services, NH CMHCs rtate telemental service cverage thrugh all five sites, sharing respnsibility fr ED cverage (previusly in-persn) ED services: Invluntary Emergency Admissin (IEA) Assessments fr state hspital, crisis stabilizatin and emergency assessments, pediatric psychiatric cnsultatins by an utside psychiatrist Dealing with a number f credentialing related challenges Savings: Apprximately 50 staff days/year are saved by reducing staff travel time Reduces burden n law enfrcement due t access t IEA assessments Learning pints: Reimbursement desn t cver technlgy acquisitin Ptential Medicaid reimbursement changes threaten sustainability

17 Muskie Schl f Public Service Avera St. Benedict Health Center, Avera Health, SD Part f Avera Health a reginal Cathlic health system based in Siux Falls, SD. Avera Health is very well wired with a central telehealth center knwn as Avera ecare Services (based in Siux Falls) 24 hur access t specialty care physicians and pharmacist and supprts the rural health care wrkfrce. Prvides numerus telehealth services including ICU, emergency, strke, pharmacy, mental health, cnsults, wmen s health, pulmnary, internal medicine, lng term care (LTC), palliative care, and dermatlgy Avera St. Benedict Health Center lcated in Parkstn, SD A 22 bed CAH, 3 RHCs, a 25 bed assisted living facility, a 50 bed lng term care facility, and a licensed day care Invlved with telemental health since 2010

18 Muskie Schl f Public Service Avera St. Benedict Health Center, Avera Health, SD Service created with utreach grant funds Services prvided; Geriatric psychiatry: A geriatric psychiatrist based at the Avera Behaviral Health Center in Siux Falls prvides services t residents f the Avera St. Benedict s residential care and lng term care services and the patients f the RHCs n a ne half day per mnth basis Adlescent psychiatry: Adlescent psychiatry based ut f the Avera Health netwrk is wrking with Our Hme, Inc. (nt part f the Avera system) t prvide telepsychiatry services directly t their residential psychiatric facility in Parkstn Ambulatry mental health services: Scial wrker at the hspital uses telemental t fill in the gaps when she is unable t be n site at the Lake Andes RHC Cntinuing medical/prfessinal educatin: Prvided fr the staff f the clinics and hspitals, typically nce r twice per mnth.

19 Muskie Schl f Public Service Grande Rnde Hspital, OR CAH perating hub and spke telemedicine prgram Gal: Increase access t specialty care Virtual health system using telemedicine Began with periperative services prvided by specialists frm St. Alphnse Reginal Medical Center in Bise, ID Added ther high acuity services including intensivist cverage, neurlgy, maternal fetal medicine, psychiatry/behaviral health, ICU, nenatlgy, pediatrics, nclgy, dermatlgy, and cardilgy Specialists frm Oregn Health and Science University, Walla Walla Clinic, Hearing Speech, and Deafness Center (Seattle), and Advanced ICU Care (St. Luis, MO) Access freign language interpreters including sign language

20 Muskie Schl f Public Service Grande Rnde Hspital, OR Benefits fr patients - better access t care and substantially reduced travel time Examples: Onclgy service saved 191 patients 36,737 miles in travel, 717 travel hurs, and $18,729 expense. Reduced physician travel by 291 hurs Dermatlgy saved 229 patients 49,016 miles, 1021 miles, and $24,511 in travel time and expenses System savings: ICU experience -in 64 mnths, 69 patient transfers were avided saving the system ver $1.9 millin Generated 515 additinal ICU and med-surg days Other benefits: Mney saved fr insurers, patients, and families Imprved timeliness f care clser t hme Imprved recruitment and retentin f primary care prviders

21 Muskie Schl f Public Service Hedrick Medical Center (HMC), MO Municipal CAH that is part f the St. Luke s Health System Sees patients thrugh its endcrinlgy telehealth clinic Als ffers diabetes care at the Hedrick Diabetes Center St. Luke s specialists prvide telemedicine services at HMC: Allergy, cardilgy, endcrinlgy, neurlgy, psychiatry, pulmnlgy, rheumatlgy, wund care Evidence Base fr tele-endcrinlgy: Study-66 patients frm five rural areas f Tennessee were fllwed by specialists frm the telemedicine unit at the Univ. f TN-Memphis 85% f the 20 diabetic patients shwed significant imprvements in Hemglbin A1c at 6 mnths, decreasing frm 9.1% t 7.5% 70% f patients with dyslipidemia shwed imprved lipid prfiles Crdinates with primary care prviders 97% were cmfrtable receiving telehealth services