Celebrating 10 years 2002 2012 Effects of TeleCare Management When Layered onto Home Healthcare Case Management Provided to a Chronically Ill Medicare Advantage Subpopulation Abstract: 47 members of a Medicare Advantage plan received TeleCare Management as part of their acute Case Management protocol delivered via home healthcare following hospital discharge. They each had a primary or secondary diagnosis of Congestive heart failure (CHF), Coronary Artery Disease (CAD) or myocardial infarction. Through this program, these members received store-and-forward telemonitoring devices to transmit biometric readings (including blood pressure, pulse, weight, O 2 and blood glucose) to a centralized webportal run by AMC Health. Nurse TeleCare Managers used this biometric data to track members health status, provide health coaching as appropriate, and forward data to the members physicians as necessary. A control group (n=132) was identified among members with one of the same three diagnoses, and who received acute Case Management from the same home healthcare vendor, only without the added Telecare Management component. Twelve months of claims were analyzed for both the telemonitored and control groups, both before and after the start of Case Management. Overall, despite the similarity in Per Member Per Month (pmpm) claims prior to the study period, for the study period, the intervention group generated 57% fewer costs than the pr-intervention period vs. 6% fewer costs generated by the control. Total admissions pre versus post increased at a rate of 8% for the control group and decreased at a rate of 50% for the telemonitoring group members. The analysis also suggests that the dramatic reduction observed in the telemonitored group is sustainable for a short period post-telemonitoring. Introduction: The Medicare Advantage plan conducting the study was motivated to do so after extremely intriguing results from an earlier, retrospective pre/post study that demonstrated a nearly 70% reduction in acute care costs, a 78% reduction in sub-acute costs, and a nearly 50% reduction in acute admissions when telemonitoring was layered onto home healthcare Case Management. As a control was not utilized in that study, the possibility of regression to the mean begged a more rigorous analysis involving a control. With the exception of members receiving wound care, all healthplan members with chronic illness receiving Case Management through the home healthcare vendor were treated identically. All were assigned Nurse Case Managers who directed field nurses visiting members in their homes. In every case, a field RN conducted a comprehensive physical assessment of the members at the start of care, and the information was used by the assigned Case Managers to develop plans of care, in conjunction with physician orders, that dictated home visit schedules by nurses and therapists, and other home care services, such as durable medical equipment and assistance with Activities of Daily Living. Sans telehealth, these Case Managers did not routinely utilize biometric information obtained at the member s home on a daily basis, but instead relied on self-reported symptomology, as well as the limited biometric measurements that may have been made during a nurse visit to the home. For purposes of this study, the health plan outsourced TeleCare Management services to the home healthcare vendor to determine if quotidian biometric data, coupled to targeted clinical feedback and education based on this data, could enhance the outcomes for those receiving standard home healthcare Case Management. The assumptions tested were that actionable information transmitted from the member s home in real-time could provide opportunities to detect pre-acute conditions and those at the earliest stages of clinical decompensation in between scheduled nurse visits to the home, and that this actionable information could trigger more effective deployment of nurse visits compared to nurse deployments based on fixed schedules. 2013 AMC Health. Medicare Advantage and TeleCare Management. Page 1 of 5
Methods: Subjects and Study Period: The healthplan used the 2006 calendar year as the study period. For both the intervention and control groups, the members had to have been enrolled onto the home healthcare s Case Management service in 2006, (as directed by the member s physician), been hospitalized in 2006 and within 30 days of this home care enrollment, and have a primary or secondary diagnosis of Congestive heart failure (CHF), Coronary Artery Disease (CAD) or myocardial infarction. The control group had the additional requirement of never receiving telemonitoring in 2006. This was a retrospective study, as the home healthcare vendor was already providing telemonitoring to healthplan members. Three factors determined whether a particular member would have received telemonitoring, namely space availability (only a certain number of Case Managers were trained in and exclusively tasked to perform Telecare Management), absence of physical limitations in using the monitoring equipment, and the member s agreement to participate. For the control group, the analysis period was all member months up to one year before a qualifying hospital admission (with the admission included in the pre period), and all months in 2006 up to one year after discharge. For the intervention group, the analysis period was all member months up to one year before telemonitoring and all months in 2006 up to one year after telemonitoring began. The Telemonitoring Implementation: All telemonitoring candidates were first engaged by a TeleCare Manager by phone to assess appropriateness for the service. At that engagement call, the TeleCare Manager described the program, including the likely technology deployed, the frequency of measurements desired, the frequency of TeleCare Manager contact (which is dependent on data coming in from the member), etc. After this, the TeleCare Manager assessed the member s ability to participate, which is a function of several factors, including cognitive status, ability to self-direct, the level of caregiver support in the home, physical impairment precluding device use (e.g. member is not weight bearing when a scale is required) and general frailty, which may preclude regular device monitoring. Lastly, the TeleCare Manager secured agreement to participate. Once agreement was secured verbally, enrollment was finalized. Telemonitoring device deployment was usually, but not exclusively, conducted while the member s visiting nurse was present, as well as a family caregiver when necessary, to best guarantee effective device instruction and proper technique, as well as to educate the members and their caregivers about which biometric values (clearly readable on the devices themselves) were desirable, and which should be of enough concern to contact the TeleCare Manger or physician. This instruction was always reinforced by phone by the TeleCare Manager. After eliminating all members who did not remain enrolled on the plan for the required 12 months, pre and post, the eventual size of the two groups was 47 for the intervention group, and 132 for the control. The total member months for each group appear below in Table 1. Table 1. Member Months for Telemonitoring and Control Group Pre/Post Periods. Time Period Control Group Telemonitoring Group Pre-Home Healthcare Enrollment 1644 586 Post- Home Healthcare Enrollment 853 -- Telemonitoring -- 219 Post-Discharge -- 107 2013 AMC Health. Medicare Advantage and TeleCare Management. Page 2 of 5
Experimental Design: TeleCare Management processes: Once enrolled onto TeleCare Management, members were assigned a specialized Case Manager trained by AMC in TeleCare Management, and the members were scheduled for device installation in the home. The array of monitoring devices was dictated by diagnostic profile and the member s physical limitations. For CHF, the member typically received a scale (unless the member was not weight bearing) and an automatic blood pressure monitor. For other cardiovascular diagnoses, the member typically received just a blood pressure monitor, unless other factors were present, such as renal disease or obesity, in which case a scale would have been added. If the member also had diabetes, the member typically received a blood glucose monitor. If the member also had COPD or Asthma, the member typically also received a pulse-oximeter. Thus, a multi-morbid member with, say, CHF and diabetes typically received a scale, a blood pressure monitor and a glucose meter. Based on the daily biometric information coming into AMC s webportal in real-time, the TeleCare Managers routinely assessed each member s health status, detected trends requiring further analysis, and managed alert-level readings as they occurred. Biometric patterns dictated the frequency of contact with the member or caregivers in the home, and adverse trends confirmed by concurrent symptomology, and which were appropriate to bring to the member s physician s attention, were. When information supported that unscheduled nurse home visits were necessary, the TeleCare Managers directed field nurses to make those visits to corroborate biometric patterns, and obtain additional symptomatic information. Conversely, if biometric patterns supported that the member was clinically stable, the TeleCare Manager had the authority to reschedule nurse visits that may have been unnecessary. If telehealth information suggested that additional resources were required from the healthplan s Care Management or Customer Service departments, the TeleCare Managers reached out to the appropriate liaisons in those departments. Results: After analyzing claims for the pre and post study period, (with incurred but not reported IBNR- claims less than 5%), total claims and acute care admissions were compared between the intervention and study groups. Additionally, for the intervention group, claims and acute care admissions were evaluated for up to 6 months post telemonitoring, to assess any lingering effects of the benefits of telemonitoring. Comparing the pre- and post- home healthcare/telemonitoring admission periods for the 2006 calendar year, total costs decreased at a rate of 6% for the control group members vs. 59% for telemonitoring members (Graph 1), despite the similarity in pmpm costs between the two groups in the prior period ($2,291 vs. $2,344 for the control and telemonitored groups respectively). Total admissions pre versus post increased at a rate of 8% for the control group and decreased at a rate of 50% for the telemonitoring group members (Graph 2). The analysis also suggests that the dramatic reduction observed in the telemonitored group is sustainable for a short period post-telemonitoring (Graph 3). 2013 AMC Health. Medicare Advantage and TeleCare Management. Page 3 of 5
Graph 1 Comparison of Acute Care Costs (12 Months) by Telemonitoring or Control Group: Pre- vs. Post-Case Management Intervention for High Risk Members* $2,500 $2,000 Acute Care Costs PMPM $1,500 $1,000 $500 n=132 n=47 $0 High Risk Pre-Intervention Pre-CHHA High Risk Post-Intervention Post-CHHA/Telemonitoring control group $2,291 $2,161 telemonitored pts $2,344 $969 * MEMBER MONTHS: Control Group - pre 1644, post 853, Telemed Group - pre 586, tele 219 Comparison of Acute Care Admissions (12 Months) by Telemonitoring or Control Group : Pre- vs. Post-Case Management Intervention for High Risk Members* 3000 Graph 2 Admissions per 1000 Members per Year 2500 2000 1500 1000 500 n=132 n=47 0 High Pre-Case Risk Pre-Intervention Management Pre-CHHA High Risk Post-Intervention Post-CHHA/Telemonitoring Post-Case Management control group 1920 2068 telemonitored pts 2396 1205 * MEMBER MONTHS: Control Group - pre 1644, post 853, Telemed Group - pre 586, tele 219 2013 AMC Health. Medicare Advantage and TeleCare Management. Page 4 of 5
Graph 3 Reduction Observed in the Telemonitored Group is Sustainable for up to 6 Months Post-Telemonitoring* Telemonitoring Period After Discharge from Telemonitoring 2500 2000 1500 1000 $969 $1,109 1205 1234 500 0 Costs PMPM * MEMBER MONTHS: Telemed Group tele 219, post 107 Admits per 1000 Members per Year Discussion: The healthplan determined that results were encouraging enough to warrant further study, and to suggest that telemonitoring be offered to members with primary or secondary chronic diagnoses other than just CHF, CAD and myocardial infarction. Moreover, additional studies were suggested to determine the efficacy of telemonitoring for members who do not benefit from the close attention of home healthcare Case Management, but who may still be at high risk for future utilization due to poorly managed chronic illnesses. Moreover, as the healthplan had questionable success with outsourced, traditional Disease Management programs in the past that did not employ technology extensively, but relied, rather, on targeted member education, delivered only periodically on disease trajectories per se, programs that provide alternative methods of driving member behavior will be aggressively pursued. 2013 AMC Health. Medicare Advantage and TeleCare Management. Page 5 of 5