Innovations in Expanding Primary Care Capacity: Moving Away from Visit Based Care for Medicare Beneficiaries IOM 9/22/11 Kathy Duckett RN, BSN Director of Clinical Programs Partners Healthcare at Home kduckett@partners.org
Outline Partners Healthcare at Home Home Care Role of Telemedicine in expanding primary care capacity Barriers & Policy adjustments to improve access to Care 2
Partners Home Care Stats and Facts Towns and Cities: 175 Average Daily Census: 3,600 Admissions Annually: 26,000 Visits/Year: 420,000 Age range of patients: 0 106 Payer mix Medicare: 52% Medicaid: 5% Insurance: 41% Free Care: 2% Technology Telemonitoring devices 300 Personal Emergency Response Units: 4000 Top Diagnoses: Heart Failure Diabetes COPD, Stroke Primary Population Elderly 65 and older Lives in private home or Assisted Living Facility
Telemedicine The Program Imperative Evolution Growth in Chronic Disease Supply and Demand Projections for Nurses: 2000 to 2020 Source: Anderson, G.; Chronic Conditions: Making the Case for Ongoing Care; Johns Hopkins University; November 2007
New Care Delivery Structure Right Care Right Cost Right Place CMS Demo Projects Accountable Care Organization - ACO Patient Centered Medical Home - PCMH Independence at Home 5
Changing Perception of Telemedicine IOM Definition The use of electronic information and communications technologies to provide and support health care when distance separates the participants. (1996) Historically Telemedicine = MD assessment, diagnosis, prescription Currently Telemedicine = Clinical Care (MD, APRN, RN, Therapist) 6
Telemedicine Adapted from Heatlhcare Promise - used with permission
Telemonitoring What does it look like? 8
Potential Savings with Telemonitoring Telehealth Program Analysis of Cost and Potential Cost Savings/ROI The purpose of this schedule is to illustrate the potential cost savings and ROI by implementing a Telehealth program designed to reduce readmissions. Source of data reflected here is based on actual 2009 cost report data and CMS Hospital Compare as reported by the American Hospital Directory. Reporting Year Number of Inpatient Stays Average Payment per Inpatient Stay Description/Location Average Cost per Inpatient Stay Annualized Cost Partners, Combined (MS-DRG 291-293), Heart failure and shock 1,526 $8,018 $10,997 $17,433,215 (MS-DRG 193-195), Pneumonia 2010 986 $8,743 $9,984 $10,077,588 (MS-DRG 190-192), COPD 562 $7,943 $10,233 $5,491,438 Total/Average 3,074 $8,234 $10,404 $33,002,241 10% reduction in readmissions 25% reduction in readmissions 40% reduction in readmissions 60% reduction in readmissions Reduce readmissions Number of Patients 3,074 3,074 3,074 3,074 Average 30-day readmission rate (HF) 24.5% 24.5% 24.5% 24.5% Number of readmissions within 30 days 753 753 753 753 Target to reduce 30-day readmissions 10% 25% 40% 60% Targeted avoidance of readmissions 75 188 301 452 Loss per inpatient stay (1) ($10,404) ($10,404) ($10,404) ($10,404) Potential cost avoidance (savings) $783,056 $2,153,404 $3,602,058 $5,638,003 Number of monitors 151 376 602 903 Average cost per month per monitor $75 $75 $75 $75 Annual cost of monitors ($135,471) ($338,678) ($541,885) ($812,827) Potential net savings $647,585 $1,814,726 $3,060,173 $4,825,176 Return on Investment-Rental/Annual 478% 536% 565% 594% Likelihood to pick the right patient % of patients (LOM) Number of monitors needed based on above census Number of monitors needed based on above census Number of monitors needed based on above census Number of monitors needed based on above census Calculation of Monitors Needed (based on (1) Probable # of readmissions within 30 days 75 188 301 452 Length of Monitoring (LOM)-30 days 50% 10% 15 38 60 90 Length of Monitoring (LOM)-60 days 50% 20% 30 75 120 181 Length of Monitoring (LOM)-90 days 50% 70% 105 263 421 632 Total 100% 151 376 602 903 (1) Illustrates current reimbursement environment and includes full cost of inpatient stay. Note: Additional savings can be generated by reducing the average length of stay. Created by Philips 2011, used by permission 9/19/11
MS-DRG, 2010 Medicare data Heart failure and shock Partners Healthcare at Home Mr. I HC &TM Location 30-day HF Readmit % # of IPPS claims ALOS Average Payment Average Cost Annual Cost Massachusetts General Hosp 23.7% 575 6.30 $10,141 $12,233 $7,033,975 Nantuckett 26.5% 15 3.53 $5,722 $12,788 $191,820 Newton Wellesley 23.8% 276 3.90 $7,041 $8,654 $2,388,504 Brigham & Women's 23.7% 438 5.76 $9,744 $13,028 $5,706,264 Faulkner 27.0% 170 4.75 $6,895 $9,408 $1,599,360 Martha's Vineyard 22.2% 52 3.46 $8,562 $9,871 $513,292 Subtotal 24.5% 1,526 4.62 $8,018 $10,997 $17,433,215 Created by Philips, used by permission 9/119/11 Prior to program: 3hosp/4mos HC &TM 117 days Cost Savings: $26,500 Mrs. G - CCCP Prior to program: 5hosp/5 mos In program 7 months with 0 rehospitalization Cost savings: $52,725 10
Barriers and Policy Changes Needed Barrier #1 No Medicare reimbursement for remote telemonitoring Policy Change needed Use of CPT codes for telemonitoring see ATA letter Barrier #2 Home is not considered site of care for reimbursement Policy Change needed Home as site of care 11
Barriers and Policy Changes Needed Barrier #3 Misalignment of incentives for care delivery Hospitals incentivized to decrease 30 day post discharge rehospitalization MD offices incentivized via PCMH, IAH to improve outcomes of care Policy Change needed Payment for remote telemonitoring services to provider of service 12
Barriers and Policy Changes Needed Barrier #4 Change Homebound requirement for access to Home Care benefit Policy Change needed Reconsider home bound requirement in Conditions of Participation for Certified home care Barrier #5 Home Care Visit defined as a F2F encounter (similar to barrier for MD) Policy Change needed Change definition of home care visit to reflect F2F or virtual visit meeting skilled requirement 13
Moving Away from Visit Based Care for Medicare Beneficiaries Right Care Remote telemonitoring, virtual visits, F2F Right Cost Proactive management reduces cost Right Place Home as the site of care 14
Thank you Kathy Duckett RN, BSN kduckett@partners.org 15
EXTRA SLIDES For Further Information and Details 16
Research Support Home monitoring with health coaching post hospitalization for heart failure rehospitalization by 72%. (Weintraub 2005) New England Healthcare Institute cost effective analysis for HF remote monitoring resulted in overall 60% reduction in hospital readmissions compared to standard care (NEHI 2009) VA study remote telemonitoring and nursing case management hospitalizations by 25% and hospital days by 17% (Darkin et al 2008) 7 studies reviewed showed that with use of telemedicine 70% of patients avoided travel for health care provisioning (Wootten 2011) Quarterly mean spending for telemonitoring group dropped between 7.7% and 13.3% over two years compared to control group (Baker 2011) 17
Research Bibliography Darkins, A., Ryan, P., Kobb, R., Foster, L., Edmonson, E., Wakefield, B., & Lancaster, A. E. Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health, December 2008; 14: 1118-11126 Laurence C. Baker, Scott J. Johnson, Dendy Macaulay and Howard Birnbaum With Chronic Disease Linked To Savings Integrated Telehealth And Care Management Program For Medicare Beneficiaries Health Affairs, 30, no.9 (2011):1689-1697 doi: 10.1377/hlthaff.2011.0216 New England Healthcare Institute (2009). Remote Physiological Monitoring: Research Update. Available at:http://www.nehi.net/publications/36/remote_physiological_monitoring_research_update. Accessed December 3, 2009. Weintraub, A. R., Kimmelstiel, C, Levine, D., Venesy, D., Levin, A., Lorell, B., Konstam, M. A. A multicenter randomized controlled comparison of telephonic disease management vs. automated home monitoring in patients recently hospitalized with heart failure: Span CHF II Trial. J Card Fail. May 2005; 11: 720. Wootten et al, Estimating travel reduction associated with the use of telemedicine by patients and healthcare professionals: proposal for quantitative synthesis in a systematic review, BMC Health Services Research 2011, 11:185 doi:10.1186/1472-6963-11-185, http://www.biomedcentral.com/1472-6963/11/185 18
Partners Telemonitoring 2 Programs ** Each focused on patient self-management success, disease management, and decreased re-hospitalization rates. Telemonitoring & Homecare Medicare patient Must be able to reduce nursing visits Must be on Partners home care program Connected Cardiac Care Program (CCCP) Patient with PHS MD Not homebound so not eligible for traditional Home Care Diagnosis of HF **Private Pay is also an option**
100% 90% 80% Proportion of CCCP enrollees with one or more Hospitalization 100.0% Proportion of enrollees with 1+ HF hospitalization Proportion of enrollees with 1 all-cause hospitalization 70% 60% 50% 58.1% 40% 39.8% 30% 20% 10% 13.3% 0% One year prior to CCCP enrollment (point estimate and 95% C.I.) One year following CCCP disenrollment (point estimate and 95% C.I.) Data Includes 332 CCCP enrollments among 301 unique patients discharged from the CCCP program prior to July 1, 2009. Results are similar within more recent cohorts of enrollees discharged from the program prior October 1, 2009 and prior to January 1, 2010.
Home Health Quality Improvement (HHQI) National Campaign Best Practice Intervention Package (BPIP): Established from evidence-based research a best practice for home care agencies. Disease management, patient self-management, and telehealth are essential interventions to reduce readmissions and improve quality of life for chronic care patients..effective quality improvement programs will merge facets from all three interventions. (HHQI, 2011) The Home Health Quality Improvement (HHQI) National Campaign is a grassroots movement of the Centers for Medicare & Medicaid Services (CMS) designed to unite home health stakeholders and multiple health care settings under the shared vision of reducing avoidable hospitalizations and improving medication management
Additional Bibliography Engelberg Center for Health Care Reform at Brookings, Achieving better chronic care at lower costs across the health care continuum for older americans, October 2010, www.brookings.edu/heatlhreform Gregory, Patricia, Alexander, Joshua, Satinsky, Jennifer, Clinical Telerehabilitation: Applications for Physiatrists, PM&R, 3, 647-656, July 2011, doi: 10.1016/j.pmrj.2011.02.024 National Association of Home Health and Hospice Care, Basic Statistics on Home Care 2010, http://www.nahc.org/facts/10hc_stats.pdf NIHCM Foundation Data Brief, Understanding U.S. health care spending, July 2011 Paula Suter, W. Newton Suter and Donna Johnston. Theory-Based Teleheatlh and Patietn Empowerment, Population Health Management. April 2011, 14(2): 87-92. doi:10.1089/pop2010.0013 Wilson, Linda, Pursuing Value, Modern Healthcare.com,September 12, 2011 http://www.modernhealthcare.com/article/20110912/supplement/309129999#
Rose s Story Cheerleaders are Welcome Did not think she needed Home Care Home Care Nurse got MD order for PHH telemonitoring Progressed to CCCP telemonitoring Successfully completed CCCP Still goes to HF Clinic I now have plane tickets to Alaska to visit relatives
Telemonitoring involves remotely monitoring patients in their home with the results flowing to nurses in our office. The nurse can then make decisions about treatment based on subjective and objective data. A great deal of information is gathered in less time without the patient leaving home. It became routine and I still measure my weight and blood pressure I walk every day 20-30 minutes unless it s icy It Was Easy to Use
I Now GET IT As the patient is more involved in their own care and treatment, they gain a better sense of what their vital statistics mean, what affects these statistics, and how they relate to how they in turn affect how they are feeling. First I went to Foxwoods and I brought my own dressing, water, fruit cup, and fiber bar. Just in case! Then my niece and I went to Atlantic City for 2 days, then went on to New York to enjoy the Rockettes. I feel great and listen to my body now and rest if needed, remembering what the visiting nurse told me
In Their Own Words (Pt A) has very little will power when it comes to salty foods. Thanks for all your help. Without such careful monitoring she would again have her legs weeping edema fluid and all infected again. Dr. E Rodman I went to meet Ms G today and also met her daughter who happened to be there. They both told me of how happy they are with Partners Healthcare at Home services, both certified and telemonitoring. The daughter gave me her name, saying she is a nurse, she has 3 other sisters who also nurses, and all of them agree that the services you provide are excellent. She went on the say, " We would love to do a commercial for you, we love you that much!" From one of our liaisons After a short stint in rehabilitation, the patient went home but Partners went with her. The patient uploads to Partners information on her vital signs via an electronic monitor in her home. Nurses, who have received specialized training in congestive heart failure, also provide care in the patient's home. Yesterday, I got an e-mail from the home-care nurse saying that my patient with heart failure's weight went up 5 pounds. She let me know that she was going to institute the protocol that we have to give (the patient) an extra dose of Lasix to reduce excess fluid, recalled Mort. Article in Modern Homecare quoting Dr. Liz Mort. The nurses are just wonderful and you understand what's going on with you. When needed, they called my doctors and let them know something was wrong with me. You feel very safe with the nurses watching your back. I always wait too long before I ll call anyone for help. They just look at my readings and they know just what to do and who to call. Thank God for the program and my nurses. A telemonitoring pt. 26