Opportunities to Leverage Telehealth Within Your ACO Strategy

Opportunities to Leverage Telehealth Within Your ACO Strategy

Shawn Valenta RRT, MHA Administrator of Telehealth Center for Telehealth Phillip Warr, MD Interim Chief Medical Officer Case Management and Care Transitions Opportunities to Leverage Telehealth Within Your ACO Strategy

Background of MUSC Health MUSC s ACO Population Skilled Nursing Facilities Remote Patient Monitoring (RPM) Direct-to-Consumer Telehealth Reimbursement What s on the Horizon?

MUSC Health Medical University of South Carolina Based in Charleston, SC Oldest medical college in the South (1824) 6 colleges train nearly 3,000 healthcare professionals and biomedical scientists each year 700-Bed Comprehensive Academic Medical Center Ranked SC s #1 hospital (by U.S. News & World Report)

MUSC Center for Telehealth Telehealth for efficient, effective care 12+ years of telehealth experience > 70 unique telehealth services Telestroke (26 hospital network; ~3,500 annual consults) School-based telehealth (50+ schools) Tele-ICU (partnership with Advanced ICU Care; 6 SC hospitals) 200+ connected sites Coordinating entity of the SC Telehealth Alliance HRSA-designated National Telehealth Center of Excellence Executive Telehealth Medical Director Dr. Jimmy McElligott

South Carolina Telehealth Alliance Funded by the SC Legislature (also leverage other external grants) 463 connected SC sites Annual collaborative strategy Legislative reporting Creating an open-access statewide network

MUSC ACO Approach

ACO Critical Planning Issues 1. Identify and risk stratify ACO Population a. Cost per member per month b. Attribution methodology c. Perform risk assessment of patient population 2. Perform gap analysis on continuum of care 3. Detailed evaluation of post-acute utilization/cost 4. Predict future utilization

1. Identify and Risk Stratify ACO Population

2. Perform Gap Analysis on Continuum of Care

3. Detailed Evaluation of Post-Acute Utilization The importance of good transitions and collaboration between acute and post-acute care providers was underscored by the IMPACT Act of 2014. Medicare Patients Greatest PAC Users, But Also Chronically Critically Ill Medicare FFS Hospital Discharge To PAC Nat l: 41.4% MUSC: 45.4% National Trends SNF 19.5% Home Health 16.8% Acute Rehab 3.2% MUSC Trend SNF 10.0% Home Health 30.2% Acute Rehab 4.0% LTACH 1.1% LTACH 1.0%

3. Detailed Evaluation of Post-Acute Cost

4. Predict Future Utilization 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Volume Change Tri-County 981 1,002 1,016 1,019 1,020 1,023 1,034 1,051 1,071 1,095 1,119 138 Secondary 1,437 1,448 1,450 1,439 1,424 1,417 1,421 1,432 1,448 1,470 1,492 55 Outside 136 137 138 137 135 135 135 136 137 139 141 5 Tertiary 2,176 2,184 2,179 2,156 2,129 2,112 2,108 2,115 2,128 2,148 2,168-8 South Carolina 4,730 4,771 4,781 4,751 4,709 4,688 4,698 4,733 4,785 4,853 4,920 190

4. Predict Future Utilization (cont.)

Skilled Nursing Facilities

SNF Partner Selection: Credentialing Criteria 1 Geographic access for all patients 2 3+ Star rating: Health inspection, Quality, and Staffing 3 Bed capacity 4 Medication availability: Pharmacy relationships and onsite medication dispensing systems 5 Laboratory and Imaging availability/turnaround time 6 Use of Pathways and Care planning tools 7 Agreeable to ACO Physicians serving as primary while in facility

Licensed Skilled Nursing Facilities in the Tri-County Charleston County SNF Rankings Facility Beds Rating White Oak Manor 176 5 NHC Healthcare Charleston 132 5 Franke Health Center 44 5 Harvest Health & Rehab of Johns Island (Owned by Orianna) 132 4 Heartland Health of West Ashley 125 4 Sandpiper Rehab & Nursing 176 3 Savannah Grace at the Palms of Mt Pleasant 42 3 Bishop Gadsden 50 NA Life Care Center of Charleston 148 2 Vibra 35 2 Mount Pleasant Manor 132 1 Riverside Health and Rehab 160 1 Dorchester County SNF Rankings Facility Beds Rating Presbyterian Home of SC 87 5 Oakbrook Health & Rehab 88 4 Hallmark Healthcare Center 88 4 St. George Healthcare center 88 2 Berkeley County SNF Rankings Facility Beds Rating Heartland Health & Rehab-Hanahan 135 3 PruittHealth-Moncks Corner 132 4 Lake Moultrie Nursing Home 88 3

SNF Partner Selection: Capabilities

Telehealth in Skilled Nursing Facilities Challenges: 1) Billing/Reimbursement 2) EHR interoperability 3) Training and turnover of SNF staff Successes: 1) High staff satisfaction with Telehealth use 2) Readmission rate improved although not overall statistically significant

SNF Telehealth Satisfaction Results

SNF Readmission Rates November 2015-April 2016 20.2% readmission rate (17/84) November 2016-April 2017 19.5% readmission rate (24/123) Catalyst to Telehealth in SNFs Skilled Nursing Facility Value- Based Purchasing Program (SNF VBP) Starts FY19 (October 1, 2018) Readmission measures included in SNF VBP program

Future Direction 1. Continuous Virtual Monitoring 2. Specialty Services

Future Direction: Continuous Virtual Monitoring Continuous Virtual Monitoring (CVM) for patients at increased fall and other safety risk Objectives o Reduce overall safety concerns at SNFs using technician observation 24/7 o Reduce falls, fall-related injuries, and fall costs o Improve collaboration with SNFs related to timeliness of transfers o Improve patient and family satisfaction that basic patient needs are met around the clock

Future Direction: Specialty Services 1) Cardiology 2) Pulmonology 3) Psychiatry

Remote Patient Monitoring (RPM)

MUSC Health s ACO By the Numbers ~$1K per bene per month ~$3K per bene per month (Heart Failure, Diabetes, Hypertension)

Remote Monitoring CHF Home Monitoring Created Heart Valve App to monitor CHF patients post-procedure Patients electronically send in daily biometric data (i.e. HR, BP, SpO2, weight) that posts to a flowsheet in the EHR Based on previously established thresholds, if an abnormal reading is obtained, a message is sent to the Telehealth RN Coordinator via EHR In-Basket. The RN reviews the data, collaborates with the physician as needed and communicates applicable instructions back to the patient.

Remote Monitoring CHF Home Monitoring Challenges: 1) EHR integration 2) Data management decisions 3) Initial technical problems with SpO2 devices (5/10) Successes: 1) Catalyzed organization on app/ehr integration discussion 2) Many lessons learned on prescribing and supporting the tech 3) Prevented at least 2 ED visits/readmissions Initial 6-month pilot (9/1/17-2/28/18) 45 total patients participated 84% completed 30-day program 1788 total telehealth interactions Next Steps: Implementing with ACO patients Targeting patients with high rates of ED utilization for CHF exacerbation

Diabetic Remote Home Monitoring -TACM Center for Healthcare Disparities Research Technology Assisted Case Management (TACM) 200 patients split between TACM-intervention and Control Group (2010-2013) 1% drop in A1c levels (10.1% baseline vs 9.1% at 6 months) for TACM group 0.1% in control group Challenges: 1) Coordination with multiple PCPs 2) Workflow challenges; new responsibilities for RNs 3) Initial technical problems with patient uploads/connectivity Improved: 1) A1c levels 2) Communication between patients and providers, 3) Access to care, and 4) Adherence to prescribed therapy

Diabetic Remote Home Monitoring TACM-2 TACM-2 Over 200 external patients recruited (FQHCs and free clinics) Began to leverage experience for internal MUSC population in Nov. 17 (~100 patients) Clinic # of Patients A1c Baseline Avg A1c 6-month Avg A1c- 12-month Avg A 35 9.96 8.47 Next Steps: B 61 10.1 7.9 C 26 9.96 8.4 7.8 D 28 10.63 8.95 Implementing with ACO patients Targeting diabetic patients with high A1c levels

Catalyst to RPM 2018 CMS Physician Fee schedule (effective 1/1/18) Un-bundled CPT code 99091 for remote patient monitoring (RPM) Key considerations: Must obtain advance beneficiary consent Must initiate with a face-to-face visit Can use code no more than once in a 30-day period per patient Reimbursement for time spent on collection and interpretation of health data that is generated by a patient remotely, digitally stored and transmitted to a provider (minimum of 30 minutes of time) Not subject to typical Medicare geographical restrictions

Direct-to-Consumer Telehealth

Direct-to-Consumer Telehealth E-visits Asynchronous interaction with MUSC provider Treats low acuity (simple) conditions Current Trends: Access Convenience Acute Chronic and Episodic Hospitals Home Connect to medical home Close the communication loop Maintain standard of care

Direct-to-Consumer Telehealth Challenges: 1) Limited EHR functionality can t keep up with industry! 2) Need consistent marketing 3) Need core group of providers to deliver quality service Wins: 1) Learned a lot! (e.g. what functionality was important, when provider support was needed most) 2) Implemented quality review committee 3) Navigated state medical board to use APPs Time of Day E-visit was Submitted

Direct-to-Consumer Telehealth In 2013, only 18% of adults ages 65 or older owned a smartphone (Pew Research Center)

Direct-to-Consumer Telehealth Next Steps: Launching within ACO patients Help support primary care base Decrease low acuity ED utilization All E-Visits Medicare Age E-Visits

Reimbursement

Medicare Reimbursement A rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract; or A county outside of a MSA 2018 MedPAC report: utilization still low (0.3% of Part B beneficiaries) significant growth in Medicare (79% increase from 2014-16) Only 54% of South Carolina Zip Codes are eligible for Medicare Telehealth Reimbursement Telehealth Medicare Eligible No Yes *Zip code eligibility determined by HRSA Medicare Telehealth Payment Eligibility Analyzer

Telehealth Expansion Waiver Next Generation ACO Model Eliminates rural geographical restriction Allows patient s home as an eligible site Allows use of asynchronous telehealth services (e.g. teledermand ophthalmology)

Bipartisan Budget Act of 2018 Signed into law by the President on February 9, 2018 Key changes to Medicare telehealth reimbursement: No more originating site restrictions for telestroke (effective 1/1/19) Extends reimbursement for telehealth dialysis services into patient s homes and independent facilities (effective 1/1/19) Providers can legally give free home telehealth equipment to at-home dialysis patients Medicare Advantage plans can include telehealth services as a basic benefit Patient s home is an eligible originating site for ACOs, including Next Gen, Track II, Track III, and certain two-sided risk models (effective 1/1/20) no geographical restrictions

What s on the Horizon?

Explosion of patient-facing digital health Significant increase in mhealth apps and devices Over 250K on the market; only ~200 cleared by FDA Health systems need to standardize processes for: validating safety, efficacy, and effectiveness of apps prescribing apps on a digital formulary defining record sets and how data is stored Expect a transition to centralized health system apps More patient-friendly; health system front door to improve patient experience Virtual care options; push generational and patient-specific health education Will drive clinical care/utilization through EHR portal

Questions? Shawn Valenta RRT, MHA Administrator of Telehealth Center for Telehealth valentas@musc.edu Phillip Warr, MD Interim Chief Medical Officer Case Management and Care Transitions warr@musc.edu