Telehealth for Hospice and Palliative Care – Realities and Challenges

Deborah A. Randall, JD & Consultant202-257-7073law@deborahrandallconsulting.comwww.deborahrandallconsulting.com

Today in Telehealth at “Home”

Market?? reaching a half billion dollars in USA in five years in telemonitoring.

Remote monitoring currently in use in Western Europe and UK, and growing in Asia. VA has >62,000 homecare.

Sensoring : movement analysis, falls detection, behavior tracking, dementia safety, communication to family

Scope and Payers

Home-based telehealth mostly chronic care management => avoid ER & re-hospitalizations. Provider funded; grants; within global fee for diagnosis.

Medicaid pays some telehealth visits. Home as “originating site” NOT

reimbursed by Medicare. Skilled nursing home= live consultations in (rural or medically underserved) area

PPACA Promising Sections

Post-hospitalization bundling pilot Independence at Home demonstration Innovation Center at DHHS ACOs Medical Home-Medicaid and Pilots Face2face HHA provision w

telehealth;hospice provision silent

Telehealth and chronic illness

St. Vincent Health System's Visiting Nurse Association [Arkansas] has used telehealth computers to monitor patients in their homes for several years, and in its 11 county region had only about 4.5% of heart attack patients re-hospitalized compared with a national rate of 37%. [National Assn for Home Care report]

Telehealth and Aging in Place

University of Missouri :sensors, computers and communication systems, along with supportive health care services monitor the health of older adults who are living at home.

Motion sensor networks installed in seniors’ homes can detect changes in behavior and physical activity, including walking and sleeping patterns. Early identification of these changes can prompt health care interventions that can delay or prevent serious health events.

Blue Cross/Blue Shield WNY

Blue Cross/Blue Shield Western New York in May 2010 initiated online physician-patient communication as a compensated service; encouraging telehealth communications and webcam visits; measuring quality of care and patient compliance factors

EVP expresses interest in home eCare

HMSA: Ambulatory MD/Home

Hawai’i Medical Services Ass’n Jan 09 Online Care connects, 24/7, patients

and physicians via the Internet or telephone;1st in the nation.

$10/45 for 10 minutes interaction Physicians can be “anywhere”; service

is across all islands

Telehealth: Dementia Patients

Residential facilities designed to allow movement of individuals through facility and grounds; Families can track on computer/internet based systems

Sensoring systems; Intel research; TRILL; diagnostic sensoring for fall prevention yielding data on Alzheimer specific movement differentials

Home Care Association of New York State 10

Home Telehealth - NY State

93 home health only providers approved to bill Daily rates as of 1/1/2010 Tier I – 62 $8.88/day/patient Tier II – 31 $10.20/day/patient Tier III – to be tied to regional connectivity Medicaid Managed Care covered service

Electronic Medical Records Approximately 50% - 60% utilization – generally

medium & large sized agencies Multiple other “pieces”

Referral software, physician portals, med management hardware etc.

Home Care Association of New York State 11

DHisease Management

American Telemedicine Assn

Home telehealth and remote monitoring practice group

Working group exploring opportunity for, and prevalence of telehospice; I chair this group.

www.americantelemed.org

MD Acceptance - CCCP

What are the New Directions?

Tele-rehabilitation; Falls prevention Tele-mental and behavioral health Continuous monitoring: diabetes;

cardiac Impaired; Alzheimer’s & dementias

Telehealth and Rehabilitation

Distanced assessments Robots in SNFs Telestroke => telerehab Wii units in senior living facilities Remote monitoring for falls anticipation Traumatic brain injury;wounded warrior

Behavioral & Mental telehealth

On-going research Post traumatic stress disorder Tele-psychiatry Distanced mental health services

under new Medicare reimbursement provisions for community mental health centers

Telehealth and “High Touch”

Does Telehealth work with the history of palliative care and hospice care as intensely “high touch /high sensitivity”?

Is some Touch better than no Touch; better than Touch which comes with travel, delay, fear, understaffing? Is it not all about ACCESS?

Is mHealth’s immediacy = palliative?

“Seeing” Patient Need

Will telehealth have accuracy and reliability for Palliative and Hospice?

Can the clinician make a palliative care decision from the distance?

If the patient is the “center of care”, where more so than end of life; pain management; suffering whether physical, psychological or spiritual?

National Association for Home Care and Hospice (NAHC)

Interest in telemonitoring for home care and hospice. www.nahc.org July 2009 Caring journal devoted to

telemonitoring – some mention of hospice NAHC Division for telehomecare

Center for the Advancement of Palliative Care [CAPC] www.capc.org

National Hospice and Palliative Care Organization

Grants to hospices working in conjunction with VA locations

Not formally looking at telehealth Current Concern: PPACA requires “visit”

by MD/NP at 180 days of care— televisit not included in regulations

American Academy of Hospice and Palliative Medicine

Hospice Care

Terminally ill or end-of-life situation Team delivery of non-curative care Generally, family as the unit of care Physical, mental, psychological and

spiritual care of holistic model Generally, home-based care but some

in-patient, “hospice home” and respite

Palliative Care

Pain and symptom management Outreach and crisis management Triage without transporting to facility Psychological pain and suffering Diagnostic opportunities; family

interactions Ethical principles= autonomy enhanced

Telehealth and Palliative Care

Telehealth and pain management TeleHospice care

•bringing patient and family into the interdisciplinary group [IDG]•counseling patients and family when social workers are scarce resources

·recorded care videos; on-call nurse

Prevalence of Telehospice

Informal survey with CIMIT Grant done in 2009

Methodology and Findings Follow-on data gathering still on-going

and informal. Professional associations are interested.

Advanced Illness –Is there a Role for Palliative Telehealth

Using an existing model of advanced illness coordination which included health counseling

Congestive heart failure, end-stage pulmonary disease, end-stage renal disease, and cancer as handled in various care settings.

Expanding a model, cont’d.

Goals for improved communication about discomfort, support for decision making;problem resolution; attention to caregiver needs.

Outcomes measurements expanded from the curent: >% DNR or intubate orders; <inpatient admissions with no difference in survival.

Opportunities and Challenges

Medical Director and other physicians Demonstrating cost savings, &/or

quality of care/life improvements- to justify expense of equipment and staff

Training and staffing. Maintenance of depth of field/bench so turnover is not a problem. Need for a "champion".

Leading nurses to embrace technology

Telehealth: Impediments

Reimbursement under Medicare Medicaid Outcomes, cost savings and care

management concerns Licensure and interstate barriers Unlawful incentives in collaboration Standards lacking: Interoperability

among devices/software/infrastructure

Attention to Legal Concerns

Licensure of palliative care provider

Liability and Consent

Privacy and confidentiality

Security of Communication

Thank You!

Deborah Randall, JDHealth Law Attorney

Telehealth Consultant202-257-7073

law@deborahrandallconsulting.comwww.deborahrandallconsulting.com