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Why Every Skilled Nursing Facility Should Be Evaluating Telemedicine Services

Kansas Health Care Association

John Whitman, MBA, NHA David Chess MDFaculty Founder & Chief Medical Officer

The Wharton School Tapestry Telehealth

September 28, 20188:15 AM – 9:30 AM

Meet Gertie

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Today’s Objectives

Why telemedicine is so important for America’s SNFsUrban SNFsRural SNFs

Why telemedicine offers “a new standard of care forAmerica’s SNFs … especially rural SNFs”

Focus on “Rural” SNFs and the care and operationalimprovements possible

America’s Skilled Nursing Facilities 15,655 SNF’s in America

11,000+ Urban (70% +/-) 4,300+ Rural (30% +/-)

70% Medicaid Physician presence in all SNFs (limited at best)

Sporadic day time in most urban 2-3 hours per week/month in rural facilities

Majority of care decisions made over the phone

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Comparison of Urban to Rural SNFsUrban SNFs Rural SNFs

Average Licensed beds: 106 74

Average occupied beds: 87 58

Average occupancy percentage: 82.3% 78.4%

Average Medicare patients: 10.5 3.2

RN 0.81 0.77Average staffing levels: LPN 0.83 0.73

CNA 2.47 2.47

Total Staffing: 4.11 3.97Source: National Rural Health Association

Sicker patients Lower reimbursement High staff turnover Smaller pool of patients (hospital census is down) Increased regulatory oversight and compliance pressure Clinical outcomes matter – STAR ratings and $ penalties Families and patients have increased expectations Litigation concerns Clinicians are hard to find and no one wants to work after hours

Key Challenges For Skilled Nursing Facilities

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“The Default Factor”

As a System, we lack the ability when utilizing “phone medicine” to effectively differentiate which nursing home residents need to be sent to the hospital and

which residents can and should remain and be cared for in the SNF!

This problem is more prevalent in rural nursing facilities because physician presence in the facility is limited

The Negative Impact of the Default Factor

Retrospective reviews confirm that 60% to 70% of all SNF to hospital admissions are unnecessary

Average cost per admission = $10,000+

In addition to cost, admitting a vulnerable senior to thehospital when they don’t need to go is…

NOT QUALITY CARE!

Estimated cost to Medicare for unnecessary admissions is estimated to be over $1 billion dollars a year

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Documented Risks for Vulnerable Seniors Admitted to the Hospital

Increased morbidity Increased confusion Incontinence Skin breakdown More medications Exposed to “hospital acquired” infections

And the added cost of responding to the risks that materialize!

Economic Impact of Telemedicine onSkilled Nursing Facilities

Urban SNFsAdditional revenue due to increased daysAdditional revenue due to new admissions

Rural SNFsReimbursement directly to physiciansOriginating fee to SNF at $20 per virtual visit

DC1

Slide 10

DC1 They also have additional revenue days and increased admits fromhospitals same as Urban plus the 20$. The reimbursement directly to Physicians doesn't make sense. This slide is not about how they pay for serrvicesDavid Chess, 9/17/2018

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How Can We Improve Care to America’s 1.4 Million Nursing Facility Residents?

By offering a New Approach to Care to our Nation’s Skilled Nursing Facilities

A New Model of Care for Rural America

Advanced TelemedicineTechnology

Great Patient Care

Experience

Dedicated Medical Team

Delivered By

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What research tells us Phone and Faxed Based Medicine is not healthy

Onsite imbedded Nurse practitioners improve quality metrics and decrease hospital transfers.

Make Care Easier for Nurses

Care Delivered virtually through telemedicine specific devices helps to prevent hospitalization.

That Telemedicine has been well received by patients and their families.

Impact of NPs on SNFsJAMDA Article 6-2018

APRNs working full time in nursing homes can positively influence quality of care, and their

impact can be measured on improving QMs. As more emphasis is placed on quality and outcomes for nursing home services, providers need to find successful strategies to improve their QMs.

Results of these analyses reveal the positive impact on QM outcomes for the majority of the MOQI nursing homes, indicating budgeting for APRN services can be a successful strategy.

Source: Impact of Advanced Practice Registered Nurses on Quality Measures: The Missouri Quality Initiative Experience – JAMDA 06/2018 Volume 19, Issue 6, Pages 541–550

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Impact of TeleMedicine in SNFsAJMC Aug 2018

After Hour Virtual Telemedicine Service Decreased Hospitalizations by almost 20% in an already better than average 5 STAR facility

Created significant cost savings for the facility Created very significant cost savings for the Payer -

Great for iSNF Strategies

Source: Impact of After-Hours Telemedicine on Hospitalizations in a Skilled Nursing Facility

– AJMC 08/2018 Volume 24, Issue 8, Pages 600 – 603, Authors Chess, Whitman et al.

A new model of care Bringing a Fully Integrated

Medical Team into your facility to supplement and support your clinical staff and Attendings.

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It is the people that Matter Most

Having Great Clinicians is every thing The Medical Team Must:

Truly care about every patient they touch Understand how important communication is

With the clinical team onsite With the patient and family With the patient’s attending

Be really smart, know there stuff Go the extra mile

Integrated Medical Care Model

Brings the Medical Team to the patient every day.

Primary Care Supplements the attending when they aren’t

in the facility. A Dedicated Nurse Practitioner (NP)

Behavioral Health works with the primary NP

Medical Specialists to support the primary care team.

Chronic Care Programs to support the wellbeing of our

patients and residents – preventing hospital admissions

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Primary Care Support Nurse Practitioner is embedded in each facility -

Becomes the facilities' go to person for day to day issues and cares

Rounds on people with change of condition available 8 to 5 PM Patients post-acute hospitalization Simplifies work flow for the nursing staff - all calls, faxes, labs go

to the NP. The Nurse Practitioner communicates with attending with open

issues and updates. The Nurse Practitioner documents in your chart

We Evaluate and Treat Fever / Infections

Pneumonia, Urinary Tract Infections, Wound infections, Cellulitis, Sinusitis Lacerations, Skin Tears Fall evaluations Shortness of Breath, CHF, Asthma, COPD, Pneumonia Pain evaluations - Chest Pain, Musculoskeletal Behavioral Issues – Limiting Psychotropic Medication Usage Change in Mental Status Diabetes Management Gastro-Intestinal Symptoms Medication Monitoring and Reconciliation Weight Loss Urinary Incontinence

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Weekly behavioral visits (or as often as clinically required) Patients and residents with:

o Depression, Bipolar,o Schizoaffective disorderso Dementia with behavioral manifestationso Medication De-escalation and monitoring

Behavioral – Promote Milieu management (non pharmaceutical approaches)

Family communication and support Acute change of condition

Staff training and supportAvailable for acute change of condition consultation (24/7)Provide consultative note (F Tag responsive)

Behavioral/Psych Services 

Consultative Specialists ServicesBringing the Specialist to the Bedside Specialists include

Dermatology PhysiatryCardiology EndocrinologyPulmonary Wound Care (weekly rounds)Infectious Disease NeurologyRenal - Nephrology Palliative Care/ Pain Control

Monthly scheduled visits, semi urgent visits are provided Communicates with Attending, NP and/related established consultant Documents in EMR

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Physiatry Physiatrists are medical doctors who specialize in rehabilitation.

They works with your physical, occupational and speech therapists to assist in patient evaluation and creating a treatment plan.

Help to maximize days of effective treatment.

Help to manage medial issues such as pain which may be related to therapies and impairing progress

Helps to represent you in conversations with your health plans

Chronic Care Management (CCM)

Medicare benefit – a critical component of primary care that contributes to better health and care for individuals.

Chart Review and Care Plan Recommendations done monthly Like the Pharmacy Consultant

Biometric Monitoring Blood Glucose Oximetry

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Diabetes Management Program Single patient device – Cellular Enabled - Rechargeable

Remote Patient Monitoring allows for your clinicians to view BGL trends and alerts daily Independent QA of facility’s diabetes management Facility and family can access portal if desired

Allows for appropriate insulin and medication management Referral to Endocrinologist for follow up when indicated

Ease of Data Entry

CHF and COPD Monitoring program

Each Patient gets their own Oxymeter

Remote Patient Monitoring allows for your clinicians to view Oxygen’s trends and alerts daily Independent QA of facility’s CHF and COPD program Facility access portal if desired Sends alerts to your clinicians

Early detection of change in condition Preventing hospitalizations

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Technology No telemedicine cart is perfect Limited by unseen forces - your internet connectivity

Impacted by many uncontrolled events, Netflix, data back ups, time of day, microwaves

Glitches- technology failures. Systems which don’t turn on properly.

Simplicity Most units on the market are TOO complicated and your nursing staff won’t

use them. They have many unessential features that slow visits and make there use complicated.

Peripherals – What you need Stethoscope Otoscope Zoom Camera Wound Care Camera

Our TechnologyDedicated telemedicine cart

• Dedicated PC, Large monitor built into a Treatment Cart• A digitally enhanced stethoscope• Zoom Camera and light intense wound care camera• Otoscope

Easy to use One button technology - Just turn on computer and connect Easy to use stethoscope Able to do wound care and look in eyes and ears Walk nurse through structured abdominal, musculoskeletal and neuro

examinationso Teaching assessment skills as we work together

Each visit takes about 7 minutes for the physical assessment

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Demo

The New Clinical Model Built for Rural SNFS

Integrates care around the patient Brings care to the bedside Simplifies workflow for your nurses Makes life easier for your attendings (less calls

and faxes) Better Patient Outcomes Happy Patients, Residents and Families

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Doing Good ! Together - “We”

Make peoples lives better.By being virtually present in the facility

We can identify problems early and treat earlyWe get to know the patients/residents and their

familiesWe treat every person with the respect and

dignity they deserveWe prevent avoidable ED, Hospital and

Consultant office visits

Financial ImplicationsTelemedicine in Rural facilities creates Revenue

For every patient seen via telemedicine the facilities bills for an origination fee of $25

Hospitalizations Direct impact on return to hospital – Keeps beds filled and helps to increase census Direct Impact on Emergency room transfer. Ability to accept direct emergency department admissions (ED Diversion)

Significant Market Differentiator – Your own medical house staff Hospital Systems and Health Plans, ACOs and Bundled Payment Plans, iSNP

CMS 2% penalty (or bonus)RUGS & Case Mix

Increased medical/clinical documentation Integrate with MDS nurse, Integrating with RTMS software if available

Transport and Escort Cost Reduction

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iSNP Opportunity

Creating medical infrastructure will allow you to benefit from lucrative risk models which will bring big profits to your bottom line

Telemedicine allows these models to work in facilities never before contemplated (i.e. smaller and/or rural facilities)

iSNP can add over $700 PMPM to your facilities

Integrated Model of Care

Doing the right thing for your patients and residents

Providing timely onsite (virtual) care

Creating a sound financial foundation

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Thank you

David Chess MD John Whitman MBATapestry TeleHealth The Wharton School dchess@tapestry.care JJW19006@aol.com