Through the Effective Use of Telemedicine HHS/CMS/ORD and Adam Sholar

Through the Effective Use of Telemedicine HHS/CMS/ORD and Adam Sholar / North Carolina Health Care Facilities Association (NCHFA) May 7, 2018 9:00 AM Sam Nunn Atlanta Federal Center 61 Forsyth St. SW, Suite 4T20 Atlanta, GA 30303 John Whitman, MBA, NHA The TRECS Institute

Meet Gertie

Today’s Objectives Telemedicine in Skilled Nursing Facilities CMS/AHCA Telemedicine Grant Key Findings Key Recommendations Telemedicine Expansion to include Rural SNFs

America’s Skilled Nursing Facilities 15,655 SNF’s in America 11,000 Urban (70% /-) 4,300 Rural 70% Medicaid Physician Sporadic 2-3 (30% /-) presence in SNFs (limited at best) day time in most urban hours per week/month in many rural facilities Majority of care decisions made over the phone

Key Challenges For Skilled Nursing Facilities Much sicker patients Lower High reimbursement staff turnover Smaller pool of patients (hospital census is down) Increased Clinical regulatory oversight and compliance pressure outcomes matter – STAR ratings and penalties Families and patients have increased expectations Litigation concerns are always there Clinicians are hard to find and no one wants to work after hours

“The Default Factor” As a System, we lack the ability 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!

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 the hospital when they don’t need to go is NOT QUALITY CARE! Estimated cost to Medicare for these unnecessary admissions is estimated to be over 1 billion dollars a year

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!

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

We Can Transform America’s Skilled Nursing Industry e Facilities By Offering High Quality Telemedicine Services at the Resident’s Bedside Across America’s 15,000 Skilled

What is “Telemedicine” “The practice of medicine when the doctor and patient are widely separated using two-way voice and visual communication” Means a lot of different things to a lot of people Remote Blood sugar levels Cardiac Basic weight and blood pressure checks monitoring primary care Medication Rural management emergency rooms Ambulances

Telemedicine The Ability To Differentiate Resident’s that Truly Need Hospitalization Two way video interaction Digitally Zoom enhanced stethoscope camera Otoscope Pillow No speaker & privacy phone log in/key board Multi-hour battery life

How Most Telemedicine Services Work 1 The facility nurse calls and connects directly to a telemedicine physician or nurse practitioner. 2 The clinician examines the patient with the nurse through the telemedicine unit and treats in place when possible. 3 4 Full notes and orders are faxed securely to the nurse to update the patient’s record. The clinician communicates with the attending on the episode and treatment plan and with the family

Telemedicine At Its Core Improves Cost Early access to care (Both urban and rural) effective way of focusing advanced and preventive care Detection - Monitoring allows the SNF to focus on residents before they require hospitalization Virtual onsite care allows a limited workforce to be virtually present when needed (on demand) This is how we can transform America’s Nursing Home

Common Concerns about Telemedicine Voiced by SNF Physicians Will this impact my billing? Will this increase my liability exposure? What’s to keep the virtual physician from “stealing” my patients?

Financial Case Study - Urban One Year Study in New York City 350 91 bed facility Avoided admissions in one year 1.3 million dollars savings for Medicare 132,000 additional revenue for SNF Better Care for Seniors Reduced System Costs Increased Financial Performance for SNF

AHCA Grant No. GFA061 Virtual Physician Services in SNFs to Prevent Avoidable Hospital Admissions Official start date: January 11, 2017 Four skilled nursing facilities included Two virtual physician practices included 8 months of actual services

AHCA Grant No. GFA061 Final Four SNFs Selected

AHCA Grant No. GFA061 Study Goals To evaluate the ability of virtual physician services to reduce avoidable SNF to hospital admissions and readmissions during off hours; To evaluate the economic impact that avoidable admissions and readmissions can generate for Medicare, the participating SNFs and the state Medicaid Program; To evaluate two separate virtual physician companies and identify key success characteristics SNFs should be looking for in seeking out a virtual physician organization to serve their residents; To evaluate the four participating SNFs and identify key success characteristics that any SNF interested in establishing a virtual physician service can use to determine if their facility is a good candidate.

AHCA Grant No. GFA061 Findings from the Clinical Perspective Ability to provide bedside evaluations (not phone medicine) Ability to prevent unnecessary hospitalizations Ability to utilize local ER when needed – but get resident back Nursing staff noted improved clinical skills and confidence Early detection of issues to prevent escalation Very effective in securing Advanced Directives Very effective at preventing “End of Life” hospital transfers Overall - Better care for the resident

AHCA Grant No. GFA061 Findings – From the SNF Perspective SNFs are turbulent organizations and difficult to organize Critical to gain NHA and DON’s commitment Critical to gain Medical Director’s commitment Critical to gain nursing staff’s commitment Need for regular discussions/review/education Tremendous Hospitals Marketing Differentiator respond well to reduced readmissions

AHCA Grant No. GFA061 Findings – Virtual Physician Companies The quality of the physician is everything! Must be clinically sound and comfortable with SNF care Must be excellent communicators With nursing staff With primary care physicians With families Must answer the phone directly Must keep good records Must have plan for equipment breakdown (it is technology!)

AHCA Grant No. GFA061 Findings – From a Financial Perspective Two of the four facilities were financially successful Increased revenue exceeded cost of telemedicine service Two of the four facilities were not financially successful Increased Problems revenue did not exceed cost of the service at both the SNF level and the virtual physician level Medicare was financially successful in all facilities Should Medicare be paying for telemedicine services? Medicaid actually pays more when admission of Medicaid resident is prevented Should Medicare be sharing savings with Medicaid?

Financial Impact on Medicare Spending Avoided Admissions: 75 Total @ 10,000 per admission 750,000 Avoided Medicare days 60% for average of 10 days @ 550/day 247,500 Cost of “other issues” from acute stay Highly vulnerable seniors being admitted ? Total Estimated Savings for Medicare months) Cost of Telemedicine Services 997,500 114,000 Estimated Savings for Medicare Average Medicare Savings per Facility/Yr. 883,500 110,437 (24

Projected National Impact on Medicare if Virtual Physician Services were Reimbursed in all SNFs Assumptions: 15,655 SNFs in America Average savings per facility from study 110,437 If 50% of America’s SNFs implemented telemedicine with the same level of success as the four pilot SNFs, Medicare would realize estimated savings of 865 million dollars a year Note: Other considerations have to be incorporated into final estimate (i.e., the fact that more residents would be seen more often (better care) with an increased cost to Medicare.

Final Thoughts On Telemedicine is good for the resident – dramatically Study improves access to care when needed most Telemedicine contributes significantly to Medicare savings Telemedicine is not for every SNF – Certain critical success characteristics must be present Not all physicians will buy into telemedicine in the short term but will need to in the long run Not all virtual companies will be successful. There are specific success characteristics they need

Preliminary Medicare should be reimbursing for telemedicine in urban and Recommendations rural skilled nursing facilities CMS should allow virtual telemedicine visits to meet the requirements for the 3 day evaluation requirement and 30/60 day review CMS should consider allowing the requirement for medical director to be fulfilled with a virtual physician with once a month or as needed on site presence State Nursing Home Associations should be encouraging their members, both urban and rural, to evaluate telemedicine for their residents State nursing home associations should consider helping their members secure CMP Grants for telemedicine

Expanding Telemedicine to Rural Skilled Nursing Facilities

Why We Need Telemedicine in Rural Skilled Nursing Facilities Availability of physicians in rural nursing facilities is often extremely limited (2-3 hours per week/month) Availability of psychiatric services often limited or not available Specialty consults are difficult to schedule: Takes weeks or more to secure an appointment Requires transport to specialist – miles away Requires nursing staff member to accompany resident Additional opportunities to improve care Physiatrist for requesting additional coverage when needed

Rural Telemedicine Services Provide Access To: Primary Nurse Daily For 9 Care Services (Multi Specialty Medical Practice) Practitioners and Specialty Clinicians Rounds when local physician not available changes in medical condition hours per day and or 24/7 models Behavioral/Psych Services Scheduled As needed including 24/7 emergency care Specialty Consults Services Scheduled and as needed Dermatology, Cardiology, Pulmonology, Nephrology, Endocrinology, Physiatry and more Wound Care & Continence Care

Rural “Primary Care” Services Clinician available 9 hours a day to see patients on demand (8 am to 5 pm, Monday through Friday) Daily Rounds (5 days per week) with facility’s nurses Available on demand to see patients when there is an acute change in condition Communicates and integrates with the attending Communicates with families Assists with Advanced Care Planning Documents visits

Rural “Behavioral/Psych” Services Monthly Behavioral Visits (or as often as clinically required) Residents with: Depression, Dementia Bipolar, Schizoaffective disorders with behavioral manifestations Medication De-escalation and monitoring Behavioral – Milieu Management Family Acute Communication and Support change of condition and 24/7 support Staff training and support F Tag response

Rural “Consultative Specialists” Services Providing Consultation via Telemedicine Scheduled and Urgent Visits Dermatology Gastroenterology Cardiology Endocrinology Pulmonology Urology Infectious Disease Neurology Physiatry Orthopedic Surgery Integrates with the attending Communicates Provides with the family consultative note

Common Telemedicine Episodes Chief Complaints Shortness of breath Fever in mental status symptoms Chest Falls CHF Pneumonia Change GI Common Diagnosis pain with injuries Behavior changes COPD Hypovolemia hypotension Urosepsis and/or

Clinical and Social Impact Early Treatment of Conditions Reduced Emergency Room Transfer Reduced Hospitalizations State Survey Assistance Medication Stewardship Advanced Care Planning High Nurse Satisfaction Onsite Experiential Nurse Training High Patient and Family Satisfaction High Attending Integration and Satisfaction

Other Benefits Nursing Staff: “When I call the doctor, he answers the phone!” Increased skills and confidence level Families: Knowing Mom gets immediate care Not going to the hospital Physicians: Gets my patients the care they need Makes my day easier Eliminates a lot of the “noise!”

Reimbursement Rural Reimbursement Originating – for clinicians (Medicare Part B) Fee ( 20 per visit) covers I.T. readiness and equipment costs Economics work because no net cost to SNF

Opportunities for Financial Impact RUGS Integrate with MDS nurse, Integrating with RTMS software STAR Rating Direct impact on return to hospital – Keeps beds filled and helps to grow census Direct Impact on emergency room transfers. Improved nursing staff skills and confidence Significant Market Differentiator Your own medical house staff Better positioned for Shared Savings Agreements

Clinical Case Study

Clinical Case Study

Financial Case Study - Rural Tapestry TeleHealth Visits to Three Rural SNFs 2018 February March April Total (4/1 - 4/13) Facility #1 (121 beds) Primary Care Visits 48 87 39 174 Psych Visits 0 0 0 0 Specialty Consult Visits (1) 0 0 12 12 48 87 51 186 Primary Care Visits 2 19 16 37 Psych Visits 0 0 0 0 Specialty Consult Visits 0 0 0 0 2 19 16 37 High Risk Visits 8 24 26 58 Psych Visits 0 19 21 40 Specialty Consult Visits 0 0 0 0 8 43 47 98 Total Visits Facility #2 (112 beds) Total Visits Facility #3 (68 beds) Total Visits

Financial Case Study – Rural (continued) 14 patients classified as “Avoided Hospitalization” 3 billing days per resident saved 42 billable Average daily billing at 275 11,550 days Plus avoided transportation/staff costs by providing 12 Specialty Consults at resident’s bed side

Proven Multispecialty Physician Practices Offering Telemedicine Tapestry TeleHealth, Inc. www.tapestry.care Rural SNFs David Chess, MD 203-521-4730 TripleCare, Inc. www.triple.care Mary Jo Gorman, MD 855-376-3669 Urban SNFs

Thank You! Please feel free to contact me if you have any questions about the potential of implementing Telemedicine in skilled nursing facilities! John Whitman, MBA, NHA Executive Director The TRECS Institute [email protected] 484-557-6980