A realistic look at why telemedicine isn’t succeeding in nursing homes

It’s the reimbursement. Telemedicine in nursing homes by specialists on call seems like a natural. A nursing home resident is usually older and frail. Nursing homes don’t generally have doctors in the facility; only 10 percent are estimated to have on-site doctors. A telemedicine consult administered by a nurse or even a trained assistant can provide proactive, just-in-time care, and possibly prevent an expensive hospital/ER visit–two-thirds of which may be potentially avoidable. That ER visit also can start a disastrous and expensive decline in the resident. 

So the problem in the stars is…economics.What insurance companies pay for telehealth/telemedicine services. It varies if the patient is covered by Medicare, Medicaid, or dual-eligible–and also by private or LTC insurance. Some providers and payers are engaged with value-based care and payment models–others are not. CMS is concerned that telehealth drives up costs, not reduces them. Finally, administrators and nursing/clinical staff in the facility are not necessarily comfortable with technology in general. (Excel spreadsheets are, believe it or not, foreign to many.)

As Readers know, Call 9 couldn’t figure out the reimbursement problem nor how to keep up with payer demands–and ceased business [TTA 26 June]. Others like Curavi and Third Eye Health provide a video cart and provide on-demand consults. On the Federal level with Medicare, payments have been expanded for end-stage renal disease and stroke treatment, and Medicare Advantage plans can now offer telehealth. Still, there is no direct payment under Medicare for virtual emergency medicine. And telemedicine remains a rarity in SNFs, who prefer to send their residents to ERs ‘just to be sure’. POLITICO

Call9: we’ll be back — with a different model!

“It wasn’t viable in the way that we did it,” Peck said. “We were very far ahead of the curve.”

Call9‘s founder, Tim Peck, MD, interviewed by local business publication Crain’s New York Business, shed a bit more light on the company’s planned reorganization as Call9 Medical. According to Dr. Peck, Call9 Medical will be in a much larger network of nursing homes and add primary care physicians to its services. The reopened company will be backed by its Silicon Valley lender, Western Technology Investment, which apparently forced the closing issue when the company’s cash on hand fell below the amount lent by WTI. No timing for resumption was given.

In the interview, Dr. Peck returned to reasons why the Call9 original model did not work. Insurers would pay for fee-for-service based telemedicine visits in nursing homes but not pay on their operating concept of fewer hospitalizations and better health outcomes that saved money, which had a longer-term payoff. 

Apparently this led to a standoff with controlling (over 50 percent) funder Redmile, which encouraged the FFS revenue stream. “We had to do services in a particular way that in no way brought value to our model,” Peck said. The ‘change in funders’ as noted in TTA’s article on the shutdown now is in a fuller context; Redmile will not be participating in the repositioned company. Confirmed in the article is that a few former investors, WTI, and some former employees will be part of it.

In this Editor’s view, Call9 had trouble accommodating both payment tracks, perhaps because they were overly invested in their concept. In the real world, it seems odd in a company of this size and investment level, which at one point employed close to 200 people and was about 100 at shutdown. Young companies, if anything, learn to be flexible when it comes to getting profitable cash flow into the exchequer, including standing their ground against ‘pilot-itis’–especially when their major investors encourage it.

One of their earliest customers also warned them of another flaw in their model. The author interviewed the CEO of one of Call9’s earliest clients, ArchCare, a Catholic nonprofit LTC organization in New York. ArchCare was able to “get its patients’ hospitalization rates low enough on its own that paying the startup no longer made sense.” “Their model wasn’t able to move the needle sufficiently to justify the ongoing expense,” CEO Scott LaRue explained. 

One hopes that Call9 Medical will avoid those pitfalls in being too far ahead of the curve and recast their telemedicine model to improve health outcomes for our most frail, vulnerable, and poorly served. Hat tip to HIStalk.

What are the impacts of NHS CCGs forcing disabled and LTC patients into care homes? (UK)

[grow_thumb image=”http://telecareaware.com/wp-content/uploads/2014/04/Thomas.jpg” thumb_width=”150″ /]Care for elderly and disabled goes off the tracks again. A report in the Health Service Journal (subscription required), covered in an opinion piece in the Guardian, indicates that thousands of patients who are disabled and also those who require long-term care may be forcibly put into care homes (US=nursing homes) rather than being treated and maintained in home care. According to the HSJ, “Freedom of Information (FOI) requests from campaign group Disability United found that 37 NHS clinical commissioning groups (CCGs) in England were introducing rules about ongoing care that could force up to 13,000 people with health conditions into care homes.” CCGs due to NHS cuts have been setting limits on financing home care, between 10 and 40 percent above the care home option. In other words, where a care home is cheaper, the CCG will withdraw payment for home care, and unless the individual can self-pay or has an advocate who can organize a care plan, that person may be involuntarily moved.

The word ‘institutionalization’ deservedly strikes fear on both sides of the Atlantic as a recipe for patient decline, physical and verbal abuse, theft and generally bad care. It’s a blunderbuss solution to ‘bed-blocking’ which we discussed here [TTA 7 Sep 16]–the care plan becomes ‘move ’em out’. By going this way in policy, NHS England is going counter-trend, against more personalized care delivered in home settings, and setting an unfortunate trend for other countries like the US.

Outside the scope of the article, but in this Editor’s thoughts, is the knock-on effect it will have on the UK’s developers and providers of telehealth and telecare services/TECS designed to support home care. Many of these technologies are in a transition period to the greater capabilities (and freedom from land line) of digital from analogue care, which was discussed in TTA here. Cutting domestic demand may not only be critical not only to companies’ survival, but also to their expansion in the (now far more open to the UK) US market. Readers’ thoughts?

Nursing home telemedicine reduces hospitalizations: study

A controlled two-year study in a chain of eleven Massachusetts for-profit nursing homes significantly reduced readmissions through the use of telemedicine (remote consults) with patients during off-hours and weekends. Those homes which used the (unidentified) telemedicine provider the most frequently–four–had the greatest reductions in rates of hospitalization: 11.3 percent, versus 9.7 percent for the six facilities which adopted the system first. A control group of five which presumably did not use telemedicine had a reduction of 5.3 percent. Calculating the savings to Medicare, the researchers estimated $150,000 per nursing home per year. With a telemedicine cost of $30,000 per nursing home, the net savings would be roughly $120,000 for each home using the services most frequently. The researchers are David C. Grabowski of Harvard Medical School and A. James O’Malley of The Dartmouth Institute for Health Policy & Clinical Practice at the Geisel School of Medicine. Abstract (full text in Health Affairs paywalled), Medical News Today. Hat tip to Editor Toni Bunting.

TTA’s Editors are highlighting several of the articles in this month’s Health Affairs ‘Connected Health’ issue: Study shows telehealth increases new healthcare usersState policies, size influence hospital telehealth adoptionHealth Affairs review of telehealth/telemedicine studies. Health Affairs provides a helpful overview of this month’s articles ( full text) in Connected Health: Emerging Disruptive Technologies

‘Green Houses’ for older adults receive $2.77 million backing (US)

Our July profile on the innovative ‘Green Houses’ model for older adults as a designed-from-ground-up alternative to nursing homes mentioned the considerable support that the Robert Wood Johnson Foundation (RWJF) has given to the Green House Project with an initial 10-year, $10 million low-interest credit facility in 2011. RWJF has added a $2.77 million grant for a three-year acceleration of the model to include an updated financial model and a stronger marketing plan to create demand. All good things for this care model for high acuity residents. Grant on the RWJF website. MedCityNews.

Tablets as ‘socializers’ for older adults

Long-time reader and now guest contributor John Boden of ElderIssues LLC and developer of the LifeLedger, reasons that if young children can use tablets fairly meaningfully, so can older adults at home or in senior communities. This is adapted from one of his series of ‘Caregiver Tips’ available via opt-in at caregivertips@elderissues.com.

Socialize With Technology: Tablets and iPads

If babies can use iPads, so can the very old.

Tablets and iPads are everywhere – EXCEPT – with nursing home patients.

This must be the season for me to have “aha!” moments. Last month it was while reading “Still Alice” and this month it was while visiting a nursing home where Sue told me she liked playing Scrabble but it was hard to find people to play with.

I am sure it is hard in a nursing home where you have to find another patient (more…)

‘Green Houses’: a better model for senior living (US)

“Let’s abolish the nursing home”–Dr. Bill Thomas

In the US, the ‘Green House Project’ model has made tremendous progress in developing homes for older adults as an alternative to nursing homes. A ‘design for living’ for 10-12 residents, a Green House is a home-like model built from the ground up with private rooms, bathrooms and community living. Currently 260 homes are open or under development across 32 states. From their website, the intent is for “Those who live in, work in, and care about a Green House [home] share the duty to foster the emergence of late-life development within the daily life they create together.” The care ratio is also much higher; care teams are organized on self-managed work teams to care for the mostly high acuity residents (including dementia). Yet costs, according to NPR, are about the same as the median for nursing homes nationally (many residents are on Medicaid) and in quality of life, it respects residents habits, privacy with the outcome that it supports residents longer in a level of independence.

The Green House concept came from the work of Bill Thomas MD, a geriatrician who also developed the Eden Alternative and frequently writes on ChangingAging.org. The news is the backing of the Green House Project by the prestigious and well-funded Robert Wood Johnson Foundation and NCB Capital Partners. The Project provides the model and guidance to independent organizations for organization, implementation and certification of these homes. MedCityNews was wowed by it (Wall Street Journal link does not work, however). See the video from RWJF on what they saw as ‘a catalyst for significant social change’.  Green House Project website   RWJF page on their support of this ‘force multiplier’.

What if you added non-intrusive health tech to these homes? The opportunities could be as varied as the ELSI Smart Floors and alert system for safety (Charles)…fitness bracelets/wearables to monitor basic vitals and ADL/activity (Jawbone, Misfit, AFrame)…biosensor ‘tattoos’ (Toni). Tablet/PC based socialization/brain stimulation (GeriJoy, GrandCare, It’s Never 2 Late). Could this humane environment move to a higher level with a touch of tech?

[This video is no longer available on this site but may be findable via an internet search]