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Advisory Council November 2020 Meeting Presentation: Telehealth in Long-Term Care

Monday, November 9, 2020

Printer Friendly Version in PDF Format (24 PDF pages)

Telehealth in Long-Term Care

Cari Levy, MD, PhD
University of Colorado Denver | Anschutz Medical Campus
Professor, Division of Health Care Policy and Research, CU School of Medicine and the Rocky Mountain Regional Veterans Affairs Medical Center

Telehealth in Long-Term Care

  • Telehealth and technologies
    • Definitions, trends pre- and post-COVID
  • Clinician clinical support (e-consults)
  • Direct clinical support
  • Staff support (wellbeing, training)

What is telehealth?

  • Telehealth:
    • Provider training
    • Administrative meetings
    • Continuing medical education
    • Clinical services
  • Telemedicine:
    • A subset of telehealth that specifically refers to provision of remote clinical services

What is telemedicine?

  • Synchronous
    • Real-time
    • Skype
    • Facetime
    • Telephone
  • Asynchronous
    • Store-and-forward images, labs to be interpreted later
    • Remote monitoring with wearables or downloaded biometric data
    • Brief check-ins via patient portal to assess need for synchronous visit
Diagram: Included in Tele-medicine--Real time, Store and forward, Remote monitoring. Included in Tele-education--Health education. Included in Tele-health--Real time, Store and forward, Remote monitoring, Health education.

 

Screen shot of telemedicine bag with contents, such as touch screen laptop, stethoscope, pulse oximeter, 12-lead ECG, ultrsound, all-in-one scope, speakerphone, HD webcame.

Common Uses of Telehealth in Senior Living

Bar Chart: Routine Primary Care, Emergent Health Issues, Mental or Behavioral Health, Physical Therapy, Speech Therapy, Occupational Therapy.
SOURCE: Senior Housing News

VA telehealth program

VA Video Connect Pre- and Post-COVID

  • Feb 2020 --> 10,000 video appointments /week
  • May 2020 --> 120,000 video visits/week
  • 3-year anniversary of VA Video Connect
    • Allows visit on any computer, tablet or mobile device with an internet connection
    • Capable of 25,000 visits/day
  • For Veterans without internet, 26,000 cellular-enabled tablets distributed (no data charges)

CMS significantly expands the telehealth provided in Medicare through telehealth to include:

Interstate Practice Post-COVID

  • Since COVID-19, more than 40 states allow their citizens to be served by practitioners from other states.
  • The provider must use an interactive audio and video telecommunications system, including commonly used services like FaceTime and Skype that permits real-time communication between the distant site and the patient at home.
TYPE OF SERVICE WHAT IS THE SERVICE? HCPCS/CPT CODE Patient Relationship with Provider
MEDICARE TELEHEALTH VISITS A visit with a provider that uses telecommunication systems between a provider and a patient. Common telehealth services include:
  • 99201-99215 (Office or other outpatient visits)
  • G0425-G0427 (Telehealth consultations, emergency department or initial inpatient)
  • G0406-G0408 (Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs)

For a complete list: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes

 For new* or established patients.
*To the extent the 1135 waiver requires an established relationship. HHS will not conduct audits to ensure that such a prior relationship existed for claims submitted during this public health emergency
VIRTUAL CHECK-IN A brief (5-10 minutes) check in with your practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed. A remote evaluation of recorded video and/or images submitted by an established patient.
  • HCPCS code G2012
  • HCPCS code G2010
 For established patients.
E-VISITS A communication between a patient and their provider through an online patient portal.
  • 99421
  • 99422
  • 99423
  • G2061
  • G2062
  • G2063
 For established patients.

Telehealth service use pre and post COVID identifying percent change in visits. Data derived from The Commonwealth Fund: The Impact of the COVID-19 Pandemic on Outpatient Visits

Telehealth Visits
Line Chart: 16-Feb through 10-May.

Mr. Lloyd

  • 86yo long-term care resident with dementia
  • Hitting, yelling, poor oral intake
  • Routine labs normal
  • No recent medication changes
  • Mild edema
  • COVID negative
  • PHQ -9 score = 10

Clinician Clinical Support for Mr. Lloyd

  • PCP
    • Enhanced Referral
      • My patient needs to see a specialist about a specific clinical issue.
      • Specialist -- I appreciate having a clear clinical question and relevant data in the EMR to help make the most out of this in-person visit.
    • eConsult
      • I have a clear clinical question for a specialist to help me manage my patient's care plan.
      • Specialist -- I reply to the PCP with my recommendation and next steps for the patient so that the PCP can continue managing the patient's care.

E-consult

  • SNF physician consults geriatrician with specific question:
    • Is additional workup indicated before we involve geriatric psychiatry?
  • Within hours the geriatrician returns a response with recommended follow-up labs and a differential diagnosis.
  • An appointment with geriatric psychiatry if scheduled

 

Direct Clinical Support

Before the visit

  • Patient/Family Engagement:
    • Educate patient about the appointment
    • Set expectations
    • Make family members aware and set expectations for f/u
  • Scheduling:
    • When/how will telehealth visit fit into staff schedule
    • Have updated medical records available
    • Identify a champion for follow up

Technical Troubleshooting

Screen shot of a diagram showing technical infrastructure solutions.

During the visit

  • How will you "Room" the resident
    • Set up room
    • Tele-exam vs. personal room
    • Who will support patient and clinician
      • Information
      • Technically
    • Communicating with patients
      • Headphones
      • Pocket talkers
      • How does the tele-presenter hear?

After the visit

  • Codes available for telehealth
    • Originating site fee for the facility Q3014
  • Integrating CPT® codes and appropriate modifiers into the EHR
  • Sharing visit summary and follow up care

Originating Site: Pre-COVID

  • The location where a Medicare beneficiary gets physician or practitioner medical services through a telecommunications system
  • Eligible geographic areas included:
    • Rural health professional shortage areas (HPSA)
    • Counties not classified as a metropolitan statistical area
    • Federal telemedicine demonstration projects as of December 31, 2000

Originating Site: POST-COVID

  • May be any location patient is experiencing the encounter from TO INCLUDE:
    • Home
    • Nursing Home
    • Family member's home
  • The originating site facility fee is a separately billable Part B payment to which SNFs are entitled

Tele-Mental Health Visit

  • Mr. Lloyd visits with his geriatric psychiatrist at the VA using headphones in a room dedicated to telehealth
  • They arrange for follow up in a few days after care plan revised and medication adjusted
  • Nursing home can see note using Joint Legacy Viewer -- a copy is made for his chart

 

Staff Support

Mr. Lloyd cont…

  • Anna comments to her supervisor that she is relieved Mr. Lloyd tested negative for COVID because she feels very anxious about how she's been wearing PPE when feeding him.
  • Her supervisor provides a 13 minute video on the correct use of PPE and acknowledges her anxiety about COVID prevention with another training video.
  • Anna is also given access to several wellness apps

Available Online

 

A Brief Tour through Telehealth Initiatives for Long-Term Care in VA

Projects

  • VetConnect: Telehealth provided from VA to urban VA-contracted Community Nursing Homes and mostly rural State Veteran Nursing Homes
  • Virtual Tours: Tours via video for inpatient Veterans to be discharged to community nursing homes
  • Evaluation: of VA to State Veterans Nursing Home Telehealth

VetConnect

  • Focus: Delivering VA specialty care services via telehealth to Veterans in contracted Community Nursing Homes (CNH)
  • VA Location: Denver, CO
  • Impetus: Closure of Denver Community Living Center in May 2017
  • Start Date: June 2017

Goals of VetConnect

  1. Increase access to care for Veterans in CNHs through Video Visits (when appropriate) with VA providers; provide prompt delivery of care; eliminate travel time/lower costs for CNH Veterans who need specialty care services.
  2. Enhance relationships between VA and CNHs
  3. Systemically measure sustainability and future replication of this approach to delivering care.

Program structure

  • Two to Three VA Project Nurses:
    • Tele-presenters for patient
    • Coordinate care between nursing home and VA
  • Referrals from:
    • VA staff and providers
    • Chart review
    • Nursing home staff
  • Technology:
    • Clinical Video Telehealth tablets
    • Headphones for the hard of hearing

 

Provider name (provider) Refresh Plot
Total Count (N) Missing Unique
736 0 (0.0%) 13
Counts/frequency: Bourg (399, 54.2%), Holman (102, 13.9%), Olson (33, 4.5%), Elmore (28, 3.8%), Levy (11, 1.5%), Lum (8, 1.1%), Schumacher (15, 2.0%), Hartz (3, 04.%), Robbins (1, 0.1%), Shea (0,0.0%), Horney (0, 0.0%), Jennings (1, 0.1%), De la Cruz (8, 1.1%), Sussman (0, 0.0%), Johnson (129, 17.5%), Other 11, 1.5%).

 

Type of visit (visit_type) Refresh Plot
Total Count (N) Missing Unique
736 (0, 0.0%) 7
Counts/frequency: Geriatrics (400, 54.3%), Palliative Care (119, 16.2%), Mental Health (263, 35.7%), Psychiatry (13, 1.8%), Geropsychology (1, 0.1%), Other (6, 0.8%), Geriatric consult, but seen in palliative care clinic (0, 0.0%), Post Surgical visit (36, 4.9%).

Visit Summaries

  • First 18 months following implementation
    • 319 visits to CNHs (Geriatrics, Palliative Care, Mental Health)
    • 136 visits to SVHs (Mental Health, Pall. Care, Psychiatry)
CNH Visits by Subspecialty SVH Visits by Subspecialty
Bar Chart: Jun-17 through Dec-8. Bar Chart: Jun-17 through Dec-18.

Cost Savings

  • Initial estimations and assumptions from our Health Economist (for a face to face visit substituted for a Video Visit):
  • VA savings of $159.95 per visit
  • NH savings of $141.60 (SVH) or 165.30 (CNH)
    • Staffing (NH staff travel to in-person visits)
    • Travel costs (van cost and mileage)
    • Video Visit technology (computer at facility)

Virtual Tour Community Nursing Home (CNH) Program

  • Virtual Tours for Nursing Homes
  • Facilitating Timely Discharge Via Video Technology
  • Virtual Tours Team:
    • Courtney Bauers, LCSW, Research Social Worker, (720) 857-5096Courtney.bauers@va.gov
    • Cari Levy, MD, PhD, COIN Associate Director, Denver VA Palliative Medicine Program Director
    • Leah Haverhals, PhD, Health Research Specialist
    • Annie Hale, BA, Professional Research Assistant
    • Mercy (Mehret) Tekle, LPN, Research LPN
    • Emily Galenbeck, BA, Professional Research Assistant

VA Community Nursing Home Virtual Tour Program

  • What is it?
    • The VA is interested in helping our inpatient veterans being discharged to a nursing home to tour the facility virtually if they are unable to tour in person.
  • What do we need from you?
    • If you are interested in participatin, let our staff know and we will reach out to your when we have an eligible veteran interested in a tour to see if you are able to participate in the tour along with our staff.
  • Common Questions:
    • What about privacy?
      • Similar to conducting in person visits, virtual tours can raise some privacy questions.
      • Our staff will work with your staff to try to only show images of the physical spaces and if we can't avoid showing images of staff or residents, we will avoid showing any identifying information. No virtual tours are saved.
    • How will your facility get tablets or iPads?
      • If your facility doesn't have tablets or iPads, we will have our staff be present for the tour itself and you can use their tablet or iPad.
  • What if I have more questions?

What they had to say about a real-time virtual tour…

  • Veteran said he was impressed by the Virtual Tour, stating, "This is pretty fancy" and remarked that it was "Amazing" that the staff could see him in his room at the VA and he was able to see the facility prior to discharge.
  • Following the Virtual Tour, the inpatient medicine social worker said this was the first time she had witnessed this veteran smile since she began working with him. She was impressed with the process and said she thought it would be beneficial moving forward and thought it was great, especially for this veteran as he was not from Colorado, has never been to a Skilled Nursing Facility, and will end up placed for months while receiving intensive wound care.
  • The veteran had some questions for the facility admission's liaison during the tour such as "Can I hang posters in my room?" "what happens if my breathing gets worse when I'm there?" Which the liaison answered. Veteran stated at the end of the tour " It looks really good, so much better than what I was picturing in my mind."
  • The veteran made several positive remarks about the facility including "it's beautiful!" and "looks great!". The veteran had some questions for the facility admission's liaison including if he could "leave the facility in his truck to go get something to eat." The veteran was tired but expressed satisfaction with the tour.

 

Evaluation of VHA Telehealth to State Veterans' Homes

Two Telehealth Configurations:

  • VHA is On-Site
    • Global Medical Cart
    • Transportable Exam Station
  • SVH employee assists in visits
    • "The goal (of the SVH-Assist Configuration) is not to add SVH staff, but instead exchanging staff time for telehealth which is [a] more efficient way to facilitate care. Currently they send a staff member with Vets to appointments, which can take hours for staff one on one with Vet, where telehealth will be 15 minutes of the staff time."
      – SVH Point of Contact, Telehealth Initiative, Site 1

Types of Current & Future Specialty Services Offered by Configuration

VHA On-Site (using GMC/TES) SVH-Assist
Dermatology for screening Wheelchair Clinic
Cardiology Psychiatry
Urology: Pre- and Post-Operation Geriatric Evaluation
Oncology: Follow-Up PADREC-Parkinson's
Anesthesiology: Pre-Operation Neurology
Low Vision Behavioral Health Therapy- Social Worker
Diabetic Clinic  
Pharmacy- Management-Hep C  
Behavioral Health Therapy-Social Worker  
Behavioral Health Intakes  
Specialties Soon to be Offered for Some SVH Veterans
Audiology Rehabilitation
  Palliative Care
  Low Vision

 

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