Telehealth for Hospice and Palliative Care – Realities and Challenges

1. Telehealth for Hospice and Palliative Care – Realities and Challenges Deborah A. Randall, JD & Consultant 202-257-7073 law@deborahrandallconsulting.com www.deborahrandallconsulting.com

2. 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

3. 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

4. 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

5. 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]

6. 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.

7. 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

8. 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

9. 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

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 Home Care Association of New York State

12. 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

13. MD Acceptance - CCCP

14. What are the New Directions? • Tele-rehabilitation; Falls prevention • Tele-mental and behavioral health • Continuous monitoring: diabetes; cardiac • Impaired; Alzheimer’s & dementias

15. 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

16. 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

17. 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?

18. “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?

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

25. 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.

26. 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.

27. 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

28. 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

29. Attention to Legal Concerns • Licensure of palliative care provider • Liability and Consent • Privacy and confidentiality • Security of Communication

30. Thank You! • Deborah Randall, JD Health Law Attorney Telehealth Consultant 202-257-7073 law@deborahrandallconsulting.com www.deborahrandallconsulting.com