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Adoption of Telemedicine in Post-Acute Care




#TelemedNow Twitter Chat Wednesday, April 29 – 8 PM ET Introduction & Welcome: Helen Burstin (@HelenBurstin) – Moderator How can we increase telemedicine adoption in post-acute settings? Q1 Please share your experience with using telemedicine in post-acute settings. What worked well? What didn’t work?

A1 Notable Responses: Jamey Edwards (@jameyedwards) #Telemedicine has a broad array of uses in #postacute care settings! From #telesitting to #remotepatientmonitoring, from #physicaltherapy to post discharge follow-up, from #woundchecks to #socialrounding, the use cases for #telehealth are endless Andrew Watson (@arwmd) We use it for remote monitoring and live video visits. @CuraviHealth @VivifyHealth @UPMCnews It’s a very active space of development right now on both provider side in the payer side. #TelemedNow Ami Bhatt (AmiBhattMD) #TelemedNow has been essential in confirming transitions of care plans. A quick visit once the patient lands in any post-acute care setting helps reiterate plan, medications and answer questions. Discharge is a confusing time for patients! Ceci Connolly (@CeciConnolly) @GeisingerHealth at Home program uses #telehealth, for consult and for docs to record data in home. Makes care for rural pops easier, enables meeting complex needs in home, helps coordination and lowers readmissions/ER visits. https://bit.ly/2Si0dAy @_ACHP #TelemedNow Ted Chan (@upwardmobility) Have used #telemedicine for urgent care type post acute follow-up. Very clunky sign up -and onboarding processes but better than having to go to facility. #telemednow David Grabowski (@DavidCGrabowski) I led an RCT of telemed in SNFs here in Mass published in @Health_Affairs. Program showed overall decrease in hospitalizations. However, implementation was a challenge with administrator & medical director resisting model at different SNFs. #TelemedNow

Joe Rotella (JRotellaAAHPM) In #COVID19, telemedicine used for advance care planning, virtual home visits, and family connections where F2F prohibited #telemednow Evan Kirstel (@evankirstel) Its a cost effective way to improve care coordination and reduce hospital readmissions @IrmaRaste @eViRaHealth @ElectronicCare #telemednow Ritu Thamman (@iamritu) #TelemedNow ˄ efficiency: ˅ number of nurse home care visits ˅number of patient transports to hospitals & physician offices ˄access to specialists - wound care experts/ pulmonologists ˄can use RPM to check medication adherence Ted Chan (@upwardmobility) In line with what I see running a healthcare review site. Strong demand for telemedicine but patients are frustrated with difficult onboarding and general UX. #TelemedNow Andrew Watson (@arwmd) We’re beginning to learn more and more than scheduling is very difficult in some settings for #Telemedicine. #TelemedNow have been thinking about this a lot lately, this problem goes beyond EHRs. Ted Chan (@upwardmobility) Elective #telehealth players offering way better user experience, eg teletherapy, digital health companies drop shipping white label prescriptions (though not necessarily better or even good care). Joe Rotella (JRotellaAAHPM) Before #COVID19, telemedicine used to extend scare specialty palliative care to rural areas https://jpsmjournal.com/article/S0885-3924(18)31297-1/pdf #telemednow Jagdish Patel, MD (@jpkca) We have continued TCM with Post-acute discharge F/U for CHF. It really works to reduce readmission rates. All TCM parts are approved by CMS before #Covid19 #TelemedNow Ritu Thamman (@iamritu): Important especially in light of growing shortages of staff in home care settings: staff absenteeism/fear of getting #covid19 staff sick w #COVID19 Staff staying home to care for their kids whose schools are closed #TelemedNow Jagdish Patel, MD (@jpkca) Transitional care management (TCM) services codes 99495 and 99496 #TelemedNow Nadeen Faza (@NadeenFaza) Many elderly patients miss their appointments as family members are not always available to take them to frequent visits (due to work hours, childcare, etc). #TeleMedNow ensures consistent follow-up! Cory Simpson (@CorySImpsonMD) In #dermatology, I've used #TelemedNow for follow-up of patients who've had biopsy/excision. #StoreAndForward is a great way to do post-procedure wound checks and I find I can avoid unnecessary antibiotics when patients are concerned for infection, but photos are reassuring.

Q2 What technical barriers need to be addressed to increase telemedicine adoption in post-acute care settings? A2 Notable Responses: Jamey Edwards (@jameyedwards) Unpredictable home #technology environments & #device variability & #broadband access still present challenges post acute. #ChronicCareManagement & #populationhealth models are aiding with reducing payment friction. #SDoH Ceci Connolly (@CeciConnolly) I'm a broken record on this: Broadband access is major issue, esp in rural areas, underserved pops. Stronger investment in broadband infrastructure is one big way gov can help expand/promote use of telehealth. @_ACHP #TelemedNow James Legan (@jimmie_vanagon) having one very good nurse that can educate and get the elderly patient up and running on the device of choice before the follow up acute care visit is very helpful #telemednow David Grabowski (@DavidCGrabowski) Connectivity...connectivity...connectivity. We had way too many meetings about broadband and hot spots when I did SNF telemed project. Aditi Joshi (@draditijoshi) better reliable wifi especially for vulnerable populations, access to devices and monitors, especially as home care expands. also research on what devices give reliable data (@annamariechang) #TelemedNow Joe Rotella (JRotellaAAHPM) Some homes lack not only broadband Internet but also a computer or smart phone #telemednow Evan Kirstel (@evankirstel) Lots of technical barriers to #telehealth: Cost of implementation, Complexity of implementation and use, and problems integrating into existing infrastructure Jagdish Patel, MD (@jpkca) Access of information was a real problem 2 years ago but seeing less and less especially Mighty EPIC is taking over most health systems. Having information of the discharged patients is more important than office visit from PCP Ted Chan (@upwardmobility) Digital acquisition needs to be talked about. Tech companies coming into the healthcare space run full marketing analytics funnels to acquire and retain customers. They are going to be taking patients like crazy from physical health systems in the next 5 years. Andrew Watson (@arwmd) I think in Pittsburgh we say needs fixed.@RasuShrestha Regardless, I think scheduling may become a greater issue than EHR interoperability. This has been on my mind a lot recently. it’s scheduling of people, processes, and technology. It’s hard. Jagdish Patel, MD (@jpkca) Agree with the connectivity problem. Not all handheld devices give good A/V quality. Cheaper iPads are almost useless in spite of having good bandwidth #TelemedNow Ami Bhatt (@AmiBhattMD) Broadband, interpreter services, access to technology like smartphones and computers. We have a lot of infrastructure to build. Must reduce bias in the system from its inception. #TelemedNow Leonor Fernandez (@lfernandezi) Ease of three-way is absolutely key for: 1) interpreters; 2) resident/med student participation; 3) caregivers/family joining visit Cory Simpson (@CorySimpsonMD) For #TelemedNow, it has also been a major challenge to incorporate MAs or RNs into visits, especially when they are not in the same physical space as the provider due to #SocialDistancing during #COVID19. Ami Bhatt (@AmiBhattMD) One challenge is not all individuals have equal access to computers at home thereby limited some MA workflow to when they are on campus. Cory Simpson (@CorySimpsonMD) This! Exactly! With our staff displaced from the clinic during #COVID19, we can't expect them to BYO device/VPN/WiFi/private room for encounters via #TelemedNow Salim Saiyed (@SalimCMIO) Lot of nursing home/#snf don’t have the infrastructure, wifi, tele carts, IT staff etc. to make this work seamless for their patients #telemednow ResolutionCare (@MichaelDFratkin) All they need is a tablet and wi-fi, then add the human effort to coordinate and the quality, efficiency, and soul of the care the residents recieve pays off beautifully on all elements of the quadruple aim! Salim Saiyed (@SalimCMIO) From a telemedicine provider perspective delivering care to remote site at a nursing home, not having ehr data can get in the way of providing high quality care. These are complex patients, with long histories, med list, that’s needed to delivery high quality care #telemednow Q3 What payment barriers need to be addressed to increase telemedicine in post-acute care? A3 Notable Responses: ResolutionCare (@MichaelDFratkin) For team based care like palliative care, value based payments are the only way to support the kind of relationships that are required for the desired outcomes. David Grabowski (@DavidCGrabowski) Historically, Medicare only covered rural telemed. Thus, SNFs had to pay for telemed but savings went to CMS. Our study in Massachusetts was a success (Medicare savings!), but SNF chain discontinued shortly after study ended because they didn’t see business case #TelemedNow Nancy Lundebjerg (@nlundebjerg) For starters, #CMS could extend some of the #telehealth payment flexibiltiies that it has in place for #COVID19 but the bigger barrier might be low-wage jobs and poor staffing in #NH since some assistance will be needed from NH staff Jamey Edwards (@jameyedwards) We need to be thinking about ROI & #quadruplebottomline as measures of success. Reimbursement needs to become a lagging indicator. Also reimursement changes often are the sign of upcoming commoditization #telemednow Ted Chan (@upwardmobility) Patients want to check into an online appointment like an e-commerce transaction, insurance as the credit card. #TelemedNow James Legan (@jimmie_vanagon) Hopefully after the pandemic crisis primary care docs will continue to be compensated by Medicare or private insurance for the time spent with the patient #TelemedNow Jagdish Patel (@jpkca) The dilemma I have using #Telemedicine is how to bill. Standard E&M coding does not justify how we evaluate patients, how many mins we spend with each patient, the physical exam is almost nonexistant and VS is also limited. Only details covered are in ROS #TelemedNow Sandeep Pulim (@SPulim) Partnering with companies like @TomorrowHealth1 to combine remote care & personalized service to “reimagine healthcare in the home” #TelemedNow Jagdish Patel (@jpkca) Because of #COVID19, all restrictions are removed but how many of us believe that most restrictions by CMS and Private insurers will come back? #TelemedNow Andrew Watson (@arwmd) Another interesting barrier can be co-pays. There are CCM codes, but they can require co-pays. Also, for monitoring, it’s hard to bill for the central monitoring call center. @VivifyHealth #TelemedNow This distortion of cash flow can make postacute #Telemedicine challenging. Ritu Thamman (@iamritu) If you don’t have reimbursement for RPM except once a month , less incentive to monitor the data. Also pts in these settings may be even more resistant to medication changes & interventions, so changes have to be done gradually& require time/patience Q4 Given the Covid-19 crisis, how has telemedicine been used for palliative care in hospital/post-acute care?

A4 Notable Responses: James Legan (@jimmie_vanagon) this isn’t palliative but the never ending RNA viral shedding and awaiting the two negative nasopharyngeal swabs in a recovering COVID pt connecting virtually can be reassuring to that particular patient wanting to get back into the swing of things #telemednow Ceci Connolly (@CeciConnolly) #COVID19 shows how important access to palliative care can be. @Intermountain/@SelectHealth have expanded use of #telehealth in palliative care, prompting growth in program. They’re planning to continue expanding program this year. @_ACHP #TelemedNow American Geriatrics Society (@AmerGeriatrics) Telehealth can help w/ focus on what matters most in #geriatrics age-friendly care. Goals should be specific, realistic, and meaningful—relevant to helping a patient what Matters most to them as individual. More from #patientprioritiescare: https://patientprioritiescare.org/wp-content/uploads/2020/04/Patient-Priorities-Care-in-an-Age-Friendly-Health-System-Telehealth-to-Address-COVID-19_PPCJF04172020.pdf

Ritu Thamman (@iamritu) #TelemedNow #Palliative #care is Key for #Covid19 pts Lack of #PPE, risk to pt families, many times dying alone & saying goodbye over FaceTime: https://www.nytimes.com/2020/03/24/opinion/coronavirus-hospital-visits.html Jagdish Patel (@jpkca) Network and staff availability of palliative care in each state is small compared to demand. There are more patients than Palliative caregivers. Having Statewide Tele-Network will be helpful to serve rural hospitals and rural population #TelemedNow Joe Rotella (JRotellaAAHPM) #telemedNow even before #COVID19, a pilot of telehospice in rural Kansas showed promise Ami Bhatt (AmiBhattMD) Right now palliative care depends on #telemedicine otherwise we risk significant moral injury when people are alone and separated from loved ones #TelemedNow Q5 How can remote patient monitoring (RPM) be implemented for post-acute care?

A5 Notable Responses: Jamey Edwards (@jameyedwards) #RPM can help bring the #hospital #home reducing need for unnecessary travel & waiting while speeding time to care & guiding to appropriate care venue instead of #ER. #CommandCenters are becoming more commonplace to monitor. Andrew Watson (@arwdd) We are just exploring the frontier of monitoring. There is so much potential here. The big question is how often you ask questions, what types of questions, and do you use peripherals? It’s all about expense, in the call center monitoring it. #TelemedNow Helen Burstin (@HelenBurstin) Great RPM resource from @LeadingAge - https://www.leadingage.org/white-papers/telehealth-and-remote-patient-monitoring-long-term-and-post-acute-care-primer-and Sandeep Pulim (@SPulim) Physiologic end points monitoring with escalation + 99457 reimbursement via telemedicine #TelemedNow @validic as a great example with #covid19 Ritu Thamman (@iamritu) RPM can be used for Post-Acute settings: ˄ drug delivery services could increase medication compliance esp among elderly ˄ use text/ed videos to improve medicine adherence ˄ using attached peripherals to pick up early pathophysiolo (sleep disturbances/O2 sats) #TelemedNow Ami Bhatt (@AmiBhattMD) MCT for post covid patients has been incredibly useful! RPM in action Andrew Watson (@arwmd) As we said earlier, I don’t think you can really deploy monitoring without machine learning. It’s not just the answers, but also the sequence of the answers and the time intervals between them. There’s so much that we have to learn here. #TelemedNow Jamey Edwards (@jameyedwards) Sp true. We need to think #MVP and then progress towards "ideal" state. Some progress is better than none and experience with MVP will inform end solution.

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