Telehealth for Hospice and Palliative Care

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Telehealth for Hospice and Palliative Care
Realities and Challenges

• Deborah A. Randall, JD Consultant
• 202-257-7073
• law_at_deborahrandallconsulting.com
• www.deborahrandallconsulting.com

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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
  gt62,000 homecare.
• Sensoring movement analysis, falls detection,
  behavior tracking, dementia safety, communication
  to family

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Scope and Payers

• Home-based telehealth mostly chronic care
  management gt 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

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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 telehealthhospice
  provision silent

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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

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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.

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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

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HMSA Ambulatory MD/Home

• Hawaii Medical Services Assn Jan 09
• Online Care connects, 24/7, patients and
  physicians via the Internet or telephone1st in
  the nation.
• 10/45 for 10 minutes interaction
• Physicians can be anywhere service is across
  all islands

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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

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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.

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DHisease Management
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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

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MD Acceptance - CCCP
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What are the New Directions?

• Tele-rehabilitation Falls prevention
• Tele-mental and behavioral health
• Continuous monitoring diabetes cardiac
• Impaired Alzheimers dementias

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Telehealth and Rehabilitation

• Distanced assessments
• Robots in SNFs
• Telestroke gt telerehab
• Wii units in senior living facilities
• Remote monitoring for falls anticipation
• Traumatic brain injurywounded warrior

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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

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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 mHealths immediacy palliative?

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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?

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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

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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

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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

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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

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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

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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.

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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.

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Expanding a model, contd.

• Goals for improved communication about
  discomfort, support for decision makingproblem
  resolution attention to caregiver needs.
• Outcomes measurements expanded from the curent
  gt DNR or intubate orders ltinpatient admissions
  with no difference in survival.

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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

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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

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Attention to Legal Concerns

• Licensure of palliative care provider
• Liability and Consent
• Privacy and confidentiality
• Security of Communication

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Thank You!

• Deborah Randall, JD
• Health Law Attorney
• Telehealth Consultant
• 202-257-7073
• law_at_deborahrandallconsulting.com
• www.deborahrandallconsulting.com