Cobble Hill Health Center “Reducing Avoidable SNF to Hospital Admissions and Readmissions by Implementing a Virtual Physician Service, Enabled through Technology” Grant Period: January 1, 2015 through February 28, 2016 Final Presentation July 11, 2016 Donny Tuchman, NHA John Whitman, MBA, NHA Administrator Executive Director The TRECS Institute Targeting Revolutionary Elder Care Solutions

Organization Background Cobble Hill Health Center is a 364 bed skilled care facility offering residents of New York City a wide range of skilled, rehabilitative and supportive services. Cobble Hill is a non profit organization that has achieved a 4 Star Medicare rating. The management team of Cobble Hill expressed concern over the industry wide accepted practice of sending nursing facility residents to the hospital during nights, weekends and holidays due to the inability to differentiate those residents that truly needed to go to the hospital from those that can and should remain and be treated at Cobble Hill Health Center.

Program Background On November 18, 2014, The Fan Fox and Leslie R. Samuels Foundation awarded Cobble Hill Health Center a grant to evaluate the ability of a virtual physician service, enabled through technology to reduce avoidable SNF to hospital admissions. TripleCare, a well established leader in telemedicine was selected to provide virtual physician services during nights, weekends an holidays. The TRECS Institute, a non profit dedicated to improving care for seniors and saving money for our health care system assisted in developing the grant application and coordinated the overall research and developed the draft findings a recommendations that were reviewed and supported by Cobble Hill management team and ultimately presented to The Samuels Foundation.

Program Goals and Results To prove the effectiveness of using a virtual physician service in reducing avoidable SNF to hospital transfers from Cobble Hill by at least 30% To quantify the economic impact on Cobble Hill through reduced admissions and readmissions To estimate the national impact this service could have on the overall health care system if adopted by all skilled care facilities across America

Results TripleCare services were provided for one full year starting March 1, 2015 and extending to February 28, 2016 TripleCare’s physicians were contacted by Cobble Hill staff as the “physician on call” on a total of 313 residents because of changes in the resident’s medical condition A total of 105 residents (33.5%) from this total were identified by TripleCare as “avoiding” admission as a direct result of the TripleCare intervention. The charts from these same residents were reviewed by Cobble Hill’s Medical Director and 91 (29%) were confirmed as “absolute” admissions if TripleCare had not intervened.

Additional Results Quality of Life Impact Sending a vulnerable senior to the hospital is anything but “quality” in our healthcare system Typically long delays being seen in the emergency room Nationally, 60 to 70% of all nursing facility to hospital transfers, when viewed in retrospect, never should have occurred which unnecessarily leads to: Confusion and delirium which is associated with higher mortality High falls risk Increased incidence of skin ulcers Increased exposure to hospital acquired infections The results of this study prevented at least 91 seniors from being admitted to local hospitals and exposed to these very serious and totally unnecessary and avoidable side effects.

Economic Impact Projected “Net System” Savings: $1,132,957 By preventing 91 hospital admissions, this program proved to have significant economic implications: For Cobble Hill Health Center: A $96,944 increase in revenue in study year This number was reduced by $60,000 to $36,944 to recognize the cost of the TripleCare Service for future years although paid for by the grant in this study year For the Medicare Program: A projected annual savings of $1,307,005 million dollars For New York State Medicaid Program: A projected increase in spending of $137,105 Projected “Net System” Savings: $1,132,957

National Economic Implications Based on actual findings at Cobble Hill Health Center, if 25% of America’s 15,700 skilled nursing facilities were to implement and utilize a virtual physician service, it could produce a net savings for the Medicare program in excess of: $1.29 billion dollars a year

Additional Recommendations CMS should consider increasing payments to SNFs for utilizing a virtual physician service and/or establishing a shared savings program similar to BPCI. CMS should develop a method to share savings with state Medicaid programs because each saved admission, while saving money for Medicare, results in added spending for the state Medicaid Program. CMS should consider requiring Medicare Advantage Programs to also encourage use of virtual physician services . CMS and State Medicaid Programs should consider requiring Medicaid Managed Care Programs to incorporate virtual physician programs.

Additional Recommendations Virtual physician evaluation of all palliative care seniors in nursing facilities should be mandatory followed by a virtual visit or conference call with family to fully describe the realities of their loved ones medical condition with the goal of preventing an unnecessary hospital admission. CMS should consider providing specialty consults in skilled nursing facilities through telemedicine with the goal of increasing access, preventing delays in treatment and reducing downstream medical expenses

Example #1: Resident Fall 86 year old woman status post hip fracture and stroke fell out of bed. Was found on the floor screaming. Historically, 911 would have been called and patient immediately taken to the ER TripleCare was called and physician talked directly to the woman and calmed her down. The TripleCare physician talked the facility nurse through a careful examination of the woman’s extremities to assure nothing was broken. The woman had no pain after the exam, was relieved and placed back in bed. The resident was thankful and was not sent to the hospital (avoiding what would have been a 10 hour ED visit, possible admission, unnecessary exposure to potentially serious additional risks and significant additional costs to our health care system )

Example #2: End of Life Care 89 year old male with end stage Parkinsonism s/p recent hip fracture and pneumonia. Unconscious and non responsive with high fever and low blood pressure Family insisting on sending their father to the hospital TripleCare physician examined the resident, started treatment for urosepsis and coordinated a conference call with five children in multiple states to discuss the realities of their father’s medical condition and options for care Through open and honest communication was able to explain to the family what their father’s prognosis was and what would happen if their father was admitted to the hospital Because the TripleCare physician was able to win the families trust, they agreed that their father would stay and be cared for in his final hours in the skilled nursing facility. This example is just one of the many reasons why expanding virtual physician services to include Palliative Care consults followed by family discussions prior to the final medical crisis has such merit

Financial Summary Project expenses of this study were all within the original grant budget. The economic impact of reducing avoidable hospital admissions was found to be significant. The breakdown of those avoiding hospitalization was not as expected. Typically, the number of short stay Medicare patients represents the largest component of the avoided admissions. In this study, 57 our of the 91 (63%) were traditional Medicaid long term care residents. While preventing these Medicaid residents from being hospitalized had major quality of life and Medicare savings implications, it also suggests that additional opportunities remain at Cobble Hill to more aggressively pursue the short stay population. Approved Budget for the grant dollars only. Should include approvals made during grant term.

Continuation of the Program Cobble Hill Health Center is pleased with the serviced provided by TripleCare and intends to utilize their services post grant. Having physician coverage nights and weekends has proven very beneficial. When those physicians also have the ability to remotely examine a patient, the value is exponentially multiplied.

Replication / Expansion Plans With the grant period over, our focus is now going to be on expanded adoption, utilization and analytics. Having proven how effective TripleCare can be, we would like to increase utilization throughout the facility. At the same time, we would like to continue to analyze data, to ensure maximum benefit from the program. It is also the goal of Cobble Hill, TripleCare and The TRECS Institute to disseminate the results of this study across the industry with the goal that more SNFs will incorporate a virtual physician service into their model helping to reduce avoidable SNF to hospital admissions.

Additional Efforts Cobble Hill’s Management Team is committed to further improving the results of this study by: Aggressively pursuing a higher use of this service with Medicare short stay residents Expanding the use with end of life residents and family Explore the possibility of utilizing TripleCare services on a 24 hour a day, 7 day a week basis Exploring possibilities of using virtual physician services for specialty consults for improved and more timely access to care for those in need

The management team at Cobble Hill Health Center, The TRECS Institute and TripleCare wish to thank The Fan Fox and Leslie R. Samuels Foundation for their generous support of this study. Donny Tuchman, NHA David Chess, MD Administrator Co-founder & Medical Director Cobble Hill Health Center TripleCare, LLC. Dtuchman@cobblehill.org dchess@triple.care John Whitman, MBA, NHA Executive Director The TRECS Institute johnwhitman@theTRECSinstitute.org