1. Using Telehealth to Improve Quality, Health Outcomes and Costs of Care in Long-Term Care Settings
2017 National Consumer Voice for Quality Long-Term care conference November 6th, 2017

2. Today’s Speakers:
Andrew Broderick Research Director, Center for Innovation and Technology in Public Health, Public Health Institute, Oakland, CA Deanna Larson Chief Executive Officer, Avera eCARE, Sioux Falls, SD Ilene Henshaw Director, Health and Family Team, State Advocacy & Strategy Integration, AARP, Washington, D.C.

3. Goals:
Learn about promising practices, including the use of teleconsultation for remote access to specialists or for emergency care, as well as other technologies;
Engage in dialogue regarding the use of telehealth in LTC settings, its availability, and barriers to more widespread adoption; and
Better understand and envision the resident and family experience.

4. Why Are We Engaging on Telehealth?
Intensity of advocacy in state legislatures
Discussions largely driven by providers, payers, technology developers
Discussions largely focused on acute care
Need to broaden the conversation: To help people live more independently in their homes and to support family caregivers.
There have been hundreds of bills dealing with TH introduced in just about every state legislature last year and this year. This is an area of incredible activity. However, these discussions have been primarily driven by providers, payers and technology developers. The voice of the consumer and especially that of the older consumer has been relatively quiet. We see great opportunities here to insert our voice.
And so far, the discussion around TH has been largely focused on acute care --- services and settings.
We are engaged expressly to change all that. We think that TH holds the promise of multiple solutions to help people access not only the health care they need, but also the services and supports they need to live in their homes and communities as independently as possible. And, the services and supports that will make it easier for family caregivers to care for their loved ones.
We want to help make the voices of our 38 million members and the nations' 40 million family caregivers heard on this issue. We see our engagement as a way to encourage lawmakers and the industry to consider the needs and preferences of older consumers and especially family caregivers as they address telehealth in their states.

5. What Are AARP’s Key Issues at the State Level?
Enactment of telehealth laws or regulations that promote an individual’s access to health and home and community- based care services and choice of providers, such as:
Removing barriers that limit or prevent accessing care via telehealth
Allowing providers to practice across state lines through the Enactment of Interstate Licensure Compacts for physicians, APRNs or RNs
Requiring benefit parity in private health plans, Medicaid or state employee health plans
Allowing reimbursement for remote patient monitoring
Inclusion of family caregivers in telehealth legislation, including task forces and implementation
AARP’s Organizational goals for state advocacy on Caregiving includes telehealth.
Most importantly, is our overarching goal to remove barriers that limit or prevent older individuals and family caregivers from benefiting from TH.
You’ll notice that the overarching TH goal is broad and bulleted below are some suggested areas for state engagement.
They include: READ

6. 2017-through June-Caregiving map

7. TELEHEALTH AND LONG-TERM CARE Using Telehealth To Improve Care Quality, Health Outcomes, and Cost of Care Consumer Voice Annual Conference
Andrew Broderick, MA MBA Center for Innovation and Technology in Public Health
Oakland, California

8. 8
PHI internal use only 8

9. PUBLIC HEALTH INSTITUTE

10. About The Public Health Institute
supports evidence-based
research and programs as well as
policy advocacy to address today’s
public health challenges.
PHI drives a diverse body of work that cuts across typical institutional and research silos to improve health and quality of life in California, across the U.S. and around the world.
Learn more at: 10 10

11. PHI: Technology and Innovation
At the forefront of promoting technology use to transform public health practices:
Focusing on health equity by examining the role of technology in improving the health of vulnerable and underserved populations.
Evaluating which technologies are effective at improving health outcomes, changing health behaviors and lowering health care costs.
Promoting the adoption of proven technologies by disseminating results to address policy and financing barriers to implementation.

12. THE TELEHEALTH SECTOR

13. 13

14. Telehealth’s Potential Benefits and Reach
Telehealth offers the potential to transform healthcare delivery by:
Overcoming geographical distance
Facilitating timely access
Improving service efficiencies
Telehealth supports the ability to perform clinical activities remotely:
Enhancing interaction between professionals
Supporting provider-to-provider training
Enhancing service capacity and quality
Enabling direct patient-provider interaction
Monitoring patient health and activities
Managing patients with multiple chronic conditions
Physician to Patient
Peer to Peer
Physician to Physician re 14

15. Telehealth Services Come in a Variety of Forms
TARGET APPLICATIONS
Primary Care
Specialty Consultations
Behavioral Health
Physical and Occupational Therapy
Home Monitoring
Chronic Disease Management
Health Education
SERVICE MODALITIES
Store-and-Forward (asynchronous)
Live and Interactive Video (synchronous)
Remote Patient Monitoring
Patient Engagement Mobile Apps
USER SETTINGS
Medical Centers
Outpatient Hospital Departments
Physicians Offices
Homes
Schools
Workplaces
Community Service Settings
Wherever Consumer Is

16. ..... With Different Value Propositions, Maturity Levels, and Business Models
Large health systems are developing hospital-based (e.g., telestroke, tele-ICU, telehospitalist care) and basic care services (e.g., behavioral health, primary care, case management) for internal use as well as marketing to other entities (e.g., physician practices)
Commercial insurers are covering telehealth services through contract with vendors in areas of basic medical (e.g., primary care) and specialty care (e.g., behavioral health, dermatology, oncology care), and rarely limit use by geographic location or originating site.
Employers are developing their own services for employees or hiring commercial insurers and health systems to provide these services. Walmart, for example, offers in-store clinics for both employees and customers.

17. Health System Milestones in Telehealth Adoption
Veterans Administration provided telehealth services to more than 702,000 Veterans during fiscal year 2016, with nearly 45% of visits involving Veterans living in rural areas.
Kaiser Permanente currently provides more virtual encounters (52% in 2016) than in-person encounters through online portals, virtual visits or the health system’s apps.
National Business Group on Health reported that 1/3 of employers offered telehealth behavioral services in 2016, and that 90% planned to make telehealth services available in states where allowed.
Source: US Department of Veterans Affairs
Source: US Department of Veterans Affairs

18. Technology Advances Enabling Telehealth
Devices
Sensors &
Services
Mobile, Apps
& Gaming
Platform technologies and services for remote delivery of and access to health care resources
Novel sensing devices for monitoring activity, physiology, location, and environmental conditions
Technologies and strategies to engage consumers in digital behavior change interventions
Smartphone
Wearables
Advanced Data
Analytics
Desktop PC
Connected Health
Tablet Computer
Live Interactive Video
Patient Engagement Apps
Remote Patient Monitoring 18

19. Consumer Comfort: Live and Interactive Video
Rock Health reports video-based telehealth adoption by consumers more than tripled from 7% in 2015 to 22% in 2016, and 83% of consumers express moderate or extreme satisfaction with the service modality.
A 2017 American Well consumer survey found that two-thirds of consumers are willing to see a doctor over video, and that 20% would switch providers if their current doctor does not provide video visits
Physician to Patient
Peer to Peer
Physician to Physician re 19

20. Barriers to Telehealth Adoption
American Telemedicine Association’s 2017 Leadership Survey reports that inadequate coverage and payments (71%), licensure (53%), and resistance to change (50%) are likely to hinder accelerated growth.
Medicare telehealth coverage restrictions limit the geographic and practice settings in which beneficiaries may receive services, while CMS leaves individual states to determine any Medicaid restrictions and limitations.
Commercial insurers have greater flexibility than public payers, but are subject to state law requirements for parity in covered services (although not necessarily the reimbursement amount).
Interstate Medical Licensure Compact introduces a voluntary expedited pathway to licensure for qualified physicians who wish to practice in multiple states.
American Hospital Association recommends lowering the administrative burden and increasing the funding cap of FCC Rural Health Program to ensure that all rural facilities have access to broadband services.
Physician to Patient
Peer to Peer
Physician to Physician re 20

21. Evidence of Efficacy is Mixed: More Targeted Research Needed
Physician to Patient
Peer to Peer
Physician to Physician re 21

22. NQF Evaluation Measures Framework
NQF recommendations for measuring the quality of telehealth services organize measure concepts into six key areas having the highest priority overall for measurement:
Travel
Timeliness of Care
Actionable Information
Added Value of Telehealth to Provide Evidence-Based Best Practices
Patient Empowerment
Care Coordination
Peer to Peer re 22

23. TELEHEALTH AND LONG-TERM CARE

24. Medicare Payment for Telehealth Services
Peer to Peer re 24

25. Telehealth Use in Medicare and Medicaid
Utilization: In ,000 Medicare beneficiaries or 0.2% Part B FFS used telehealth services (500% growth )
Typical User: Beneficiary tends to be young, disabled, dually eligible and to reside in rural area.
Geographic focus: 10 states accounted for 42% of visits with SD, IA, ND accounting for highest use
Common visits: evaluation and management services (66%) and psychiatric visits (19%)
Drivers: potential to improve or maintain quality, alleviate provider shortages, increase patient convenience.
Barriers: payment, coverage restrictions, and infrastructure requirements.
Medicaid states that are generally more rural than urban use telehealth more frequently. re 25

26. Medicare Telehealth Requirements Waived for Selected Models and Demonstrations
CMS has various efforts underway that have the potential to expand the use of telehealth in Medicare
Peer to Peer
Eight models and demonstrations
Certain Medicare restrictions waived
Access in urban areas and homes
Cost-based payments possible re 26

27. Hospital and SNF Use by Medicare Beneficiaries who Reside in Nursing Facilities
Peer to Peer
Hospital admission rates of long-stay NF residents are generally declining, but a large degree of variation in rates across facilities suggests opportunities to reduce unnecessary use even further.
Implementation of Medicare’s Hospital Readmission Reduction Program has led to the use of practices to promote care coordination and quality that have led to lower readmissions for PAC beneficiaries
Common practices include medication review and advance care planning, palliative care programs, communication tools, use of NPs to provide direct patient care, telehealth, and skill training for staff.
Implementation of these same care coordination and quality practices that lower readmissions of post-acute care beneficiaries could be used to reduce hospital admissions of long-stay NF residents. re 27

28. The Evidence Base is Limited but Promising
Hospitalization rates declined 9.7% in intervention facilities (5.3% among facilities not receiving the service).
There was a significant decline of 11.3% in hospitalization rates at facilities that were deemed “more engaged” with the service.
Medicare could expect an average of about $151,000 in savings per nursing home per year based on based on the more-engaged facilities, .
The annual cost of the telemedicine service was $30,000 per nursing home, suggesting that there could be $120,000 in net savings per facility. re 28

29. Telehealth in Skilled Nursing Facilities
Identified 3 Telehealth Applications for SNF settings:
Teleconsultation in Emergency Care—enables a 24/7 consult between SNF staff and emergency department (ED) physician to conduct a patient assessment to determine if an ED visit is necessary
Teleconsultation with Specialists—enables remote communication between a SNF provider and specialist for the monitoring, evaluation, and management of clinical conditions
Remote Patient Monitoring—enable monitoring of resident safety and wellness through measuring and tracking indicators, including movement, vital signs, and sleep quality, among others.
Peer to Peer re 29

31. The Future of Long-term Care
in a review of the future of long-term care over the next decade:
Post-acute care and telemedicine were noticeable for their absence among the top ten clinical topics found in PubMed during 2015.
Technology in the form of telemedicine and the introduction of more functional EHRs are expected to play a major role in the long-term care future.
This will require attention to possible challenges with workflow integration and documentation into electronic record management systems.
Peer to Peer re 31

32. NH Provider Perceptions of Telemedicine for Reducing Potentially Avoidable Hospitalizations
Physician to Patient
Peer to Peer
Physician to Physician re
Source:
Source: Driessen, J. al. “Nursing Home Provider Perceptions of Telemedicine for Reducing Potentially Avoidable Hospitalizations.” JAMDA 32

33. NH Provider Attributes of Telemedicine for Reducing Potentially Avoidable Hospitalizations
Physician to Patient
Peer to Peer
Physician to Physician re
Source:
Source: Driessen, J. al. “Nursing Home Provider Perceptions of Telemedicine for Reducing Potentially Avoidable Hospitalizations.” JAMDA 33

34. Bringing Geriatric-led Care to Long-Term Care
Consumer Voice Conference
Bringing Geriatric-led Care to
Long-Term Care
Deanna Larson, CEO Avera eCARE
Title slide for eCARE Overview

35. BACKGROUND
Avera Health
Avera is a health ministry rooted in the Gospel. Our mission is to make a positive impact in the lives and health of persons and communities by providing quality services guided by Christian Values.
Mission
Our mission and summary of our history.

36. Vision for Telemedicine
OUR JOURNEY
Vision for Telemedicine
Telemedicine is Healthcare –
Needs to be integrated, not separated
Workforce Sustainability -
Recruitment & retention
Quality Access to Care –
Extend expertise & resources
Research
Investment – Educate and inform on telemedicine

37. eCARE’s Impact Saving Lives Reducing Costs Improving Workforce
OUR JOURNEY
eCARE’s Impact
Saving
Lives
Reducing
Costs
Improving
Workforce
Impacting
Communities
Share the major milestone’s with the development of eCARE and how Avera grew a virtual hospital.

38. Model of Senior Care AVERA eCARE
Show the model of care and describe how eCARE works

39. Senior Care Equipment AVERA eCARE
Show the model of care and describe how eCARE works

40. Changing Expectations for LTC
AVERA eCARE
Changing Expectations for LTC
Increasing Aging Population
Improving quality & decreasing costs
Staffing shortages
Sicker residents & higher acuity
Reimbursement
Specialized geriatric care needed
Pressure to reduce ED transfers
Multiple preferred partners

41. INDUSTRY CHALLENGES
Senior Population
15%
50%
Older adults constitute 15% of the population
Older adults constitute ~50% of health care costs
U.S. Department of Health and Human Services. (2014). A Profile of Older Americans. Washington, DC.

42. Hospitalizations 46% Avoidable 5 Million Hospitalizations Annually
INDUSTRY CHALLENGES
Hospitalizations
Acello, Barbara. Ending Hospital Readmissions: A Blueprint for SNFs. HCPro. March 2011.
5 Million Hospitalizations Annually
46% Avoidable
Each hospitalization costs an average of $11,255 or
$15 Billion annually

43. Geriatric-Led Care Results:
INDUSTRY CHALLENGES
Physicians
By 2020, the U.S. will be lacking:
45,000 primary care physicians
46,100 surgeons and medical specialists
20%
…of Americans older than 65 see 14 or more physicians and average 40 physician visits per year
The American Geriatrics Society. The Demand for Geriatric Care and the Evident Shortage of Geriatrics Healthcare Providers. March 2013.¹
Marquez, Len. Physician Shortages to Worsen Without Increases in Residency Training. AAMC. ²
One Geriatrician for every 2,200 elders
Geriatric-Led Care Results:
133 Fewer ER visits per 1,000
10% Reduction in cost of care per year

44. Census Mix Medicaid Private Insurance Medicare INDUSTRY CHALLENGES
(27-29%)
Medicaid
(55-57%)
Medicare
(12-14%)
?Reference

45. Nursing Staff/Facility Impact
LONG-TERM CARE
Impact of eCARE – Senior Care
Resident Impact
Increased access to urgent care services
Timeliness of care
Reduced re-hospitalizations
Reduced unnecessary ER visits
Nursing Staff/Facility Impact
Nursing staff recruitment, satisfaction, and decreased turnover
Resident and family satisfaction
Decrease transportation costs
Decrease pharmacy costs
Maintain census
Higher acuity patients
Preferred partnerships (Medicare Advantage, ACO, Bundles, Post Acute Discharges)
Decrease in paperwork, phone calls, and faxing
Communicate with PCP when intervention occurs
Physician Impact

46. Using CMMI HCIA Innovation to Transform Long-Term Care
Definition: Represents the monthly rate of unplanned transfers to the ED/Hospital per 1000 resident days.
Analysis: Positive trends in unplanned transfers since March 2015.
The project described was supported by Grant Number 1C1CMS from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the independent evaluation contractor.

47. Estimated Medicare Cost Savings PBPM
eCARE SENIOR CARE
Resident Impact
7,100 Residents Impacted
$342
Estimated Medicare Cost Savings PBPM

48. Access to Geriatricians
eCARE SENIOR CARE
Solutions to Improving Care
Payment Structure
Physician-Focused Payment Model Technician Advisory Committee (PTAC)
Aging Population
By 2050, 1/5 of the total US population will be elderly* - extends access & coverage to services
Centers for Medicare & Medicaid Innovation awarded eLTC $8.8M
Innovation
Lack of access attributes to only
One Geriatrician for every 2,200 elders
Access to Geriatricians
*Congressional Budget Office

49. Avera eCARE Acute & Post Acute Emergency ICU Care Pharmacy Senior Care
ABOUT US
Avera eCARE
Acute & Post Acute
150
Sites
Oct. 2009
Emergency
36 Sites
Aug. 2004
ICU Care
101
Nov. 2008
Pharmacy 55
Jan. 2012
Senior Care
4 Sites
Apr. 2012
Correctional Health
2017
Hospitalist
Behavioral Health
Ambulatory
190 Sites
Nov. 1993
Consult 13
Mar. 2015
School Health
Specialty Clinic
Jul. 2015
AveraNow
8469 Enrollees
1 Site
1 Site

50. Avera eCARE 350+ Sites 14 States
ABOUT US
Avera eCARE
350+ Sites
14 States
Serving 13% of Critical Access Hospitals (170/1332) in the United States

51. Notice/Acknowledgement
DISCLAIMER
Funding Opportunity
Notice/Acknowledgement
The project described was supported by Grant Number 1C1CMS from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the independent evaluation contractor.
Josh

52. Thank You! Deanna Larson Avera eCARE Chief Executive Officer
For more information, please visit:

53. Questions/Discussion