1. Introduction To Home Telehealth
WebEx
Learning Session I

2. Home Telehealth
This Introduction to Home Telehealth is the first of a four part series on home telehealth for all clinicians
This has been sponsored by your state Quality Improvement Organizations (QIO)
Welcome to the WebEx Learning Session on Introduction to home telehealth.
This Introduction to Home telehealth is the first of a four part series on home telehealth for all clinicians including nurses, therapists, and social workers.
This has been sponsored by your state Quality Improvement Organization - QIO.

3. Objectives of Introduction to Home Telehealth
Identify that home telehealth is available in many Home Care settings
State at least 2 patient disease groups that would benefit from home telehealth
State basic differences between Phone Monitoring, Telemonitoring & Teletriage
Recognize several benefits for home telehealth for patients, staff or home care agencies
By the end of this learning session, you will be able to:
Identify that home telehealth is available in many Home Care settings
State at least 2 patient disease groups that would benefit from home telehealth
State basic differences between Phone Monitoring, Telemonitoring & Teletriage
Recognize several benefits for home telehealth for patients, staff or agencies

4. What is Home Telehealth
Definition: Home Telehealth is the remote care delivery or monitoring between a health care provider and a patient outside of a clinical health facility, in the patient’s place of residence (home or assisted living residence). It is the all-encompassing term that includes phone monitoring, telemonitoring, interactive home telehealth, self-monitoring, and teletriage. Home telehealth involves the use of normal phone lines and/or other electronic communication systems for the exchange of information and data focused on health promotion, disease prevention, diagnosis, consultation, and education. There are two types of home telehealth: phone monitoring and telemonitoring.*
*Home Telehealth Reference 2005
This is the definition for home telehealth from the Home Telehealth Reference 2005.
This is very lengthy, but let’s review it so you will have a better understanding what home telehealth encompasses.
(Definition) Home telehealth is the remote care delivery or monitoring between a health care provider and a patient outside of a clinical health facility, in the patient’s place of residence (home or assisted living residence). It is the all-encompassing term that includes phone monitoring, telemonitoring, interactive home telehealth, self-monitoring, and teletriage. Home telehealth involves the use of normal phone lines and/or other electronic communication systems for the exchange of information and data focused on health promotion, disease prevention, diagnosis, consultation, and education. There are two types of home telehealth: phone monitoring and telemonitoring.
Simply this means, some type of monitoring between the health care provider and the patient in his residence.

5. Home Telehealth Is a tool to help clinicians manage their patients
Assist patients to manage themselves
Does NOT replace the clinician
Not a “physical” visit
Intervention to support reducing
Acute Care Hospitalizations
Home telehealth is a tool to help clinicians manage their patients and patients manage themselves.
It does not replace the clinician. It is to complement the skilled visits.
Home telehealth is also not considered a “physical” visit. At this time a telehealth encounter is not a billable visit.
Telehealth can be an intervention to support reducing Acute Care Hospitalizations.

6. Patient Diagnosis Good examples of common patient diagnosis are: CHF
HTN
COPD
Diabetes
Some of the most common patient diagnoses that are effectively managed using home telehealth are:
CHF
HTN
COPD
Diabetes

7. Patient Criteria Acceptance of home health monitoring
Ability to hear, answer & talk clearly on phone (phone monitoring)
Ability to read & safely connect or use telemonitoring unit (telemonitoring)
Accurately perform & communicate the necessary self-monitoring activities
There are also some patient criteria that needs to be present for home telehealth to be successful.
The patient & caregiver acceptance of home telehealth monitoring. These include:
Patient/caregiver’s ability to hear, answer, & talk clearly on phone for phone monitoring.
The ability to read & safely connect or use the telemonitoring unit.
The ability to accurately perform & communicate the necessary self-monitoring activities, such as weighing self or doing a blood glucose.

8. Self Monitoring
Periodic & scheduled collection of clinical data by patient/caregiver to measure patient’s health status
Examples: BP, weight, glucose, temperature
Data collection, with or without monitors, daily and submits data
Self Monitoring is a very important aspect of home telehealth.
The patient or his caregiver will be responsible to collect clinical data to measure his/her own health status.
Examples are BP, weight, glucose, temperature
The data collection can be with or without monitors and performed at least daily. The patient or caregiver then submits the data.
These are all functions of self monitoring.

9. Rural & Urban Usage
Home telehealth is not just for rural areas, but also appropriate for cities and everywhere in between.
It occurs between the patient’s place of residence and your Home Health Agency.
Most home telehealth systems are supported with just simple phone lines.
Some systems do require Internet connection and a some are wireless.
Usually home telehealth activities are performed daily and as needed if patient’s clinical status declines.

10. Home Telehealth Promotes
Early identification of changes in condition
Early interventions
Strong relationship with patient
Increased patient self-management and compliance
Reduction in hospitalizations & emergent care visits
Home telehealth promotes:
Early identification of changes in condition. It allows for early interventions, such as medication or treatment changes.
The patient clinician relationship is strengthened because of more frequent and improved communication. Telehealth assists the patient with self-management and compliance. Telehealth permits the patient to take an active role in managing his health status and controlling debilitating exacerbations.
Home telehealth also supports reduction in hospitalizations & emergent care visits by identifying early changes in condition, and disrupting the continuous circle of disease exacerbations and hospitalizations.
Home telehealth’s role in reducing Acute Care Hospitalizations is significant because Center for Medicare and Medicaid Services, CMS, has selected this outcome as the the national priority outcome for improvement. Agencies around the country are working on Reducing Acute Care Hospitalizations, specifically, preventable hospitalizations. Can you see the direct link between home telehealth and this national goal?

11. Home Telehealth Includes:
Phone Monitoring
Telemonitoring
Teletriage
Self-Monitoring
Home telehealth includes Phone Monitoring and Telemonitoring. Teletriage and Patient Self-Monitoring are a component of both.

12. Phone Monitoring Basic form of home telehealth
Scheduled patient encounters
Does not use electrical information processing technologies
Includes patient self monitoring
Phone Monitoring is the most basic type of home telehealth. Phone monitoring is scheduled patient encounters via the telephone between a health care provider and a patient and/or caregiver. Simply, the agency schedules phone calls to check on patients in addition to onsite visits. Phone monitoring does not use electronic information processing technologies. Patients self-monitor and report findings such as their weight, pulse, temperature, and signs and symptoms such as increased SOB, increased edema, etc.

13. Case Scenario
Mr. Tempas was referred for homecare with new diagnosis of CHF and new medications, including diuretics.
Phone Monitoring was selected after evaluating him using agency home telehealth guidelines and his ability/willingness to participate and self-monitor.
Here is a Case Scenario for Phone Monitoring.
Mr. Tempas was referred for homecare with new diagnosis of CHF and with new medications, including diuretics, such as Lasix.
Phone Monitoring was selected as an intervention after evaluating him with the agency home telehealth guidelines and his ability and his willingness to participate.

14. Case Scenario –cont-
During scheduled phone monitoring encounter, patient reports abnormal signs and symptoms indicating exacerbation of CHF.
A staff member was scheduled to call him and obtained clinical data including daily weights, and any signs and symptoms of exacerbation, such as edema, SOB, etc.
Mr. Tempas’ weight had increased 6 # in 48 hrs. He also reports significant increase in SOB & leg edema.
The nurse called the physician. PRN orders were obtained for additional Lasix and Potassium as well as an electrolyte order.
The patient was instructed by the nurse on the order change and what signs and symptoms to report to the agency. A PRN skilled nursing visit was scheduled for the following day.
This common scenario could occur in any home care agency, when phone monitoring is used. No high tech equipment is used, just a plain old phone line and scheduled telephone calls to evaluate high risk patients.

15. Telemonitoring Now we will be looking at Telemonitoring.
Telemonitoring includes the collection of clinical data such as vital signs and transmitting the data from the patient in his /her residence to the home care agency. The agency conducts a clinical review of the data and provides a response, such as calling the patient for more information or calling the physician. Telemonitoring is the more sophisticated type of home telehealth.

16. Telemonitoring May Include
Pulse oximetry
Vital signs
Weights
EKGs
Lab data
Still/video images
Other
There are many patient measurements that can be performed with telemonitoring.
These include: pulse oximetry, vital signs, weights, EKGs, and lab data, such as, blood glucoses & Protimes.
Also still or video images can capture pictures of wounds and/or edema.
Most telemonitors attach to plain telephone lines, some connect through the Internet, and a few wireless units are available at this time. Technology is just starting to explode in this field for home use.
Additionally, some units can do home messaging, such as sending reminders and patient/caregiver education.

17. Case Scenario
Mr. Walker was admitted with a new MI, secondary diagnosis of HTN & COPD and multiple new medications. The patient met the criteria for telemonitoring. He agreed to participate and self monitor. He was taught how to use the equipment the following day.
Here is a Case Scenario with Telemonitoring.
Mr. Walker was admitted with a new MI, secondary diagnosis of HTN & COPD and with multiple new medications. The admitting nurse completed a hospitalization risk assessment, and the patient met the agency’s selection criteria for telemonitoring, and he agreed to participate and self monitor.
A telemonitoring unit taken to his home the next day, and the clinician instructed him and his wife on connecting to the monitor, weighing himself, etc. They practiced it several times, and easy to read, simple instructions were placed by the equipment.
The clinician called Mr. & Mrs. Walker and walked them through the process the next day.

18. Case Scenario – cont -
Mr. Walker’s blood pressure continued to rise. The nurse contacted the physician with the readings. The patient’s plan of care was modified.
His blood pressure continued to rise over several days. The clinician in the office monitored the readings until established parameters were surpassed. The nurse contacted the physician with the readings. This permitted the opportunity for the physician to make necessary changes to help manage his disease process with medication changes, extra skilled nursing visit orders and lab work.

19. Teletriage
Teletriage is a component of both phone monitoring and telemonitoring.
Teletriage is the process your agency establishes to appropriately address health-related issues when they are submitted to the agency.
The clinician will triage the patient over the phone and select the best course of action for the patient.
This could be a call to the physician or a PRN visit. It could be as simple as some patient/caregiver education or talking a patient through some anxiety issues.

20. Case Scenario
Mrs. Tucker was instructed to call HHA if weight increased > 5lbs/48 hrs or SOB worsened. Her weight did increase as well as her SOB. She called agency and gave message to clerical staff, who left written message for primary nurse who was expected at end of the day.
Here is a case scenario for a Teletriage process.
Mrs. Tucker, a CHF patient, was instructed to call Home Health Agency if her weight increased greater or equal to 5lbs in 48 hrs or if her SOB increased.
Her weight did go up 7 lbs in 48 hours and her SOB was worse. She called the agency and a message was taken by clerical staff, who left a written message for her primary nurse. The nurse was expected into the office at end of the day.

21. Case Scenario - cont - The nurse did not come in the office that day.
Many variables could occur resulting in a significant lapse of time, and may have led to a hospitalization.
The nurse had an additional PRN patient visit added to her schedule that day and did not come into the office where the written message was left on her desk.
Many variables could occur resulting in a significant lapse of time.
This may have led to the patient’s hospitalization or resulted in difficulty in controlling her exacerbated Congestive Heart Failure.
This scenario demonstrated poor triage processes.
Is this a scenario that could happen at your agency? Or do you have a process in place to avoid this problem?
Mrs. Tucker’s case would have benefited from a structured Teletriage program.
The agency should have processes in place so patient /caregiver messages are given to the nursing manager or intake nurse, if the primary nurse is not available.
The nursing manager or intake nurse would have triaged the patient over the phone and made decisions using a multidisciplinary approach.
If the Therapist or Home Health Aide were at the patient’s residence, ask them to check patient's weight. Perhaps the therapist could have assessed the patient’s lung status for the manager.
Triage interventions are more than just scheduling a PRN nursing visit. A multidisciplinary effort is necessary to manage the patient’s health status.

22. Impacts patients, clinicians, agencies and physicians
Home Telehealth
Home Telehealth impacts patients, clinicians, agencies, and physicians
Impacts patients, clinicians, agencies and physicians

23. Patients Benefit Stay home longer, with less stress on their families
Chronic conditions are managed more efficiently
Patients/caregivers are actively involved with their own care
There are many patient benefits from home telehealth.
Patients are able to stay home longer, in their own comfortable environment.
There is less stress on their families, especially since they don’t need to travel to and from the hospital or find transportation.
Patient's chronic conditions are managed more efficiently.
Patients and caregivers are actively involved with care, and take responsibility for managing their diseases.

24. Clinicians Benefit Ability to manage patient caseload more efficiently
Impacts travel time
Improves management of more acutely ill patients
Impacts on call visits
Clinicians also benefit from home telehealth.
Nurses are able to manage their patient caseload more efficiently, allowing more time to care for their patients.
Also home telehealth can impact travel time. Rather than scheduling a PRN visit for a patient who calls and is experiencing vague signs and symptoms, ask the patient/caregiver to self monitor. This could include obtaining a blood sugar level or weight. In this situation, patients on telemonitors could have clinical data obtained along with the self monitoring.
There is a great impact in managing sicker patients. Agencies can obtain daily vital signs, especially on patients with labile readings that may need frequent medication adjustments or treatment changes.
Home telehealth may impact on call visits because of the ability to obtain real time data. If a patient calls after hours with general signs and symptoms, ask the patient/caregiver to self monitor for vital signs, weights, or other measurements. This helps the on call staff to determine what should be done for the patient.

25. Agencies Benefit
May help reduce Acute Care Hospitalizations & Emergent Care Outcomes
Enhance case management and Chronic Disease Management
Aid with nursing shortages
Can increase physician referrals
Your agency can benefit from home telehealth.
It may help improve your Acute Care Hospitalizations & Emergent Care Outcomes. Remember, Acute Care Hospitalization is the national priority outcome for CMS.
Home Telehealth enhances case management of patients. It also gives more information to better supervise Chronic Disease Management. Chronic diseases account for most of the health care expenditures. These are diseases, such as CHF, COPD, & Diabetes.
Home telehealth can aid with nursing shortages, by reducing non-necessary visits.
It can also be used as a marketing tool to increase physician referrals.

26. Physicians Benefit
Real time & objective data to promote early interventions
Increased patient satisfaction
Documentation for their Medicare billing
Marketing tool
Physicians also benefit.
Physicians have the capability of having their sickest and more unstable chronic disease patients using some type of home telehealth. Agencies provide real time objective data for the physician. Physicians will have the opportunity to intervene early before patient symptoms lead to hospitalization. Home telehealth will improve patient satisfaction. Home telehealth could also be used to help validate and document for their Medicare billing. Physicians, too, can market home telehealth for their patients.

27. “The right care for every person
CMS (Medicare)
“The right care for every person
every time”
“The right care for every person every time” is Medicare’s vision.
The use of telehealth promotes this vision by allowing the patient to remain in home while receiving more intense assessment and care.

28. Home Telehealth Binder
Forms
Protocols
Policies
Examples
Templates
References
The Home Telehealth Binder is a detailed guide for agencies in planning, developing, implementing and evaluating a home telehealth program.
It includes
Forms
Protocols
Policies
Examples
Templates and
References
It is absolutely free to download and use.

29. Resources
– web site for Medicare Quality Improvement Community and Home Health Agencies– articles, resources, tools, etc.
Home Telehealth Reference 2005 – Quality Insights of PA – available on Medqic under tools and entitled Resource Package – Home Telehealth Reference 2005
“Home Telehealth to Reduce Avoidable Hospitalizations” WebEx located on MedQIC under Telehealth
Additional home telehealth resources include:
MedQIC which is a web site for the Medicare Quality Improvement Community including Home Health Agencies. There are articles, resources, tools and presentations available to use. MedQIC is located at
Also the Home Telehealth Reference 2005 is located on MedQIC web site.
There is a WebEx recording entitled “Home Telehealth to Reduce Avoidable Hospitalizations” located on MedQIC under Telehealth. This educational session focuses on telehealth as an intervention to reduce Acute Care Hospitalizations.

30. Questions??
If you have any questions about home telehealth contact the managers/supervisors at your agency
Your QI Team may contact their state QIO with any questions
If you have any questions about home telehealth, you should contact the managers or supervisors at your agency. Your QI Team may contact their state QIO with any questions.

31. Post Test
There is a simple post-test to be completed and turned into your agency.
There is a simple post-test to be completed and turned into your own agency.

32. We hope that you have gained better understanding of some basics of
State & National QIOs
We hope that you have gained better understanding of some basics of
Home Telehealth
Watch for more educational information from your QIO including the next Home Telehealth WebEx
on Phone Monitoring
This material was prepared by Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization Support Center for Home Health, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication number: 8SOW-PA-HHQ05.16
We hope that you have gained better understanding of the basics of home telehealth in this Introduction to Home Telehealth Learning Session.
Watch for more educational information from your QIO, including the next home telehealth WebEx which will feature Phone Monitoring in more detail.
Thank you for joining us and continuing to strive towards higher level of quality of care for your patients.