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The American Journal of Managed Care August 2018
Impact of a Medical Home Model on Costs and Utilization Among Comorbid HIV-Positive Medicaid Patients
Paul Crits-Christoph, PhD; Robert Gallop, PhD; Elizabeth Noll, PhD; Aileen Rothbard, ScD; Caroline K. Diehl, BS; Mary Beth Connolly Gibbons, PhD; Robert Gross, MD, MSCE; and Karin V. Rhodes, MD, MS
Choosing Wisely Clinical Decision Support Adherence and Associated Inpatient Outcomes
Andrew M. Heekin, PhD; John Kontor, MD; Harry C. Sax, MD; Michelle S. Keller, MPH; Anne Wellington, BA; and Scott Weingarten, MD
Precision Medicine and Sharing Medical Data in Real Time: Opportunities and Barriers
Y. Tony Yang, ScD, and Brian Chen, PhD, JD
Levers to Reduce Use of Unnecessary Services: Creating Needed Headroom to Enhance Spending on Evidence-Based Care
Michael Budros, MPH, MPP, and A. Mark Fendrick, MD
From the Editorial Board: Michael E. Chernew, PhD
Michael E. Chernew, PhD
Optimizing Number and Timing of Appointment Reminders: A Randomized Trial
John F. Steiner, MD, MPH; Michael R. Shainline, MS, MBA; Jennifer Z. Dahlgren, MS; Alan Kroll, MSPT, MBA; and Stan Xu, PhD
Currently Reading
Impact of After-Hours Telemedicine on Hospitalizations in a Skilled Nursing Facility
David Chess, MD; John J. Whitman, MBA; Diane Croll, DNP; and Richard Stefanacci, DO
Patient and Physician Predictors of Hyperlipidemia Screening and Statin Prescription
Sneha Kannan, MD; David A. Asch, MD, MBA; Gregory W. Kurtzman, BA; Steve Honeywell Jr, BS; Susan C. Day, MD, MPH; and Mitesh S. Patel, MD, MBA, MS
Evaluating HCV Screening, Linkage to Care, and Treatment Across Insurers
Karen Mulligan, PhD; Jeffrey Sullivan, MS; Lara Yoon, MPH; Jacki Chou, MPP, MPL; and Karen Van Nuys, PhD
Reducing Coprescriptions of Benzodiazepines and Opioids in a Veteran Population
Ramona Shayegani, PharmD; Mary Jo Pugh, PhD; William Kazanis, MS; and G. Lucy Wilkening, PharmD
Medicare Advantage Enrollees’ Use of Nursing Homes: Trends and Nursing Home Characteristics
Hye-Young Jung, PhD; Qijuan Li, PhD; Momotazur Rahman, PhD; and Vincent Mor, PhD

Impact of After-Hours Telemedicine on Hospitalizations in a Skilled Nursing Facility

David Chess, MD; John J. Whitman, MBA; Diane Croll, DNP; and Richard Stefanacci, DO
A case study highlighting clinical and financial outcomes of an after-hours on-demand telemedicine intervention in a skilled nursing facility.

Skilled nursing facilities (SNFs) are increasingly being called upon to prevent avoidable hospitalizations. Primary care provider (PCP) bedside assessment for change of condition in SNF patients is believed to improve care and reduce unnecessary hospitalizations, but PCPs are not always available on site in an SNF. This study addresses the potential clinical and financial impacts of an after-hours physician coverage service enabled by technology, TripleCare (TC), to prevent avoidable hospitalizations.

TC was launched in a 365-bed SNF in Brooklyn, New York, in March 2015. Outcomes were tracked and evaluated for the initial year. Avoided hospitalizations were identified as such by the covering physicians and confirmed by the facility’s medical director.

Of the 313 patients cared for by the telemedicine-enabled covering physicians during the year of service, 259 (83%) were treated on site, including 91 who avoided hospitalizations as verified by a third party, and 54 were transferred to the hospital. It is estimated that the associated cost savings to Medicare and other payers exceeded $1.55 million, approximately $500,000 of which went to a managed care Medicare payer, in this 1 SNF during this period. Medicare would annually save $500,000 in an average 120-bed facility, or $4167 per bed.

Use of a dedicated virtual after-hours physician coverage service in an SNF demonstrated a significant reduction in avoidable hospitalizations.

Am J Manag Care. 2018;24(8):385-388
Takeaway Points

This case study explores the impact of having a physician available on demand for assessment and treatment of changes in medical conditions in a skilled nursing facility (SNF). Leveraging telemedicine technology specifically designed for use in the SNF, nurses can access physicians when a patient has a clinical problem. The physician can see and examine the patient within minutes and can initiate treatment or send the patient to the hospital. The program has a significant impact on:
  • Reducing hospitalizations
  • Creating significant healthcare cost savings
  • Improving nurse assessment skills
  • Providing comfort and confidence for patients and their families
  • Integration within the clinical team (primary attending physician)
The benefit of primary care provider (PCP) services in skilled nursing facilities (SNFs) has been demonstrated through many studies and embraced by several care models, such as the Special Needs Plan (SNP) and the Program for All-inclusive Care for the Elderly (PACE). Both SNP long-term care models and PACE have demonstrated improved outcomes through increased clinical services. CMS, realizing this benefit, moved to require an in-person PCP evaluation through their proposed rule in 42 CFR § 405, 431, 447, et al, Medicare and Medicaid Programs; Reform of Requirements for Long-Term Care Facilities.1 In this rule, CMS proposed to require an in-person evaluation of a resident by a physician, a physician assistant, nurse practitioner, or clinical nurse specialist before an unscheduled transfer to a hospital. This proposal was founded in the belief that in-person clinical evaluations of SNF residents reduces unscheduled transfers through improved care in the SNF.

Although this CMS proposed rule was not enacted, the principles upon which this requirement was founded (improved quality of life for SNF residents and cost savings) are being embraced by others. Specifically, new accountable care models, such as accountable care organizations, bundled payments, and Comprehensive Primary Care, are attempting to deploy bedside clinical evaluation prior to unscheduled emergency department (ED) transfers from SNFs.

On-site, bedside clinical management for a change of condition in SNF patients is believed to result in improved care and reduced avoidable hospitalizations. However, PCPs are not always available on site in the SNF, especially outside of normal workweek hours.

In an effort to evaluate the effectiveness of an after-hours telemedicine-enabled coverage service, the Fan Fox and Leslie A. Samuels Foundation provided a grant to support the integration of TripleCare (TC), a physician group specializing in caring for medically frail patients through telemedicine, into a 365-bed nonprofit SNF in Brooklyn, New York, for 1 year starting in March 2015. The TRECS (Targeting Revolutionary Elder Care Solutions) Institute oversaw the implementation of the study and the evaluation of outcomes.


Prelaunch activities included Wi-Fi upgrades in the facility, meetings between TC’s clinical team and the facility’s medical staff (medical director, attending physicians, and managed care nurse practitioners), obtaining electronic health record (EHR) read-only access, establishing an emergency medication supply to support the clinical practice, and training the nursing staff on how to use the technology and when to call TC.


When nurses identified a change in condition (ie, fever, shortness of breath, chest pain) (Table 1) during the service’s hours of operation (Monday through Thursday 6 pm to 7 am; Friday from 6 pm, all day Saturday and Sunday, through Monday at 7 am; and 6 major holidays), they placed a call to TC’s toll-free number and gave a report directly to the TC physician. The physician supplemented the patient history by accessing the facility EHR. When the patient’s clinical status warranted a physical exam, the nurse would transport the telemedicine unit to the patient’s bedside and the physician would access the unit through software installed on the physician’s computer. The telemedicine unit was designed for simplicity and use in the SNF. The nurse and physician would “meet” in the patient’s room, using bidirectional secure video conferencing to interview the patient when possible and collaboratively complete an appropriate physical exam using the unit’s digital stethoscope and 18× zoom camera. Based on the information from the nurse’s report, data found in the EHR, the patient exchange, and the physical exam, a working diagnosis was developed and a plan of care created and executed. Frequent follow-up interactions occurred as indicated and a note and order set were faxed to the facility to be included in the patient’s medical record.

The TC physician contacted the attending physician or nurse practitioner when the need arose during an encounter; otherwise, he or she provided them with a patient report the morning of the next business day following the encounter. The patient’s family member or significant other was contacted if the patient was very ill or there was a need to address advanced directives. The TC physician contacted the local hospital ED if a patient had received on-site care but did not improve or if a procedure (eg, intravenous [IV] access, gastrostomy tube replacement) or diagnostic test (eg, head computed tomography) was needed and the SNF could provide care once the procedure was completed or the test was negative.

Data analysis was done by the TRECS Institute in collaboration with the facility and TC. Census and insurance-related data were obtained from the facility billing system. Patient/resident encounter information was obtained from reports and data extractions from TC’s and the facility’s EHRs.

With regard to interoperability and the Health Insurance Portability and Accountability Act (HIPAA), although the facility and TC HIPAA-compliant EHRs were not integrated, each had HIPAA-compliant access to each other’s record system. Additionally, a secure fax was sent after each patient visit, which was uploaded into the patient’s EHR chart.

For the purposes of estimating the financial impact of the after-hours program, several assumptions were made. For long-term residents who experienced an avoided hospitalization, the facility estimated that 25% of these residents, when they do go to the hospital, qualify for the Medicare rehabilitation payment benefit for a period of 15 days.

During the period of study, the SNF introduced no new significant delivery system changes and had the same director of nursing and medical director.


The project took place from March 2015 to March 2016. The facility’s bed census remained constant at 365, of which 44 were dedicated short-term beds. From 2014 through 2016, the facility occupancy ranged from 97.4% to 98.3%, with the number of admissions per year at 957, 1045, and 947 in 2014, 2015, and 2016, respectively. TC physicians completed 313 encounters with a wide variety of diagnoses (Table 1). Of these encounters, 105 were identified by the TC physician as being avoided hospitalizations. Avoided hospitalizations are defined as those episodes of care that would have been expected to result in ED evaluations if routine after-hours telephonic care with the attending or their covering physicians were called to provide care. A retrospective review by the facility’s medical director, who was not associated with TC, of all encounters identified by the TC physicians as avoided hospitalizations resulted in a consensus that 91 of the encounters actually represented avoided hospitalizations. Of the 313 total encounters, 54 (17%) resulted in ED transfers and 259 (83%) were treated on site. The preceding year, 490 patients were hospitalized from the facility compared with 402 during the study period, representing an 18% reduction in the number of patients transferred to the hospital.

Payers were the major financial benefactor of TC. Treating patients on site eliminated Medicare’s payment to the hospital, the emergency ambulance, and the facility for the skilled days that some of the patients would have received following a 3-day qualifying Medicare acute care stay. Of the 91 avoided hospitalizations, 31 were individuals whose SNF stay was covered under a Medicare Advantage plan, 57 were dual-eligible individuals (those enrolled in Medicare and Medicaid) whose SNF stay was covered under Medicaid, and 3 were privately paid. Of the 57 individuals covered by Medicaid who avoided hospitalization, the facility estimated that, based on their clinical status, 14 (25%) would have been eligible for Medicare benefits had they experienced a hospitalization and returned to the facility. Because they remained in the SNF, they did not convert to Medicare, resulting in Medicare savings. Based on the 91 patients with avoided hospitalizations, the total Medicare savings were estimated to be more than $1.55 million in this 1 SNF during this period (Table 2). According to the HHS Office of Inspector General in 2013, the average hospital admission cost in Brooklyn, New York, was $15,000.1 This translates to an annual Medicare cost savings of $500,000 in an average-sized SNF of 120 beds, or $4167 per bed.

The SNF paid $60,000 annually for this service (including the technology). This fee was offset by preventing hospitalizations; helping the facility maintain census, especially in its short-term rehabilitation unit; capturing lost Medicaid days while a patient was hospitalized; and a decrease in transportation costs. It is estimated that the facility netted $20,000 above the cost of the program. The facility continues to support this clinical service.

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