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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
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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.
DISCUSSION

As each segment of the healthcare industry is subject to regulatory and reimbursement challenges, the nursing home industry is experiencing a torrent of change and is struggling to remain relevant and financially sustainable. Hospitals have experienced progressively higher financial penalties and payment reductions based on rehospitalization rates,2 and nursing homes are now experiencing similar penalties and incentives.2,3 To reduce the likelihood of readmissions, hospitals are narrowing the network of nursing facilities to which they discharge patients. These decisions are driven by star ratings and facilities’ return-to-hospital (RTH) rates. There are many factors impacting facility RTH events (eg, patient acuity, comorbidities, facility preparedness, nursing home staff turnover rates, and availability of healthcare practitioners to care for acutely ill patients “in house”).4 To provide safe and advanced medical care for postacute patients within the SNF, many facilities have invested in their physical infrastructure, creating specialized areas with additional staffing, and have embraced the on-site nurse practitioner model. There has been a broad acceptance and integration of Interventions to Reduce Acute Care Transfers,5,6 and other initiatives that have reduced the RTH rates from 23% to 8%,7,13 but unnecessary rehospitalizations continue to be common.8,9

The most common diagnoses resulting in hospital readmissions include congestive heart failure, pneumonia, sepsis, and chronic obstructive pulmonary disease.10 This reflects our experience. However, patients’ conditions are in fact much more complex. An example was a 78-year-old man admitted to the facility after falling and sustaining a hip fracture. The patient presented with a fever of 102°F (39°C), lethargy, and low oxygen saturation. He had a history of advanced parkinsonism and recurrent pneumonias and diabetes, and he was requesting aggressive life-sustaining interventions. The patient was seen and examined, conversations with nurses and the patient’s family proceeded, and care was initiated with IV hydration and IV antibiotics (both started within 2 hours of visit) and included a discussion of advanced care directives. The patient was monitored closely with frequent vitals and follow-up. This patient was successfully treated on site and was designated as “do not resuscitate or hospitalize.”

Telemedicine has been utilized in many settings over the past several decades, but there is limited evidence of it being applied to the care of SNF postacute patients. In a study by Grabowski and O’Malley, telemedicine was shown to be a promising intervention for SNF patients; however, the results were not statistically significant.11 Embedding an after-hours coverage service enabled by telemedicine, such as the service provided by TC, to complement the daytime primary care practitioner presence in the SNF was shown to reduce rehospitalizations and has the potential to increase staff performance (data not reported here).12 This intervention provided on-the-job training in physical assessment skills to the nurses.

We did not study the impact of our intervention over the following 7 days at this facility. However, this was studied in 2 unrelated (unpublished) populations wherein 85% to 92% of patients treated on site remained in the facility or went home over the following 7 days.

CONCLUSIONS

As nursing facilities are called upon to care for higher-acuity patients and drive better clinical outcomes at a fraction of the cost of a hospitalization, systems that deliver quality physicians to the bedside at times of change of condition will be required. This study found that use of a dedicated, virtual, after-hours physician coverage service in an SNF demonstrated a significant reduction in Medicare costs (acute inpatient hospital, subacute care, and transfer costs). These efforts present an opportunity to improve both clinical outcomes for older adults in need of long-term and postacute services and financial outcomes for those providing the care. Of note, the TC physicians were exclusively dedicated to providing care to our client facilities and were not providing medical care simultaneously in other settings (ie, working in the ED or rounding in the hospital).

This study demonstrated that the health plan (payer) is the major financial benefactor from this after-hours medical care program. Ninety-one prevented admissions resulted in $1.55 million in savings over the course of 1 year in 1 nursing facility. Extrapolating these findings to 30% of America’s 1.7 million nursing facility beds could produce actual savings for the Medicare program in excess of $1.5 billion per year. Although the payer was significantly advantaged by preventing hospitalizations, the SNF also showed modest financial gains by helping to keep their rehabilitation beds filled (by preventing hospitalization and being a desirable referral source to their referring hospital systems and payers) (unpublished data). As the CMS 2% hospitalization penalty to the SNFs engages in 2018, the financial consequences of hospitalization will become even more marked. 

Acknowledgments

The authors thank all the nurses and patients at Cobble Hill Health Center who participated in this study. Particular thanks to Donny Tuckman, the executive director at Cobble Hill, whose leadership was critical to the study; Dr Himanshu Pandya, the medical director at Cobble Hill, who reviewed every patient seen for purposes of this study and provided the appropriate categorization of the patient encounter; and Evan Rakowski, the chief operating officer of TripleCare, who ensured the successful implementation of the program.

Although portions of this manuscript were part of a doctoral thesis, neither the full manuscript nor any component parts have been or will be submitted elsewhere for publication.

Author Affiliations: Tapestry Telehealth (DCh), Stratford, CT; TRECS Institute (JJW), Chalfont, PA; The Wharton MBA Health (JJW), Philadelphia, PA; TripleCare (DCr), Long Island City, NY; Jefferson College of Population Health, Thomas Jefferson University (RS), Philadelphia, PA.

Source of Funding: This case study was funded by the Fan Fox and Leslie A. Samuels Foundation to the TRECS (Targeting Revolutionary Elder Care Solutions) Institute. The TRECS Institute contracted with TripleCare and Cobble Hill Health Center. TRECS managed the project and performed the research and analysis. Both TripleCare and Cobble Hill Health Center contributed in kind to this study.

Author Disclosures: Dr Chess is a board member, employee, and equity holder of TripleCare and Tapestry TeleHealth. Dr Croll is employed by TripleCare and owns stock in TripleCare as part of her compensation. Dr Stefanacci has no ownership interest in TripleCare but has ownership interest in a nursing facility in which TripleCare is deployed. The remaining author reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DCh, JJW, DCr, RS); acquisition of data (JJW, DCr); analysis and interpretation of data (DCh, JJW, DCr); drafting of the manuscript (DCh, DCr, RS); critical revision of the manuscript for important intellectual content (DCh, DCr, RS); statistical analysis (DCr); obtaining funding (JJW); administrative, technical, or logistic support (DCr); supervision (DCh, RS); and physician management (DCh).

Address Correspondence to: John J. Whitman, MBA, TRECS Institute, 1129 Petrick Ln, Chalfont, PA 18914. Email: JohnWhitman@theTRECSinstitute.org.
REFERENCES

1. CMS, HHS. Medicare and Medicaid programs; reform of requirements for long-term care facilities. final rule. Fed Regist. 2016;81(192):68688-68872.

2. SNF value-based purchasing (SNF VBP). American Health Care Association website. ahcancal.org/facility_operations/Pages/SNF-Value-Based-Purchasing.aspx. Accessed May 3, 2018.

3. Proposed fiscal year 2016 payment and policy changes for Medicare skilled nursing facilities. CMS website. cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-04-15.html. Published April 15, 2015. Accessed March 28, 2017.

4. Burke RE, Whitfield EA, Hittle D, et al. Hospital readmission from post-acute care facilities: risk factors, timing, and outcomes. J Am Med Dir Assoc. 2016;17(3):249-255. doi: 10.1016/j.jamda.2015.11.005.

5. Ouslander JG, Bonner A, Herndon L, Shutes J. The Interventions to Reduce Acute Care Transfers (INTERACT) quality improvement program: an overview for medical directors and primary care clinicians in long-term care. J Am Med Dir Assoc. 2014;15(3):162-170. doi: 10.1016/j.jamda.2013.12.005.

6. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations from nursing homes: evaluation of the INTERACT II collaborative quality improvement project. J Am Geriatr Soc. 2014;59(4):745-753. doi: 10.1111/j.1532-5415.2011.03333.x.

7. Ouslander JG, Berenson RA. Reducing unnecessary hospitalizations of nursing home residents. N Engl J Med. 2011;365(13):1165-1167. doi: 10.1056/NEJMp1105449.

8. Rau J. Rehospitalization rates fell in first year of Medicare penalties. Kaiser Health News website. kaiserhealthnews.org/news/rehospitalization-rates-fell-in-first-year-of-medicare-penalties. Published December 9, 2013. Accessed March 28, 2017.

9. Vasilevskis EE, Ouslander JG, Mixon AS, et al. Potentially avoidable readmissions of patients discharged to post-acute care: perspectives of hospital and skilled nursing facility staff. J Am Geriatr Soc. 2017;65(2):269-276. doi: 10.1111/jgs.14557.

10. Walsh EG, Wiener JM, Haber S, Bragg A, Freiman M, Ouslander JG. Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and Home- and Community-Based Services waiver programs. J Am Geriatr Soc. 2012;60(5):821-829. doi: 10.1111/j.1532-5415.2012.03920.x.

11. Grabowski DC, O’Malley AJ. Use of telemedicine can reduce hospitalizations of nursing home residents and generate savings for Medicare. Health Aff (Millwood). 2014;33(2):244-250. doi: 10.1377/hlthaff.2013.0922.

12. Chess D, Croll D. Telemedicine provides bedside care in the nursing home. Caring for the Ages. 2016;17(8):12. doi: 10.1016/j.carage.2016.07.011.

13. Levinson DR. Medicare nursing home resident hospitalization rates merit additional monitoring. HHS Office of Inspector General website. oig.hhs.gov/oei/reports/oei-06-11-00040.pdf. Published November 2013. Accessed July 2018.
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