Planning the Program for Underserved Areas

Home health agencies are more in demand in rural areas because of the difficulties patients have in accessing doctors, and it also is difficult for home health providers to get to patient homes. Generally, there are fewer “local” home health agencies in rural areas. The trend is toward large urban medical centers to provide outreach through home health to remote areas. Extending home health into remote areas involves long distances and drive times for providers.

Generally, the remote area population is rural, low income and either uninsured or underinsured. Rural economies struggle under the weight of poorly developed public sector infrastructure, including under-funded schools, public health facilities, an aging population and a stagnant tax base. The payor mix weighs heavily toward the uninsured, underinsured and Medicare patients. When there are hospitals available in rural areas, they often are the largest employers, but in many rural counties, there is an inadequate supply of quality medical clinics, specialists, mental health

providers and too often, even primary care providers. Referral patterns generally are ingrained and gravitate toward a specialist or two in the nearest town geographically. Potential partners include those that operate durable medical equipment businesses; home monitoring suppliers; physician offices; local hospitals; and contractors for services related to physical therapy, occupational therapy and speech therapy. Hold meetings to discuss telehealth with the potential partners within the remote

community. This may include: Meeting with the rural home health agency if one exists. Give the agency a general overview of telehealth and how it works to meet patient needs in home health. If an urban-oriented home health agency has plans for expansion into rural areas, meetings with physician groups and hospital

administrators are pertinent. Generally speaking, “due diligence” meetings with health care providers would be conducted to assure the community that home

telehealth is an excellent tool for keeping people in their own homes and in their own communities for as long as is feasible.

It is important to obtain verbal buy-in from area physicians and hospital administrators. Cost estimates for the appropriate home telehealth

telecommunications equipment that will fit the needs of a particular home health agency and its patients needs to be defined. Under the PPS requirements, the “revenue stream” for home telehealth generally is in terms of cost savings from mileage and drive time saved. However, work on contracts or memorandums of agreement between equipment vendors or home telehealth consultants need to be developed so that all network partners understand the costs and responsibilities that each party will assume. Identify who needs to be involved both internally and

externally in this agreement. Also identify who will be responsible for collecting evaluation data.

C. Technical Analysis

One should identify equipment used by other successful programs as well as review the TDRT web site (http://tdrt.aticorp.org/) and OAT Technical Guidelines

for information about vendors. Determine how on-going maintenance will be

provided. This includes a decision as to whether to buy spare equipment or to buy extended service contracts (24/7). Determine remote network connectivity. In the case of home telehealth, the connectivity is generally POTS, so most dealings will be with the local telephone company.

A few home telehealth equipment suppliers offer ISDN or IP capabilities, so purchase of this type of equipment requires a good understanding of network capacity in the individual counties in which the home health agency operates.

Determine who will be responsible for equipment management. Technical staff must understand home variations (lighting, sound, camera/equipment placement, and privacy considerations) for optimal telehealth consultations.

Prior to the operational phase, planning following the seven steps shown above should be done. After planning is completed, the operational phase shown below would begin.

D. Operational

Start-up – The First 30 days 1. Order equipment.

2. Initial meetings with the home health agency: Agency staff should determine the location of the home telehealth nursing station unit.

3. Administrative, technical and clinical staff should determine that the nursing station unit in the consulting room can be adequately wired.

4. Technical staff should determine the general layout of the room and what changes (lighting, sound, wall color), if any, need to be made. The agreement should specify which party is responsible for any room modifications.

5. Administrative and clinical staff should meet to discuss the logistics of scheduling, billing, reimbursement, evaluation, consent, and other administrative issues related to the program.

The 31 to 60 Day Start-up Window

1. Administration should continue to work on all of the logistical issues related to scheduling, billing, etc.

2. Nurse’s station room remodeling, if needed, should begin around day 31, to be completed by the 60th day.

3. Develop policies, procedures and protocols. 4. Develop consent forms and tele-visit forms. 5. Develop evaluation tools to pilot in the next step. The 61 to 90 Day Start-up Window

1. Nurse’s station equipment installed.

2. Home equipment placed and patient instruction begins. 3. Training of home health provider personnel.

4. Administrators finalize the logistics of scheduling, billing, etc..

5. Mock cases are conducted to determine the smoothness of the process and to make refinements as necessary.

The 91st Day

1. The telehealth program begins to care for patients based on the groundwork laid during the first 90 days.

2. Refinements and adjustments to the program can be made at this point. 3. Evaluation data begins to be collected.

IV. Lessons Learned from the Field

TeleWatch System from Johns Hopkins

TeleWatch is a telephone-based, automated telemedicine system that allows health care providers to monitor physiologic parameters and symptoms of outpatients in their homes. The system is also easily adapted to monitor the efficacy of treatment, provide real-time feedback, educate patients and disseminate information to individual patients or large cohorts. Because no specialized monitoring equipment is required for patients

to use the system, it is easy to deploy, simple to use and very cost effective. It does require that the patient provides physiological data by self-report.

Because patients interact with the Johns Hopkins TeleWatch System using a telephone, no other telecommunications equipment is required within their home. Additionally, since individuals may access the system from any telephone, their mobility is markedly enhanced without degrading the level of monitoring. Since greater than 95% of the population has access to and knows how to use a telephone, a telephone-based

approach ensures widespread accessibility to the TeleWatch system. It also makes the system simple to use and easy to deploy.

As of August 2002, approximately 140 patients were using TeleWatch at Johns Hopkins and an additional 50 patients in the heart failure program. Patient utilization rates are very high with an average of 65% of heart failure patients and 54% of diabetic patients using the system on a daily basis. Over 70% of all patients access the system at least three times a week. In addition to patients displaying their satisfaction with the system by calling in regularly, they have also provided written feedback.

Physicians have also been pleased with the system as evidenced from this letter from a Cardiologist:

“I recently had a fax of his latest BP and weight as well as his laboratory results which proved to be extremely helpful in his medical management…I think this TeleWatch is an excellent one and has already improved my ability to treat [the patient].”

UC Davis Health System: Center for Health & Technology Televisits in Home Health -- Deployment in Rural Areas

The Center for Health and Technology at the University of California, Davis Health System received Federal funding from the Office for the Advancement of Telehealth in September 2000. A major focus of the grant is the development of home health

A valuable piece of information that came from the first site visit was the request to be able to speak with other home care agencies that have used this technology. To address this need, a multi-site videoconference was put together with guest speakers from the east, northeast, southeast and west to provide an overview of their program and experiences deploying this type of technology in the home care setting. Quarterly video meetings have been and are being held to provide a forum of discussion on what is working and challenges faced.

University of Tennessee Telehealth Network, Knoxville, TN

Rural patients were initially reluctant to accept home telehealth when the equipment agreement stipulated that they had some liability for equipment damage. When that clause was removed from the agreement, more patients were willing to participate in home telehealth.

Lighting in the home is the biggest technical challenge home health agencies may face. Don't be afraid to suggest a rearrangement or supplementation of lighting sources within the home.

The biggest sticking point in patient acceptance of home telehealth continues to be having a camera in the home for audio-video applications. Patients must be shown and reminded that the camera lens can be covered, and that they in fact control the camera view by selecting a consistent place within the home where the televisit is conducted and that this view is quite limited.

Diffusion of home telehealth in a home health agency appears to be more rapid when a particular nurse or staff member is designated as the "go to" person for making home telehealth happen in the Agency. This individual becomes the expert and as the technology diffuses to all providers within the agency, there is still a single source of knowledge and encouragement when technical problems develop.

One of the most important lessons learned is that initial marketing efforts must be repeated at three-month intervals to remind providers that home telehealth visits are

available. Additionally, a marketing effort directed at patients to make them aware that home telehealth is available in their area can be an effective strategy.

V. Useful References (websites and documents)

VENDORS