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TELEHOSPICE- TELEHOSPICE- INNOVATIONS IN OUR INNOVATIONS IN OUR HOSPICE MISSION © HOSPICE MISSION © Deborah A. Randall, JD Deborah A. Randall, JD www.deborahrandallconsulting. www.deborahrandallconsulting. com com law@deborahrandallconsulting. law@deborahrandallconsulting. com com 202-257-7073 202-257-7073

TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © Deborah A. Randall, JD @deborahrandallconsulting.com202-257-7073

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Page 1: TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © Deborah A. Randall, JD @deborahrandallconsulting.com202-257-7073

TELEHOSPICE- INNOVATIONS TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION ©IN OUR HOSPICE MISSION ©

Deborah A. Randall, JDDeborah A. Randall, JDwww.deborahrandallconsulting.comwww.deborahrandallconsulting.comlaw@[email protected]

202-257-7073202-257-7073

Page 2: TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © Deborah A. Randall, JD @deborahrandallconsulting.com202-257-7073

OBJECTIVESOBJECTIVES

Review current activities in the area of remote Review current activities in the area of remote monitoring, consulting and telecommunication monitoring, consulting and telecommunication for end of life care and palliative care.for end of life care and palliative care.

Understand the legal and regulatory issues Understand the legal and regulatory issues related to the use of telehealth to deliver end-of-related to the use of telehealth to deliver end-of-life care and services.life care and services.

Explore the potential of remote monitoring and Explore the potential of remote monitoring and telecommunication innovations in the United telecommunication innovations in the United States and Canada.States and Canada.

Page 3: TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © Deborah A. Randall, JD @deborahrandallconsulting.com202-257-7073

Moving Towards Electronically Moving Towards Electronically Enabled Care Delivery@HomeEnabled Care Delivery@Home

HIT = Health Information TechnologyHIT = Health Information Technology HIE = Health Information ExchangeHIE = Health Information Exchange EHR = Electronic Health RecordEHR = Electronic Health Record EMR = Electronic Medical RecordEMR = Electronic Medical Record PHR = Personal Health RecordPHR = Personal Health Record ONC = Office of the National Coordinator ONC = Office of the National Coordinator

for HIT [DHHS]for HIT [DHHS]

Page 4: TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © Deborah A. Randall, JD @deborahrandallconsulting.com202-257-7073

Today in Telehealth at “Home”Today in Telehealth at “Home”

Market?? for remote monitoring estimated Market?? for remote monitoring estimated [2 yrs ago] at reaching a half billion dollars [2 yrs ago] at reaching a half billion dollars in USA in five years. Numbers variable.in USA in five years. Numbers variable.

Remote monitoring most currently in use Remote monitoring most currently in use in Western Europe and UK, and growing in in Western Europe and UK, and growing in Asia. VA treating Asia. VA treating >45,000 in homecare.>45,000 in homecare.

Sensoring devicesSensoring devices:: movement analysis, movement analysis, falls detection, behavioral tracking, falls detection, behavioral tracking, dementia safety, communication to familydementia safety, communication to family

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Where is Telehealth in UseWhere is Telehealth in Use

Care coordination and Chronic DiseaseCare coordination and Chronic Disease Patient self-managementPatient self-management Ambulatory care and safetyAmbulatory care and safety Palliative carePalliative care Rehabilitative servicesRehabilitative services Behavioral & mental health servicesBehavioral & mental health services

Page 6: TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © Deborah A. Randall, JD @deborahrandallconsulting.com202-257-7073

VA Chronic Care Coordination VA Chronic Care Coordination via Telehealth Studyvia Telehealth Study

CONDITIONCONDITION # % # % DECREASE ER/HospitalizationDECREASE ER/Hospitalization

DiabetesDiabetes 8,954 20.4 8,954 20.4

HypertensionHypertension 7,447 30.3 7,447 30.3

CHFCHF 4,089 25.9 4,089 25.9

[congestive heart failure][congestive heart failure]

COPDCOPD 1,963 20.7 1,963 20.7

[chronic pulmonary obstruction][chronic pulmonary obstruction]

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VA Chronic Care Coordination VA Chronic Care Coordination via Telehealth Studyvia Telehealth Study

Posttraumatic stress disorder 45.1%Posttraumatic stress disorder 45.1% Depression 56.4%Depression 56.4% Other mental health condition 40.9%Other mental health condition 40.9% Single condition 10,885 patients;24.8%Single condition 10,885 patients;24.8% Multiple “ “ 6,140 patients;26.0%Multiple “ “ 6,140 patients;26.0% Interventions “just in time”; “air traffic Interventions “just in time”; “air traffic

control”control”

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VA Chronic Care Coordination VA Chronic Care Coordination via Telehealth Studyvia Telehealth Study

The cost ($1,600.24 pp/yr compares favorably) The cost ($1,600.24 pp/yr compares favorably) direct cost of VHA’s home-based primary care direct cost of VHA’s home-based primary care

services of $13,121.25 per annum andservices of $13,121.25 per annum and market nursing home care rates that average market nursing home care rates that average

$77,745.26 per patient per annum”. $77,745.26 per patient per annum”.

Conclusion: a flexible and cost-effective adjunct to Conclusion: a flexible and cost-effective adjunct to VHA’s existing services. Darkins et al., VHA’s existing services. Darkins et al., Telemedicine & EHealthTelemedicine & EHealth, 12/2008., 12/2008.

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Scope and PayersScope and Payers

Home-based telehealth mostly chronic care Home-based telehealth mostly chronic care management => avoid ER & re-management => avoid ER & re-hospitalizations. hospitalizations. ProviderProvider funded;grants. funded;grants.

Medicaid paying for some telehealth visits.Medicaid paying for some telehealth visits. Home as Home as “originating “originating site” site” NOT NOT

reimbursed by Medicare. Skilled nursing reimbursed by Medicare. Skilled nursing home= live consultations in (rural or home= live consultations in (rural or medically underserved) areas. Carve outs.medically underserved) areas. Carve outs.

NY Blue Cross/Shield plan begins to pay for NY Blue Cross/Shield plan begins to pay for live physician-patient video telehealth.live physician-patient video telehealth.

Page 10: TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © TELEHOSPICE- INNOVATIONS IN OUR HOSPICE MISSION © Deborah A. Randall, JD @deborahrandallconsulting.com202-257-7073

Blue Cross/Blue Shield WNYBlue Cross/Blue Shield WNY

Blue Cross/Blue Shield Western New York Blue Cross/Blue Shield Western New York in May 2010 initiated online physician-in May 2010 initiated online physician-patient communication as a compensated patient communication as a compensated service; encouraging telehealth service; encouraging telehealth communications and web cam visits; communications and web cam visits; measuring quality of care and patient measuring quality of care and patient compliance factorscompliance factors

Senior VP interested in home monitoring Senior VP interested in home monitoring and interactive video.and interactive video.

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Originating Sites for MedicareOriginating Sites for Medicare

The office of a physician or practitionerThe office of a physician or practitioner Hospital-based; critical access hospital-Hospital-based; critical access hospital-

based renal dialysis center (including based renal dialysis center (including satellites)satellites)

Hospital; Critical access hospitalHospital; Critical access hospital Skilled nursing facility; Rural health clinicSkilled nursing facility; Rural health clinic Community mental health centerCommunity mental health center Federally qualified health centerFederally qualified health center

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LEGISLATION 2009-2010LEGISLATION 2009-2010

HITECH ACT 2009- Stimulus BillHITECH ACT 2009- Stimulus Bill

HIT Policy Committee of ONCHIT Policy Committee of ONC

Infrastructure got first fundingInfrastructure got first funding

Aging Services Technology StudyAging Services Technology Study

PPACA – Health Reform Act 2010PPACA – Health Reform Act 2010

Independence@Home; Medicaid Medical Independence@Home; Medicaid Medical Home; Chronic Care; Innovation CntrHome; Chronic Care; Innovation Cntr

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Patient Protection and Patient Protection and Accountable Care Act of 2010Accountable Care Act of 2010

““PPACA” --This is where the expansion PPACA” --This is where the expansion will continue to be.will continue to be.

PPACA drives the process towards PPACA drives the process towards management of chronic disease.management of chronic disease.

Health information technology is finally Health information technology is finally showing, with reliable data, that telehealth showing, with reliable data, that telehealth can integrate with traditional care and use can integrate with traditional care and use staffing innovations.staffing innovations.

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PPACA Promises? Promises!PPACA Promises? Promises!

Post-hospitalization bundling pilotPost-hospitalization bundling pilot Independence at Home demonstrationIndependence at Home demonstration Innovation Center at DHHS; chief policy Innovation Center at DHHS; chief policy

person in place;telehealth focusperson in place;telehealth focus ACOsACOs Medical Home-Medicaid and PilotsMedical Home-Medicaid and Pilots Face2face HHA provision w telehealthFace2face HHA provision w telehealth

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Telehealth and “High Touch”Telehealth and “High Touch”

Does Telehealth work with the history of Does Telehealth work with the history of palliative care and hospice care as palliative care and hospice care as intensely “high touch” or “high sensitivity”?intensely “high touch” or “high sensitivity”?

Is some Touch not better than no Touch, Is some Touch not better than no Touch, or better than Touch which comes with or better than Touch which comes with travel, delay, fear, understaffing? Is it not travel, delay, fear, understaffing? Is it not all about ACCESS?all about ACCESS?

Are these interventions HELPED by Are these interventions HELPED by newest technology-mHealth’s immediacy?newest technology-mHealth’s immediacy?

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““Seeing” Patient NeedSeeing” Patient Need

Will telehealth have the accuracy and Will telehealth have the accuracy and reliability for Palliative and Hospice care?reliability for Palliative and Hospice care?

Can the clinician make a palliative care Can the clinician make a palliative care decision from the distance?decision from the distance?

If the patient is the “center of care”, where If the patient is the “center of care”, where more so than pain management; suffering more so than pain management; suffering whether physical, psychological or spiritual; whether physical, psychological or spiritual; and in end of life decisions.and in end of life decisions.

Is Immediacy itself palliative?Is Immediacy itself palliative?

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New Areas; StandardsNew Areas; Standards

Areas established: teleradiology, Areas established: teleradiology, teledermatology and telecardiology. teledermatology and telecardiology.

Standards developing or Emerging: Standards developing or Emerging: telehomecare, telemental health.telehomecare, telemental health.

See ATA See ATA www.americantelemed.org

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Standards, contStandards, cont..

New: Telerehabilitation---physicians, therapists [PT, OT, New: Telerehabilitation---physicians, therapists [PT, OT, speech/hearing]speech/hearing]

Newest: Telehospice and palliative care—beginning interest Newest: Telehospice and palliative care—beginning interest among physicians, home care providers, hospices, academiaamong physicians, home care providers, hospices, academia

VA’s palliative care VA’s palliative care standards.standards. National Consensus Project for Quality Palliative Care 2009; National Consensus Project for Quality Palliative Care 2009;

NQFNQF

The National Consensus Project for Quality Palliative Care, The National Consensus Project for Quality Palliative Care, 20092009

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American Telemedicine Ass’nAmerican Telemedicine Ass’n

www.americantelemed.org Homecare and Remote Monitoring Interest Homecare and Remote Monitoring Interest

Group is preparing new Standards, andGroup is preparing new Standards, and

has a Telehospice/Palliative Care Wk’g has a Telehospice/Palliative Care Wk’g Group, for which I am Chair.Group, for which I am Chair.

Telemental health ATA standards carved Telemental health ATA standards carved out delivery through remote monitoring out delivery through remote monitoring forms of delivery [for now]forms of delivery [for now]

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National Association for Home National Association for Home Care and HospiceCare and Hospice (NAHC) (NAHC)

Interest in telemonitoring for home care and Interest in telemonitoring for home care and hospice. www.nahc.orghospice. www.nahc.org July 2009 July 2009 CaringCaring journal devoted to home care journal devoted to home care

telemonitoring – some mention of hospicetelemonitoring – some mention of hospice NAHC Division for telehomecareNAHC Division for telehomecare

Center for the Advancement of Center for the Advancement of Palliative Care [CAPC] Palliative Care [CAPC] www.capc.orgwww.capc.org

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National Hospice and Palliative Care National Hospice and Palliative Care Organization www.nhpco.orgOrganization www.nhpco.org

Has funded some grants to hospices Has funded some grants to hospices working in conjunction with VA locationsworking in conjunction with VA locations

Not yet formally looking at use of Not yet formally looking at use of telehealth for hospice & palliative caretelehealth for hospice & palliative care

Current Concern: PPACA requires “visit” Current Concern: PPACA requires “visit” by MD/NP at 180 days of care— by MD/NP at 180 days of care— televisit?televisit?

American Academy of Hospice and American Academy of Hospice and Palliative MedicinePalliative Medicine

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Research on TelehospiceResearch on Telehospice

Initial research papersInitial research papers Work in Missouri and Washington StateWork in Missouri and Washington State Directions –Directions –

IDG involvement patients and familiesIDG involvement patients and families Education/emotional support to caregiversEducation/emotional support to caregivers Reactions of patients to use of health Reactions of patients to use of health

information technologyinformation technology Preferences of video versus audio onlyPreferences of video versus audio only Questions about safety and equivalencyQuestions about safety and equivalency

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Prevalence of TelehospicePrevalence of Telehospice

Informal surveyInformal survey CIMIT Grant to reviewCIMIT Grant to review MethodologyMethodology FindingsFindings Follow-on researchFollow-on research Canadian telehealth research in palliative Canadian telehealth research in palliative

areaarea

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Exploration of TelehospiceExploration of Telehospice

Partners Homecare Grant on prevalence: Partners Homecare Grant on prevalence: Survey of 49 hospices, most patients Survey of 49 hospices, most patients follow-on from homecare. High patient follow-on from homecare. High patient acceptanceacceptance

Canadian telehealth research project in Canadian telehealth research project in palliative area initiated in 2010palliative area initiated in 2010

Extension to Health System expansions Extension to Health System expansions with ACOs; Independence @ Home? with ACOs; Independence @ Home? Beacon Grants?Beacon Grants?

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Palliative CarePalliative Care

Pain and symptom managementPain and symptom management Outreach and crisis managementOutreach and crisis management Triage without transporting to a health Triage without transporting to a health

facilityfacility Psychological pain and sufferingPsychological pain and suffering Diagnostic opportunities; family Diagnostic opportunities; family

interactionsinteractions Ethical principles of autonomy enhancedEthical principles of autonomy enhanced

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Canadian StudyCanadian Study Outcome measuresOutcome measures

Patient acceptancePatient acceptance Family acceptanceFamily acceptance Professional acceptanceProfessional acceptance Improved quality of lifeImproved quality of life

Participants – 20 pts over 3 monthsParticipants – 20 pts over 3 months Recruitment – oncology nurseRecruitment – oncology nurse Palliative Performance Score 60% or <Palliative Performance Score 60% or <

MonitoringMonitoring Home care nurses perform home visits, monitor Home care nurses perform home visits, monitor

remote monitoring data daily and prn video visits as remote monitoring data daily and prn video visits as indicatedindicated

Hospital oncology nurses – prn review of data and Hospital oncology nurses – prn review of data and scheduled weekly video visitsscheduled weekly video visits

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Advanced Illness –Is there a Advanced Illness –Is there a Role for TelehealthRole for Telehealth

Using an existing model. Could you Using an existing model. Could you expand on, e.g., Kaiser’s Advanced Illness expand on, e.g., Kaiser’s Advanced Illness Coordinated Care Program (AICCP) Coordinated Care Program (AICCP) included health counseling?included health counseling?

developed for patients with advanced developed for patients with advanced illness (congestive heart failure, end-stage illness (congestive heart failure, end-stage pulmonary disease, end-stage renal pulmonary disease, end-stage renal disease, and cancer) in 3 settings of a disease, and cancer) in 3 settings of a multistate health plan.multistate health plan.

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Expanding a model, cont’dExpanding a model, cont’d..

Improved communication about Improved communication about discomfort, support for decision making;discomfort, support for decision making;

increased formulation of advance directives increased formulation of advance directives (5.5 months sooner),problem resolution; (5.5 months sooner),problem resolution; attention to caregiver needs.attention to caregiver needs.

more agreement to do-not-resuscitate or more agreement to do-not-resuscitate or do-not-intubate orders, and fewer inpatient do-not-intubate orders, and fewer inpatient admissions, with no difference in survival.admissions, with no difference in survival.

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2009: CMS Home based care management 2009: CMS Home based care management grants failed because they were “Patient-grants failed because they were “Patient-centered programs w Disease Management centered programs w Disease Management that were not that were not connected to, selected by or connected to, selected by or valued by physiciansvalued by physicians“, Linda Magno, CMS“, Linda Magno, CMS

2010: Center for Innovation:proposal of 2010: Center for Innovation:proposal of hospice/palliative care with telehealth hospice/palliative care with telehealth modality & home as center of care…….?modality & home as center of care…….?

New Directions from DHHS?New Directions from DHHS?

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Opportunities and ChallengesOpportunities and Challenges

Bringing the Medical Director and other Bringing the Medical Director and other physicians on board in hospicephysicians on board in hospice

Demonstrating cost savings, Demonstrating cost savings, &/&/or quality of or quality of care/life improvements sufficient to justify care/life improvements sufficient to justify the expenses of equipment and staffthe expenses of equipment and staff

Training and staffing. Maintenance of Training and staffing. Maintenance of depth of field/bench so turnover is not a depth of field/bench so turnover is not a problem. Need for a problem. Need for a ""championchampion""..

Convincing nurses to embrace technologyConvincing nurses to embrace technology

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Hospice delivery = TelehealthHospice delivery = Telehealth

Resource flexibility; aggregate CAPResource flexibility; aggregate CAP No express barrier to a virtual visitNo express barrier to a virtual visit Social work core service, difficult to staff Social work core service, difficult to staff Social work @ a distance [telephonic] in Social work @ a distance [telephonic] in

CMS line-item billing directionsCMS line-item billing directions IDT care plans w family; on-call nurses IDT care plans w family; on-call nurses

using telehealth to guide caregivers; video using telehealth to guide caregivers; video with family can be re-played for educationwith family can be re-played for education

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Further On the ContinuumFurther On the Continuum

mHealth; personal health direction and mHealth; personal health direction and controlcontrol

The 2d half of the Baby Boomer The 2d half of the Baby Boomer generation expects to use technologygeneration expects to use technology

Disease and condition groups forming Disease and condition groups forming Web presences….why not End of LifersWeb presences….why not End of Lifers??

Use of “Second Life” alternates to explore Use of “Second Life” alternates to explore pain modification, emotional relief, PTSDpain modification, emotional relief, PTSD

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Legal Barriers and ConcernsLegal Barriers and Concerns

Providers’ Conditions of Participation Providers’ Conditions of Participation [homecare/hospice] Meet them? or [homecare/hospice] Meet them? or become a become a different kind of provider?different kind of provider?

Licensure –Example: Nursing state lawLicensure –Example: Nursing state law Consent, Safety and LiabilityConsent, Safety and Liability Management of the CaseManagement of the Case Privacy and confidentialityPrivacy and confidentiality Security of CommunicationSecurity of Communication Fraud and Abuse-What can you “give” free Fraud and Abuse-What can you “give” free

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QuestionsQuestions??

Deborah Randall, Esq. Deborah Randall, Esq. Health Services and Telehealth ConsultingHealth Services and Telehealth ConsultingLaw Office of Deborah RandallLaw Office of Deborah Randall

[email protected] [email protected] www.deborahrandallconsulting.com 202-257-7073202-257-7073

© Deborah Randall© Deborah Randall