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Our Family Is Crazy
Telehealth Workgroup

Update
By: Mike Billings
Date: June 25, 2020

COVID-19 has been devastating in so many ways. Yet, it has produced a few silver linings. One of those silver linings is the rapid adoption of telehealth. Telehealth is defined as the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance. The use of telehealth has grown dramatically since its earliest modern use in the 1960s. Before COVID-19, the telehealth market was predicted to be worth $2.6 billion in 2020. With COVID-19, that prediction has been updated to $250 billion. And it appears there’s no going back following the outbreak. “I can’t imagine going back,” said Seema Verma, administrator of the Centers for Medicare and Medicaid Services, during a recent live virtual event. “People recognize the value of this, so it seems like it would not be a good thing to force our beneficiaries to go back to in-person visits.”

There is a growing body of evidence to support the clinical efficacy of telehealth in various practice settings and with multiple populations. For example, telerehabilitation, a subset of telehealth, has been found to achieve outcomes comparable with those from conventional in-person rehabilitation. Also, patient satisfaction, the most studied element of telehealth, has consistently high levels of satisfaction with the technology. Telehealth is often cited to reduce health care costs to meet one arm of the triple aim of health care reform. Studies involving Medicare beneficiaries found that care delivered by telehealth was more economical than usual care.

Before the coronavirus global pandemic, several significant barriers were preventing the adoption of telehealth in post-acute care and rehabilitation.

Barrier: Practice

Clinicians are required to not only practice within the guidelines outlined by their professional association, but they must also abide by practice guidelines governed by the state in which they practice. In the example of physical therapy, unfortunately, most state practice acts are silent on the use of telehealth. Some states use vague language on telecommunications. An additional barrier, even if the state allows use of telehealth, often is the requirement of “onsite” supervisory visits.

The good news is that more states are addressing this critical practice barrier. Several years ago, Oregon approved new physical therapy practice act language that addresses explicitly telehealth. Also, the Federation for State Boards of Physical Therapy (FSBPT) issued a policy document for states to use as guidance. The solution for this barrier to telehealth adoption is a grassroots movement by clinicians bringing this to their practice governing boards’ attention. Rural parts of many states have severe access problems to healthcare providers. Telehealth could help alleviate this problem.

Barrier: Licensure   

Telehealth nearly completely removes geography from consideration when providing health services to a distant patient. A clinician can treat a patient literally from anywhere on the globe with the use of technology. Unfortunately, archaic licensure laws in the U.S. make practicing telehealth across state lines extremely cumbersome. For example, Portland, Oregon and Vancouver, Washington are adjacent to one another separated only by the Columbia River. However, licensure rules prohibit an Oregon licensed PT from treating a patient located just minutes away in Vancouver via telehealth. This requires clinicians to become licensed in multiple states, with some clinicians maintaining licenses in all 50 states.  Of course, the time and costs to support numerous state licenses are considerable.

The federal government believes the licensure barrier is a public protection issue. In a report to Congress, the Health Resources and Services Administration states that “overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals to address workforce needs and improve access to health care services, particularly in light of increasing shortages of healthcare professionals.” A solution to this problem is the licensure compact.

Compacts between states are very common. There are more than 215 interstate compacts in existence today, with each state belonging to an average of 25 compacts. In healthcare, a compact license allows a clinician to work in another state without having to obtain licensure in that state. There are several notable medical and licensing compacts. The most recognized is the driver’s licensing compact, which includes all 50 states. Medical compacts include the nurse licensure compact (25 states), mental health compact (45 states and DC), and the emergency management assistance compact (50 states). The Physical Therapy Licensure Compact now includes 20 member states, including both Oregon and Washington. Licensure compacts in development include occupational therapy, speech-language pathology, and the advanced practice registered nurses. Licensure compacts would greatly facilitate the adoption of telehealth.

Barrier: Reimbursement

Finally, reimbursement is another significant hurdle for telehealth adoption. Despite the growing body of evidence-based research demonstrating positive clinical outcomes and increasing telehealth utilization, improved state and federal reimbursement for telehealth services has remained stagnant. The goal of telehealth reimbursement is full parity, which is classified as comparable coverage and reimbursement for telehealth-provided services to that of in-person services. Innovative payment models and recently proposed bills are encouraging solutions for the reimbursement problem. Also, waivers during the public health emergency allow reimbursement for telehealth visits equivalent to in-person care in most cases, at least temporarily.

Patients and providers are increasingly demanding access to healthcare via telehealth. Barriers such as state practice acts, licensure laws, and reimbursement must be removed to meet this demand.  Telehealth could play a significant role in helping the U.S. meet its triple aim objectives with these barriers removed. The good news is that waivers to most of these barriers have been declared during the public health emergency clearing the path for rapid telehealth adoption.

A cross-company and cross-disciplinary team at Avamere, Infinity Rehab, and Signature Healthcare at Home have been working on ways to leverage these waivers to increase the use of telehealth in all Avamere companies. In many cases, patients have received direct care provided via telehealth that would not have received care otherwise due to COVID-19 restrictions. Here are some examples of how telehealth is being used in innovative ways to enhance patient care and quality outcomes at the Avamere companies:

Avamere

Wound Healing: As a key partner to improve quality outcomes for patients requiring wound care, United Wound Healing began providing onsite wound consultations prior to the COVID-19 outbreak. United Wound Healing partners with our facility care providers utilizing ARNPs and PAs to provide services and consultation to patients at risk for and with known skin breakdown. To reduce the risk of the spread of the virus, some of these consultations are being provided via synchronous telehealth visits as well as asynchronous (via review of photos in the medical record). Our interdisciplinary approach including onsite and telehealth solutions have reduced wound healing times, increased staff knowledge, and improved patient health and safety.

Signature

Nurse practitioner: Nurse practitioners from Signature Healthcare at Home’s NP2U division have provided some care to Avamere SNF patients virtually. In most cases, due to COVID-19, this is critical care that would have otherwise not been delivered.

Remote patient monitoring: Signature started using remote patient monitoring devices to manage high-risk patients long before the COVID-19 outbreak. These devices allow Signature’s nurses and therapists to monitor key biometrics of patients from a distance and to intervene in a timely manner when readings are abnormal. Remote patient monitoring has become a key strategy for preventing patients from returning to the hospital and achieving superior clinical outcomes.

Signature home health and hospice have taken advantage of recent Waivers related to the Public Health Emergency which allow for telehealth or virtual visits for our lines of service. This has been crucial in staying connected with our patients and families and promoting positive outcomes during this time of limited face to face contact. Although these visits are not reimbursable under the home health or hospice model, it has allowed us to continue to provide quality services and ensure our patients are able to connect with clinicians and remain safe. We are planning to continue these visits beyond the pandemic to supplement in person visits for those high-risk patients that require closer monitoring to remain safe in their place of residence and prevent re-hospitalization.

Infinity

Recognizing the positive impact telehealth can have on its patients, Infinity Rehab put together a work group to research and create training materials to help our clinicians navigate this new therapy delivery mode. With quality care and best practices in mind, we identified skilled nursing facilities and outpatient clinics in which we could provide clinician training and implement telehealth. Various applications have been trialed:

On-site virtual visits (OVV): Infinity Rehab utilized on-site virtual visits as a solution to provide necessary and quality rehabilitation services while minimizing infection exposure risk during the public health emergency in skilled nursing facilities. Due to efforts to reduce spread of infection therapy staff were limited in their ability to cover multiple facilities or move within different wings/floors of a facility, which posed a staffing challenge to meet patient needs. OVV enabled the clinician to be in the same building, but not in the same room, as the patient and provide evaluations and/or treatments using telecommunication technology.

Telesupervision: Infinity Rehab has a long history of providing telesupervision, dating back over 11 years.  Telecommunications technology has been successfully utilized to meet the Washington state PT supervisory visits and with SLP Clinical Fellow mentoring as part of a hybrid approach (in-person and virtual).

Synchronous telehealth evaluations and visits: Synchronous, or real-time, telehealth visits have been implemented to meet patient needs in both outpatient and SNF settings by Infinity Rehab. The CMS telehealth waivers have authorized PT, OT, and SLP as distant site providers during the public health emergency. This has allowed to us to provide the best evidenced care to patients who may have limited access to services.

As Infinity Rehab continues to work toward implementing various telehealth strategies to maintain core quality measures, we welcome feedback from stakeholders, will continue to partner with experts within the telehealth community, and will modify and adapt to changes as we navigate this opportunity.

Telehealth has been a vital technology to meet patient needs during the COVID –19 pandemic. However, we do not see it stopping there. Now that we have experienced its value firsthand, we are actively examining what other care delivery challenges it can help us overcome. And thanks to the dedication of the Avamere, Infinity, and Signature early telehealth adopters, we have the resources and training needed to expand telehealth to additional sites and clinicians, meeting even more patient needs. In closing, stop and consider, “How could telehealth make a difference for your patients today?”

Telehealth Committee Members

Shannon Becerra

Angie Quesnell

Lisa Vander Linden

Sarah Townsend-Grant

Michelle Jabczynski

Wade Bennett

Jodi Kelley

Melissa Bruce

Paula Love

Stephen Fitton

Kevin Hill

Jesse Watson

Alex Bibb

Laura Cantrell

Liz Johns

Terri Roberts

Tim Esau

Carl Tabor

Shannon Heizenrader

Mike Billings

 

“In an age where the average consumer manages nearly all aspects of life online, it’s a no-brainer that healthcare should be just as convenient, accessible, and safe as online banking.” Jonathan Linkous, former CEO of the American Telemedicine Association


Telehealth Workgroup Update

By: Mike Billings
Date: June 25, 2020


COVID-19 has been devastating in so many ways. Yet, it has produced a few silver linings. One of those silver linings is the rapid adoption of telehealth. Telehealth is defined as the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision, and information across distance. The use of telehealth has grown dramatically since its earliest modern use in the 1960s. Before COVID-19, the telehealth market was predicted to be worth $2.6 billion in 2020. With COVID-19, that prediction has been updated to $250 billion. And it appears there’s no going back following the outbreak. “I can’t imagine going back,” said Seema Verma, administrator of the Centers for Medicare and Medicaid Services, during a recent live virtual event. “People recognize the value of this, so it seems like it would not be a good thing to force our beneficiaries to go back to in-person visits.”

There is a growing body of evidence to support the clinical efficacy of telehealth in various practice settings and with multiple populations. For example, telerehabilitation, a subset of telehealth, has been found to achieve outcomes comparable with those from conventional in-person rehabilitation. Also, patient satisfaction, the most studied element of telehealth, has consistently high levels of satisfaction with the technology. Telehealth is often cited to reduce health care costs to meet one arm of the triple aim of health care reform. Studies involving Medicare beneficiaries found that care delivered by telehealth was more economical than usual care.

Before the coronavirus global pandemic, several significant barriers were preventing the adoption of telehealth in post-acute care and rehabilitation.

Barrier: Practice

Clinicians are required to not only practice within the guidelines outlined by their professional association, but they must also abide by practice guidelines governed by the state in which they practice. In the example of physical therapy, unfortunately, most state practice acts are silent on the use of telehealth. Some states use vague language on telecommunications. An additional barrier, even if the state allows use of telehealth, often is the requirement of “onsite” supervisory visits.

The good news is that more states are addressing this critical practice barrier. Several years ago, Oregon approved new physical therapy practice act language that addresses explicitly telehealth. Also, the Federation for State Boards of Physical Therapy (FSBPT) issued a policy document for states to use as guidance. The solution for this barrier to telehealth adoption is a grassroots movement by clinicians bringing this to their practice governing boards’ attention. Rural parts of many states have severe access problems to healthcare providers. Telehealth could help alleviate this problem.

Barrier: Licensure   

Telehealth nearly completely removes geography from consideration when providing health services to a distant patient. A clinician can treat a patient literally from anywhere on the globe with the use of technology. Unfortunately, archaic licensure laws in the U.S. make practicing telehealth across state lines extremely cumbersome. For example, Portland, Oregon and Vancouver, Washington are adjacent to one another separated only by the Columbia River. However, licensure rules prohibit an Oregon licensed PT from treating a patient located just minutes away in Vancouver via telehealth. This requires clinicians to become licensed in multiple states, with some clinicians maintaining licenses in all 50 states.  Of course, the time and costs to support numerous state licenses are considerable.

The federal government believes the licensure barrier is a public protection issue. In a report to Congress, the Health Resources and Services Administration states that “overcoming unnecessary licensure barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals to address workforce needs and improve access to health care services, particularly in light of increasing shortages of healthcare professionals.” A solution to this problem is the licensure compact.

Compacts between states are very common. There are more than 215 interstate compacts in existence today, with each state belonging to an average of 25 compacts. In healthcare, a compact license allows a clinician to work in another state without having to obtain licensure in that state. There are several notable medical and licensing compacts. The most recognized is the driver’s licensing compact, which includes all 50 states. Medical compacts include the nurse licensure compact (25 states), mental health compact (45 states and DC), and the emergency management assistance compact (50 states). The Physical Therapy Licensure Compact now includes 20 member states, including both Oregon and Washington. Licensure compacts in development include occupational therapy, speech-language pathology, and the advanced practice registered nurses. Licensure compacts would greatly facilitate the adoption of telehealth.

Barrier: Reimbursement

Finally, reimbursement is another significant hurdle for telehealth adoption. Despite the growing body of evidence-based research demonstrating positive clinical outcomes and increasing telehealth utilization, improved state and federal reimbursement for telehealth services has remained stagnant. The goal of telehealth reimbursement is full parity, which is classified as comparable coverage and reimbursement for telehealth-provided services to that of in-person services. Innovative payment models and recently proposed bills are encouraging solutions for the reimbursement problem. Also, waivers during the public health emergency allow reimbursement for telehealth visits equivalent to in-person care in most cases, at least temporarily.

Patients and providers are increasingly demanding access to healthcare via telehealth. Barriers such as state practice acts, licensure laws, and reimbursement must be removed to meet this demand.  Telehealth could play a significant role in helping the U.S. meet its triple aim objectives with these barriers removed. The good news is that waivers to most of these barriers have been declared during the public health emergency clearing the path for rapid telehealth adoption.

A cross-company and cross-disciplinary team at Avamere, Infinity Rehab, and Signature Healthcare at Home have been working on ways to leverage these waivers to increase the use of telehealth in all Avamere companies. In many cases, patients have received direct care provided via telehealth that would not have received care otherwise due to COVID-19 restrictions. Here are some examples of how telehealth is being used in innovative ways to enhance patient care and quality outcomes at the Avamere companies:

Avamere

Wound Healing: As a key partner to improve quality outcomes for patients requiring wound care, United Wound Healing began providing onsite wound consultations prior to the COVID-19 outbreak. United Wound Healing partners with our facility care providers utilizing ARNPs and PAs to provide services and consultation to patients at risk for and with known skin breakdown. To reduce the risk of the spread of the virus, some of these consultations are being provided via synchronous telehealth visits as well as asynchronous (via review of photos in the medical record). Our interdisciplinary approach including onsite and telehealth solutions have reduced wound healing times, increased staff knowledge, and improved patient health and safety.

Signature

Nurse practitioner: Nurse practitioners from Signature Healthcare at Home’s NP2U division have provided some care to Avamere SNF patients virtually. In most cases, due to COVID-19, this is critical care that would have otherwise not been delivered.

Remote patient monitoring: Signature started using remote patient monitoring devices to manage high-risk patients long before the COVID-19 outbreak. These devices allow Signature’s nurses and therapists to monitor key biometrics of patients from a distance and to intervene in a timely manner when readings are abnormal. Remote patient monitoring has become a key strategy for preventing patients from returning to the hospital and achieving superior clinical outcomes.

Signature home health and hospice have taken advantage of recent Waivers related to the Public Health Emergency which allow for telehealth or virtual visits for our lines of service. This has been crucial in staying connected with our patients and families and promoting positive outcomes during this time of limited face to face contact. Although these visits are not reimbursable under the home health or hospice model, it has allowed us to continue to provide quality services and ensure our patients are able to connect with clinicians and remain safe. We are planning to continue these visits beyond the pandemic to supplement in person visits for those high-risk patients that require closer monitoring to remain safe in their place of residence and prevent re-hospitalization.

Infinity

Recognizing the positive impact telehealth can have on its patients, Infinity Rehab put together a work group to research and create training materials to help our clinicians navigate this new therapy delivery mode. With quality care and best practices in mind, we identified skilled nursing facilities and outpatient clinics in which we could provide clinician training and implement telehealth. Various applications have been trialed:

On-site virtual visits (OVV): Infinity Rehab utilized on-site virtual visits as a solution to provide necessary and quality rehabilitation services while minimizing infection exposure risk during the public health emergency in skilled nursing facilities. Due to efforts to reduce spread of infection therapy staff were limited in their ability to cover multiple facilities or move within different wings/floors of a facility, which posed a staffing challenge to meet patient needs. OVV enabled the clinician to be in the same building, but not in the same room, as the patient and provide evaluations and/or treatments using telecommunication technology.

Telesupervision: Infinity Rehab has a long history of providing telesupervision, dating back over 11 years.  Telecommunications technology has been successfully utilized to meet the Washington state PT supervisory visits and with SLP Clinical Fellow mentoring as part of a hybrid approach (in-person and virtual).

Synchronous telehealth evaluations and visits: Synchronous, or real-time, telehealth visits have been implemented to meet patient needs in both outpatient and SNF settings by Infinity Rehab. The CMS telehealth waivers have authorized PT, OT, and SLP as distant site providers during the public health emergency. This has allowed to us to provide the best evidenced care to patients who may have limited access to services.

As Infinity Rehab continues to work toward implementing various telehealth strategies to maintain core quality measures, we welcome feedback from stakeholders, will continue to partner with experts within the telehealth community, and will modify and adapt to changes as we navigate this opportunity.

Telehealth has been a vital technology to meet patient needs during the COVID –19 pandemic. However, we do not see it stopping there. Now that we have experienced its value firsthand, we are actively examining what other care delivery challenges it can help us overcome. And thanks to the dedication of the Avamere, Infinity, and Signature early telehealth adopters, we have the resources and training needed to expand telehealth to additional sites and clinicians, meeting even more patient needs. In closing, stop and consider, “How could telehealth make a difference for your patients today?”

Telehealth Committee Members

Shannon Becerra

Angie Quesnell

Lisa Vander Linden

Sarah Townsend-Grant

Michelle Jabczynski

Wade Bennett

Jodi Kelley

Melissa Bruce

Paula Love

Stephen Fitton

Kevin Hill

Jesse Watson

Alex Bibb

Laura Cantrell

Liz Johns

Terri Roberts

Tim Esau

Carl Tabor

Shannon Heizenrader

Mike Billings

 

“In an age where the average consumer manages nearly all aspects of life online, it’s a no-brainer that healthcare should be just as convenient, accessible, and safe as online banking.” Jonathan Linkous, former CEO of the American Telemedicine Association

© 2019 Avamere Family of Companies
© 2019 Avamere Family of Companies
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© 2019 Avamere Family of Companies