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Background
Equipment set-up for patients
For the nurse
Patient selection
Documents for Tele-Home Care services
Conclusions

EL PROYECTO REMINGTON

Tele-Home Care in a managed care setting:
A case study of a provider using Tele-Home Care (Telemedicine)
By Barry K. Baines, M.D.
Reprinted with permission from The Remington Report, November/December 1996, pp. 27-29.

As the growth in home health care continues, new challenges will appear that will create opportunities for those organizations whose clinical, operational and financial "worlds" are in alignment. This alignment will allow for innovation in the delivery of home healthcare services to patients. One such innovation is the use of "tele-home care" technology. For the purposes of this article, tele-home care is defined as providing an interactive video telephone home-care visit by a home health nurse.
This article will describe the application of this technology by a home healthcare agency in a managed-care setting. Equipment set-up, patient selection and outcomes of the project will be described.

BACKGROUND

The home-care agency is part of an integrated healthcare delivery system. It operates as a "cost center" rather than a "profit center." In addition, most of the over-sixty-five population is enrolled in a Medicare risk contract. This situation empowers the home-care agency to pursue care delivery options that focus on improving care for the entire system. Whether or not a service is reimbursable is not a critical issue. The added value of the service to the system is critical. This is important in the case of tele-home care services which currently are not reimbursed by Medicare.

EQUIPMENT SET-UP FOR PATIENTS

Ten portable telemedicine units were purchased. These units utilize regular telephone lines for their operation. They are simple to use, requiring the push of one button to activate. The units allow for direct viewing of the patient, measurement of blood pressure, and a telephonic stethoscope that enables the nurse to listen to heart and lung sounds.
Once a patient was referred for tele-home care services, and patient consent was obtained, an additional telephone line was installed in the patient's home at the expense of the healthcare plan. The tele-home care nurse would install the unit in the patient's home and educate the patient on how to operate the unit. Tele-home care visits were set up on a scheduled basis. While the patient was receiving tele-home care services, the health plan also paid for the monthly telephone service.

FOR THE NURSE

A central telemedicine unit was purchased and installed in the office of the home health agency. The central unit allowed for two-way viewing (nurse-patient and patient-nurse). One nurse conducted almost all of the video visits on a scheduled basis.

PATIENT SELECTION

Criteria were developed for appropriate patient selection. These criteria were categorized by their clinical, operational or utilization indications. Patients usually met at least one indicator in each of the following categories.

Clinical Indications

• Chronic disease in a state of decline
• ongestive Heart Failure
• Chronic Lung Disease
• Diabetes
• Dementia
• Cancer
• Operational Indications
• Patients requiring two or more home-care nursing visits per week
• Patients who do not require "hands-on" care with each visit
• Patients with an unreliable caregiver situation
• Patients with poor compliance to instructions or medication use

Utilization Indications

• Patients requiring frequent clinic visits (they are usually anxious)
• Patients seen in the emergency room within the past two months
• Patients hospitalized within the past six months

OUTCOMES FOR TELE-HOME CARE SERVICES

There were fourteen patients for whom outcome measurements were initially obtained. These outcomes were measured in the areas of care utilization, medical costs, patient satisfaction and provider satisfaction.

Care Utilization

Patients received tele-home care services an average of three months. The average number of tele-home care visits for each patient was 5.3 per month. After tele-home care services were started, patient-provider contacts increased almost 30 percent; however, in spite of these increased contacts, there was a 30 percent reduction in overall per-member-per-month medical costs. Half of these savings was the result of a decrease in inpatient costs; the remainder of the savings was distributed among emergency room, durable medical equipment, home care and outpatient clinic costs.

Patient Satisfaction

The results of a patient-satisfaction survey indicated that the majority of patients receiving tele-home care services were highly satisfied with the services. Patients found the system easy to use. They especially appreciated the security and convenience of having personal and professional attention without requiring travel. Patients and their families found the use of this system reassuring because of the perceived increased accessibility to care providers.

Provider Satisfaction

The home health nursing staff believed that the tele-home care visits resulted in more efficient use of professional nursing time. There were several times that early detection of deteriorating status resulted in a timely intervention which avoided an inpatient admission.

The primary physicians generally had a minimal awareness as to whether or not patients were receiving tele-home care services. When apprised of this program, several did acknowledge a reduction in physician visits and/or phone calls.

CONCLUSIONS

Upon reviewing all of the information collected on tele-home care patients, the following conclusions were reached:

1. Quality of care was either improved or maintained by tele-home care visits;
2. Operational implementation of tele-home care was not difficult;
3. Tele-home care was readily accepted by patients, their families
and healthcare providers; and
4. Tele-home care was associated with reduced healthcare costs.
Although the use of tele-home care is still in its infancy, these early results support the continued experimentation with this technology. Many questions remain to be answered, such as:
Which patients receive the most benefit from tele-home care?
Is there an optimal length of time to provide these services?
In what other care venues will this technology add value?
To thrive and succeed, it is imperative that home health care position itself as a discipline committed to innovation in the application of technology to improve the care of patients and their communities. It is important that we are not diverted by technology for technology's sake, but rather that we use technology as a tool to improve the quality of life of the patients we serve.

Barry K. Baines, M.D., is Associate Medical Director for Centralized Patient Care Services for HealthPartners, Minneapolis, Minnesota.

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