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News Roundup: March 18, 2016

Vermont VA saves $63,000 a patient through telehealth use, study says

Published by Healthcare Finance News
By Jack McCarthy
March 18, 2016

The U.S. Department of Veteran Affairs' use of telemedicine to treat patients at its Vermont hospital at White River Junction resulted in an average travel payment savings of $18,555 per year between 2005 and 2013, according to a study published in the journal Telemedicine and e-Health.

The study found that telemedicine resulted in an average savings of 145 miles and 142 minutes per visit, resulting in the aforementioned payment reductions, while telemedicine services volume grew significantly over the study period such that by the final year the travel savings had increased to $63,804, or about 3.5 percent of the total travel pay for that year.

Authors of the report explained that the number of mental health telemedicine visits increased during the study period but remained small relative to the number of face-to-face visits. And a higher proportion of telemedicine visits involved new patients.

On a nationwide scale, the VA has taken strides to use telehealth tools for treating its patients. For example, an August 2015 study determined that older veterans with depression benefited from telemedicine talk as much as in-person therapy sessions.

That study, published in The Lancet, found that older veterans with depression benefited from telemedicine talk as much as in-person therapy sessions. With many seniors facing difficulties to getting help for depression, including mobility issues and fear of social stigma, telemedicine can increase their access to treatment, the study found.

And with the national VA healthcare system's travel pay to patients for getting to appointments projected to cost nearly $1 billion in 2015, a 3.5 percent reduction, if achievable at scale, can yield significant savings.

Doctors Revive House Calls for Children with Serious Illnesses

Published by Stat News
March 18, 2016

Old-fashioned doctors’ house calls have come back to meet a modern need — taking care of a growing number of children who rely on masks, tubes, and ventilators to breathe.

As thousands of patients headed to Boston’s Longwood Medical Area one recent morning, Dr. David Casavant, a critical care doctor at Boston Children’s Hospital, set off in the opposite direction, breaking away from the medical complex to visit five patients in the comfort of their homes.

Casavant is part of a small medical squad at Children’s that visits kids and young adults who, because of acute injuries or chronic illnesses, need intensive respiratory support. Dr. Robert Graham and respiratory therapist Lauren Perlman launched the program in 2007 after noticing that these patients kept getting readmitted to the intensive care unit because they had trouble transitioning from hospital to home.

At a time when the biggest insurance payouts come from hospitalization, and patients are squeezed into shrinking office-visit time slots, house calls are rare. For Casavant, who also works in the hospital’s intensive care unit and on its pain treatment floor, getting out of the hospital offers a chance to get a fuller picture of patients’ lives.

For families, it’s a welcome break from the laborious — and risky — task of taking vulnerable children to the hospital with the equipment they need to breathe and eat.

At 11 a.m. on a recent workday, with two house calls completed, Perlman and Casavant rolled down a country road past a horse stable in Middleborough, Mass., about an hour south of Boston. Perlman parked her Honda CRV in the driveway, popped the trunk, and grabbed her version of a country doctor’s bag — black tote bag stocked with hand sanitizer, Clorox wipes, and a machine that measures patients’ breathing.

Casavant, who chose a checkered dress shirt instead of a white doctor’s coat, knocked on the door with a stethoscope around his neck. Inside, he slipped off his shoes, following the family rules.

The patient, 8-year-old Addy Stricklin, waited for them in the kitchen wearing a pink flower in her hair and a shirt that read, “Mermaid at Heart.” The newest member of the household, a 4-month-old red toy poodle named Finn, bounded up to greet the visitors. Casavant scooped him up and asked Addy: “Is he a boy or a girl?”

Addy, who usually brims with chatter, said nothing. She was feeling sick. To make her comfortable, Casavant and Perlman conducted her six-month checkup on a big blue couch in the living room. Casavant knelt beside her, checked her heart and lungs and ears, and peered with a penlight into her tracheostomy tube, which is inserted in the throat to make it easier to breathe.

A rare genetic disorder, campomelic dysplasia, gave Addy a very small stature and curved bones. Thanks to recent spinal surgery, she can walk quite well. She goes to school, accompanied by a nurse. She just got back from a trip to Disney World, where she went on lots of rides. But she faces many challenges, including hearing, eating, and breathing.

Her mom, Hannah Stricklin, took Addy to her bright pink bedroom, where she lay down beneath Minnie and Mickey Mouse and breathed through a ventilator. Her night tables gave a glimpse of how much is required for her care: ventilator, humidifier, and oxygen monitor on one side; bottles of pink liquid medicine on the other.

Charging, packing, and lugging that equipment — not to mention food, clothes, a feeding tube, and a suction tool — to Children’s and navigating the waiting room and Boston traffic can easily eat up most of the day, said Stricklin.

Instead, she was grateful to talk to the doctor beside Addy’s bed. Addy won’t eat much beyond yogurt and a few sips of juice, she told Casavant: “She doesn’t want to chew anything. She acts like she’s going to die.”

Casavant spent a full hour with the family, far longer than the 10 to 15 minutes he typically spends with a patient on the hospital’s pain treatment floor. In all, the home care team — Casavant, Perlman, Graham, a nurse practitioner, a social worker, and an administrator — tend to 300 patients through at-home visits, clinics, and round-the-clock phone calls. The program, called CAPE (Critical Care, Anesthesia, Perioperative, Extension, and Home Ventilation), makes five to 10 house calls per week.

Those calls range widely, from spacious homes like Addy’s to subsidized housing, from Cape Cod to western Massachusetts. Getting a peek inside the home lets the CAPE team check rooms for safety — and discover other risks to a patient’s health that wouldn’t be obvious at the hospital.

Casavant and respiratory therapist Lauren Perlman check Derek Orcutt’s breathing during a visit at his home in West Wareham, Mass.
When Casavant first visited the home of Derek Orcutt, for example, he asked the history buff and diehard Bruins fan how he would escape in an emergency. Orcutt, now 24, has Duchenne muscular dystrophy, a rare disorder that debilitates the muscles until the heart stops. He can move only his fingers, toes, head, and shoulders.

His mother, Carol, told Casavant that the plan was to pass her son out of the window — and risk breaking a leg if need be — rather than try to navigate the narrow hallway with bulky equipment.

Casavant found a solution: He called a Boy Scout troop leader in Westwood and got the troop to install glass sliding doors and a back deck last March. Now Orcutt can roll outside on a wheelchair or even in his bed. When the doctor visited recently, Orcutt reported that he has been getting out more often now, and even spent one evening watching a meteor shower.

Orcutt’s case gives a glimpse of why more patients are living at home on breathing machines. When he was diagnosed at age 2, his family was told he wouldn’t live past 16. But modern medicine, including multiple surgeries, a tracheostomy, and a home ventilator, has enabled him to live longer, and to spend his days outside the hospital.

Medical advances have also dramatically improved survival rates for premature babies and kids born with congenital anomalies, and there has been a “change in attitude towards the use of mechanical ventilation to prolong life, especially in muscular dystrophy,” said Dr. John J. Downes, a professor emeritus at the Children’s Hospital of Philadelphia. He created a pioneering home care program for Pennsylvania kids on ventilators in 1979. At that time, he said, there were just five patients. Now there are 225 per year.

Downes estimated there are 5,000 patients under age 22 nationwide who need daily help breathing. About half have disorders of the lung, heart, or airway, and may be liberated from breathing equipment one day. The other half, who have nerve, muscle, or brain disorders, will never be able to breathe on their own, he said.

Similar home care programs have emerged across the country, including in Los Angeles and Indiana.

One of the biggest challenges is finding money to keep the programs going. In Boston, CAPE has relied on grant money and support from Children’s. Graham argued that the program saves money by preventing costly visits to the ICU, but that’s hard to prove.

He said Children’s is taking the long view that the program is worth the investment in preventive care, since if these patients land in the hospital, they tend to stay a long time. But as of now, the house calls are not reimbursed by insurance and the program is not financially sustainable, Graham said.

It doesn’t sound personally sustainable either: Graham is on call 365 days a year, 24 hours a day for these patients. He said he gets 90 after-hours pages from them per month. Graham said CAPE’s social worker is beyond capacity in her caseload, and he still gets requests every other day to take on new patients.

“I have never turned anybody down,” he said.

Insurers Push Hard to Keep Seniors at Home

Published by Home Health Care News
By Tim Mullaney
March 18, 2016

Private insurance companies continue to concentrate on in-home services as a way to prevent hospitalizations and reduce overall costs of care, growing these efforts despite pushback from the federal government.

One such program, Humana at Home, is enrolling about 1,500 members daily and has reached nearly 1 million people nationwide, the Tampa Bay Times reported Sunday.

Humana at Home dispatches care managers to its beneficiaries’ homes. The social workers and nurses who take on the care management role do not provide medical treatment, but assess the beneficiary’s condition and provide assistance with health management.

For instance, Humana at Home participant Betty Herz has gotten help with her medications. One of Herz’s medications is expensive, so her care manager has taken steps to try to get the pills at a reduced cost, reported Tampa Bay Times Staff Writer Kathleen McGrory. Thanks to interventions like this, participants have had 45% fewer hospitalizations than anticipated, according to one internal analysis.

Insurers typically offer these type of programs through their Medicare Advantage plans. Another example is the HouseCalls program from OptumCare, which has made more than 1 million home visits to beneficiaries of UnitedHealthcare Medicare Advantage.

However, these initiatives have stirred controversy. Some insurers have utilized the in-home assessments to improperly inflate the risk scores used by the government to set Medicare Advantage payments, according to the Centers for Medicare & Medicaid Services (CMS).

But when CMS proposed getting stricter on how risk-score calculations would be tied to these home visits, the insurers protested, and the agency has backed off, noted McGrory.

Despite continued scrutiny from federal officials, programs like Humana at Home appear to be popular with beneficiaries and may be just another way in which in-home care is becoming the heart of the U.S. health care system.

Interdisciplinary Teams Connect the Dots in Home Health Care

Published by Home Health Care News
By Kourtney Liepelt
March 18, 2016

Between physical therapy, medication administration, assistance with activities of daily life and more, a home health patient’s care needs can be quite complex and at times prove difficult to manage.

That’s why once patients move from an acute setting back to their homes, care coordination and collaboration become more important than ever, according to experts at the 2016 Illinois HomeCare & Hospice Council Annual Conference and Expedition in Lombard, Illinois. Enter interdisciplinary teams, where various professionals come together to organize care and communicate throughout the process.

“We have a lot of great individual performers, but we’re not worth a dime if we can’t get on the same page,” said Cindy Kraft, CEO of Kornetti & Kraft Health Care Solutions, a health care consulting company that focuses on interdisciplinary, patient-centered care management primarily for home health agencies. “[Patients] are responding to multiple programs trying to exist simultaneously.”

Panelists expressed the importance of several disciplines working together to make decisions and set goals for patients receiving in-home care during last week’s session, titled “Interdisciplinary Approaches: What Home Health Providers Can Learn from Hospice IDTs about Patient Care and Cross Continuum Transitions.” They also outlined care models they’re employing at their respective companies and explained how they can be employed in different settings.

Take Western Illinois Home Health Care, for example, which implemented a behavioral health program called Restoring Wholeness at Home involving multiple disciplines. With a focus on anxiety and depression and the incorporation of behavioral health into the management of the agency’s home care patients, the program seeks not only to return a certain quality of life to those it serves, but also to prevent readmissions.

Interdisciplinary care is an integral part of the program, said Barb Byers, the agency’s CEO and president, and it requires that the entire staff meet monthly to collaborate on projects, interventions and goal-setting.

“When depression is not controlled, there is rehospitalization,” she said.

Another example presented was a complex care management program through Riverside Medical Center in Kankakee, Illinois, which provides nursing and other services in chronic disease management through all transitions of care in a patent’s journey. Someone first meets eligible patients while they’re in the hospital to see what concerns them most about going home, and from there, a team keeps in touch with the patient and other providers involved to monitor health status and assess early signs of problems, program coordinator Beth Ludwig said.

“I think we all know the reality of transitional care—it’s a mess,” she said. “We need to work together.”

Even pharmacists have their role in ensuring that a patient continues to receive care at home, said Jason Williamson, a registered pharmacist at McDonough District Hospital located in Macomb, Illinois. When it comes to interdisciplinary measures, pharmacists can serve as a drug information resource, as well as to prevent adverse drug events, inappropriate medication use and regulatory issues.

“Home health and hospice try to go it alone when it comes to medication problems, but they can reach out to us and utilize us as a resource—especially when it comes to reaching out to prescribers,” Williamson said.

Overall, the purpose of interdisciplinary teams is simple—allowing people to remain at home.

“We need to break down those walls and take care of it in the best place possible, and that’s in a patient’s home,” Ludwig said.

Bridging the gap between hospital and home

Published by King5
KING 5 HealthLink
March 18, 2016

Today's healthcare model includes mandates to improve the patient experience while reducing costs. They seem to be opposing forces, but there's a national movement to help accomplish both by providing transitional medical care, bridging the gap between a hospital stay and recovery.

Henry Campbell, 72, was hit by a car last summer.

He needs a little help in these last stages of recovery and that's where Karen Coppin literally comes in.

As part of the Transitional Care team at Southwestern Vermont Medical Center, she makes house calls.

“I would say on average we see three patients a day,” Coppin noted.

Transitional care nurses provide support through home visits or simply checking in by phone with patients after they're discharged from the hospital.

Often, like Campbell, they're confused by all their medications.

“So I went with Henry to one of his visits so that we could talk with his doctor about it a little bit more, but I thought it would be better for Henry to have all his medications prepackaged,” explained Coppin.

People are identified for care by their primary care doctor, hospital staff or nursing home staff.

“We've had patients that are in their 30s and we've had patients that are 101,” pointed out Billie Lynn Allard.

She developed the program about two years ago in response to health care reform, which mandates shorter hospital stays.

However, shorter stays can mean little time for patients to understand their discharge instructions. That can get in the way of another mandate: to reduce readmission rates.

Transitional care helps on both counts.

Knowing they have a lifeline, patients return home feeling more secure and less anxious about their recovery.