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Experts addressing the need to provide targeted home healthcare to elders within the Medicaid population share their thoughts…Join us to hear what these experts have to say... Sylvia Talkington, Dawn Hall, and Jean Jackson have to share.
The invited panel answers 2 questions provided to them for this forum, as follows:
- What do you think is the best use of home telehealth particularly for the Medicaid elderly population? What tools have you seen used so far?
- What do you perceive (or what have you already seen) being the main obstacles for use of telehealth with this group (elders on Medicaid)?
Sylvia Talkington, RN, Clinical Consultant, Honeywell HomMed:
Question 1. What do you think is the best use of home telehealth particularly for the Medicaid elderly population? What tools have you seen used so far?
When I think of our elderly Medicaid population, what comes to mind is complex- chronic- complicated. As a home care nurse case manager coordinating care of these fragile seniors, I believe the best use of home telehealth for this population is remote monitoring on a daily basis. These seniors want to be at home not in the hospital or nursing home. With remote monitoring changes in status can be identified early. Subtle changes can signal a deterioration that, if unchecked, would lead to more expensive levels of service.
From my view, a home telehealth system must have the capability of assessing and trending both objective and subjective changes. Such a system has a design that respects and preserves a senior’s independence and sense of control. The equipment is reliable yet unobtrusive, non-threatening in size and simple to use. Visual and verbal cues in a preferred language, with adjustments to accommodate vision and hearing, are features that enhance use and contribute to accuracy.
However, early identification is useful only if there’s a corresponding intervention. Telehealth tools that deliver a response in the form of a personal contact, for example a phone call, can provide timely support for reducing symptoms, facilitating medication and treatment compliance or changes, and addressing learning needs for diet, meals, and activities. While a number of systems and equipment have some of these characteristics, the Honeywell HomMed system meets all these criteria; a criteria most suitable to elderly Medicaid patients, because of design, features and intended use.
Question 2. What do you perceive (or what have you already seen) being the main obstacles for use of telehealth with this group (elders on Medicaid)?
As clinical consultant in remote home telemonitoring with past involvement in home care and telemedicine research and demonstration projects, I consider access to telehealth applications will continue to be the main obstacle. Currently, there is a reluctance of home care providers, the primary source of home telehealth, to establish a payer mix dominated by a high % of Medicaid patients. For some, it’s not a viable business decision at this time.
Access is further complicated because the numbers of physicians accepting Medicaid patients is decreasing. This contributes to a situation where the senior may have more than one entry point into the system and multiple care providers, even in states with mandated single entry points.
Home care providers are a logical origination point for providing access to a home telehealth intervention. Yet, access will need to expand to include other entry points, such as inpatient and outpatient facilities and affiliated community services agencies. Providers who intersect with Medicaid health care or services, such as social services case workers, advanced practice clinicians, clinic staff, and others will have to become the origination point by facilitating and coordinating access and use of telehealth interventions.
A hidden barrier to access is an overall lack of awareness of home health services and in particular the availability of homecare to Medicaid recipients.
Finally, another less obvious, but very real, barrier to access is a disconnect between traditional telemedicine programs and telehealth applications in the home. First of all, there is, a lack of awareness that each exist. And second (taxonomy aside), there is little awareness that telemedicine and home telehealth are like night and day. Having an understanding of telemedicine does not correspond to an understanding of the technology, applications, and rationale for
remote monitoring in the home , whether for Medicaid patients or not.
Both telemedicine and home telehealth are telehealth applications and are not mutually exclusive. In fact, they can and should be complementary. When telehealth is applied across the continuum for Medicaid patients, access will improve.
Here are a few thoughts on how well the technology is working with the elderly Medicaid population to date. First of all, let’s look at how well the patients think it “works”—here are some common responses to the technology after an initial demonstration of the
Honeywell HomMed system in patients’ homes :
- “Well that’s nothing, I can do that”
- “Gee, I thought it was going to be something I wore or would keep me confined”
- “That’s easy”
- “You mean I don’t have to do anything but just what the voice says?”
- A 90 year old WWII veteran about whose management of the technology I was a little concerned -- given he lived alone and had no regular caregivers-- when he was a little slower with getting on the cuff; said: “Honey, I was in the Pacific in WWII, if I can’t deal with this I might as well give it up all together; Hell yes I can do it”
Dawn Hall, RN, Administrator of Home Telehealth Program, Baptist Hospital Home Care, Winston Salem, NC
Question: 1. What do you think is the best use of home telehealth particularly for the Medicaid elderly population? What tools have you seen used so far?
In 2003, Baptist Hospital Homecare began our telehealth monitoring program by placing four patients on monitors. One of those patients was a 69-year-old male with congestive heart failure, diabetes, and end stage renal disease. This case, and all the ones to follow, made the need for this type of program painfully obvious. Over the last four years of directing the telehealth program, I have become acutely aware of the benefits this program brings to our service population and their families.
For instance, before being admitted to our program, many of our Medicaid patients had frequent and unscheduled visits to the emergency department and other hospital facilities. Our program provided these patients with daily assessments of their health status and quick responses to any abnormal variations. Based on the need, nurses may place phone calls to patients and/or their physicians, conduct in-home nursing visits, schedule visits to health care providers, or change medications based on physicians’ orders. Without these types of services, the only alternatives are emergency room visits, hospitalizations, or even death.
The following case illustrates this need:
The patient is an 83-year-old female with atrial fibrillation, hypertension, CVA, and vertigo. She was living alone when her vertigo became so severe that she had to move in with family. Facility placement was not available in her area at that time. Her family was having a difficult time managing her presyncopal episodes. She began having frequent falls.
This is when Baptist Hospital Home Care began daily HomMed monitoring. Within the first month of monitoring, the patient developed bradycardia in the 40’s which was detected by the telemonitor. It was determined by the patient’s doctors that the bradycardia was related to her beta blockers. At this time, her medication were adjusting, improving her presyncopal episodes. The patient was able to return to her own home alone with continued daily monitoring. One month later the patient had a syncopal episode which caused her to black out for 15 minutes. She then called the HomMed central clinician, who requested that she test her vitals. Her heart rate was found to be in the 20-30’s. The clinician at this time activated the EMS signal and the patient was taken to the hospital. This hospitalization resulted in a pacemaker placement. The patient has returned home healing well from surgery without episodes of syncope. Monitoring saved this patient’s life!
Clearly, there are benefits for the families of telehealth patients, as well. Family members, near or far, can rest assured knowing that their loved one is receiving daily care from trained professionals without having to leave the comfort of their home. In addition, families observe how patients learn to comply with and participate in the management of their disease.
Question 2: What do you perceive (or what have you already seen) being the main obstacles for use of telehealth with this group (elders on Medicaid)?
Through my work in this program, I’ve learned that this population requires our current healthcare system to modify its traditional approaches to treatment. Sometimes these patients need close attention and repeated instruction on how to manage their disease. Through their interactive involvement with the telehealth program, patients begin to realize how their actions impact their health and learn ways to live within the limits of their disease.
The following is one case illustrating this point.
This patient is an 87-year-old male on home oxygen, with a long history of congestive heart failure, COPD, and CAD. He has been on our service several times in the pas [prior to home telemonitoring use by our agency], requiring frequent hospitalization. In a span of four months, he was admitted to the hospital at least four times. On one occasion, he was discharged from the hospital, only to be readmitted the following day.
Following this hospitalization, this man was placed on the HomMed monitor. During the 6 months this patient was monitored, he was hospitalized only one time for CHF, and had no unscheduled doctors’ office visits! Because we were able to monitor his weight daily, we were able to work with his cardiologist and primary care physician to adjust his diuretic therapy to prevent frequent CHF exacerbation. Monitoring helped this patient to become very compliant with his medical regime.
Jean Jackson, RN BSN, Telehealth Coordinator, Good Samaritan Society Colorado Home Care, Boulder, CO
Question: 1. What do you think is the best use of home telehealth particularly for the Medicaid elderly population? What tools have you seen used so far?
The Good Samaritan Society Colorado Home Care staff has used Honeywell HomMed telehealth equipment with 23 Medicaid clients within the past 3 years. Most clients transmitted Vital Signs daily, a few only transmitted when a Home Care staff member was present to assist them. We have seen a wide variety of results, so let me tell you a few successes and a few challenges we have faced.
Since the needs of the Medicaid clientele we serve through Home Care are generally more chronic and long term than those of our other clients, the benefits of using telehealth to record and monitor daily vital signs are different, in many cases. For example, one client has been receiving weekly Skilled Nurse visits for medication set-up and assessment for the past 2 years. Because she lives alone, is on oxygen, has limited endurance and mobility, her daily transmission of VS allows the Home Care staff to monitor her condition on the six days of the week that the RN is not present. When her weight started to decline, weighing in at only 78 pounds to start, her Home Care RN knew to address the cause of the weight loss before her weight loss progressed. At one point, when answering the questions on the monitor, this client started reporting an increase in fatigue. When the RN followed up with the physician ordered blood work, she was diagnosed with anemia, treated and remains at home, alone, today.
Another client, who lives with his sister and monitors daily, was noticed to have a few low oxygen saturation readings. The nurse was called to assess the client prior to her scheduled visit and found the beginning symptoms of pneumonia. This client ended up receiving treatment in the hospital, but is convinced that the early detection of the pneumonia allowed him to return home much more rapidly than he had previously experienced.
Question 2: What do you perceive (or what have you already seen) being the main obstacles for use of telehealth with this group (elders on Medicaid)?
Looking back on our experiences in home telehealth with Medicaid patients, bstacles are few and far between. Using the telehealth monitor to keep in touch with clients on a daily basis has clearly demonstrated to this agency that early intervention of complications of chronic disease processes can prevent or shorten hospitalizations. The clients report, in most instances, being comforted by knowing there is someone watching out for them and someone who will check in with them if they fail to monitor or if the results are concerning.
Part of our use of Telehealth is for education of the clients to learn to use the information so they can better control their own health and well being. The clearest example of this is when a client has wears oxygen, either continuously or intermittently, the RN teaches the client and/or the family to assess the SpO2 readings, to check them outside of the routine monitoring time, and to take action if the readings are low. Often, they will find the oxygen tubing has been disconnected or the filter is clogged and can remedy the situation before harm is done.
Some clients will be unwilling or unable to make changes based on the monitor results. However, those that are willing receive a second layer of reinforcement from the nurse who is reading the results as well as from the Home Care RN visiting the home. Again, many clients report feeling secure and comfortable with the monitoring process and the support of the Home Care staff.
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