Case Studies.what's working

Five home telehealth providers share their experiences from the funding trenches-- in Ohio, Wisconsin, Iowa, Minnesota, and upstate New York. Common thread: establishing community support gained through education about telehealth, using telehealth with persons in the community, and providing them and still others in the community with continuing education about the value of telehealth use. Views are provided by LeeJean Krach of Fidelity Health Care (Dayton, OH); Laura Hieb of Bellin Home Health (Green Bay WI), Kim and Allen Anderson of Rural Health Care Advantage, Inc. (Chariton, IA), Beverly Gillund, of Hendricks Community Hospital Home Health Agency (Hendricks, MN), and Mary Beth Rutkowski, the Eddy VNA (Troy, NY).

Case1 | Case 2 | Case 3 | Case 4 | Case 5

Case 1: LeeJean Krach provides a step-by-step view of the typical need to start small, garner initial support for using telehealth to help reduce high cost CHF and COPD patient care, and then using the good outcomes results for ongoing education efforts to garner still more support.

The days of approaching MCOs with the idea of hypothetical potential savings with telehealth are over. Recorded numbers of reduced costs have to be in hand when approaching these potential clients/funding sources. Read this piece as the Fidelity Health Care effort to gather 4 years of ammunition for growing and sustaining a home telehealth program.

LeeJean Krach, RN, BSN, CRNI
Disease Management Coordinator
Fidelity Health Care

Fidelity Health Care (FHC), located in Dayton, Ohio is a non profit home health agency providing home health services to a 12 county area. As part of our home health services, Fidelity also has a cardiopulmonary telehealth program. The telehealth program is specifically designed for patients with either congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD). The program began in 2001 and at the time consisted of 6 televideo units. The program was created as a result of a disease management initiative to reduce CHF hospital readmissions and improve disease management skills. Since the beginning, the program has been funded by the Miami Valley Hospital Foundation, which supports programs and services for patients of Miami Valley Hospital and its affiliated organizations only.

The program has grown significantly and now houses 36 televideo units and services the COPD population as well. FHC is currently in-servicing our referral sources, attending health fairs and creating marketing brochures regarding the benefits of telehealth. The program will continue to expand in the future as the benefits of telehealth are shown by reducing hospital readmission rates, reducing ER encounters and improving patient outcomes. With the overall reduction healthcare cost, it is with great hope that the MVH foundation will continue to support our efforts as they have done in the past. We would also like to explore reimbursement options with managed care companies for telehealth services.

Case 2: Laura Hieb, of Bellin Home Health, provides a view of the considerable legwork that was involved in targeting and receiving funding for home telehealth from local donations and local grant organizations. Continually educating one’s community about telehealth and its value is a must for making telehealth work.

Laura Hieb, RN
Team Leader
Bellin Home Health
Green Bay,WI

Funding of telemedicine.
Bellin Home Health was fortunate in that we were able to secure funding to cover the first year of our telemedicine project and parts of subsequent years.  We have been using monitors for 3 years now.  We started with 25 monitors and now have 80.  We will likely be adding another 16 in the next few weeks. 

One of the ways we were able to cover our expenses the first year was by obtaining local donations.  Our team completed a series of one-on-one presentations to local agencies and organizations asking them to support the program.  One of the local donors was a cardiac support group that contributed and sponsored some monitors.  We also had our hospital system auxillary that made a sizeable donation and we also had an anonymous donor that contributed to our cause.

 More recently we received a grant from a local community group that had a goal to 'assist people in staying in their homes'. (We hope to continue to tap this resource this next year also.)  The grant is incredibly helpful, but does require some paperwork follow up that someone must track. 

We truly found that if you have someone on your team that has time to go out and market the program, share results, share case stories, and discuss the impact telemedicine can make that you will find people to contribute.  It took a great deal of time and energy, but the rewards were positive. 

Our agency has looked at some of the larger grants, but the time it would take to do the application process was just too intensive.  The immediate approach seemed to work better for the size of our agency.

The other thing that we do at our agency is subcontract our telemedicine units to other agencies.  This helps us cover the costs of the program and also allows the impact of telemedicine to spread in our region.  We have found that it is much more widely accepted now than 3 years ago.  Patients, families and physicians now know about telemedicine and call us directly to ask for its use.

In the past our agency had also placed the telemedicine units in some CBRF's and assisted living facilities.  We had some success with this program, but not as much as we hoped.  Often times we found that the facility was trying hard to keep their prices low, so they didn't want to add another expense.  If the patient and family paid directly to put the device in their home, then that works well (except some facilities did not have phone lines in the direct patient rooms).

Overall, the following is a list of how we covered our costs:
Local support group donation
Anonymous donation
Hospital auxillary donation
Local community grant
Subleasing

We have also had some commercial insurance carriers, the VA, the Community Options Program, and private pay patients that have paid for the telemedicine use.

Clinically, we have also increased our participation with the hospital wide congestive heart failure collaborative.  Our interaction with this team has helped telemedicine become more popular and a recommended tool for patients that have moderate to sever CHF.

The monitors have also assisted in bringing in new referral  sources to the agency.  Physicians that did not use our service in the past are starting to call us now because they want their patients on the monitor.  The added volume then assists in bringing up our total volumes.

Case 3: Allen and Kim Anderson, owners of Rural Health Care Advantage, Inc., report on their view of the value of home telemonitoring and the need for smaller agencies to shoulder the investment in the technology, if state or corporate funding is not easily available. They estimate that: “For $75,000 to $100,000, an agency can get a program started and build on that.” The building, particularly as described in their final paragraph, includes establishing a chronic disease-monitoring program at a local senior meal site, and in effect taking telehealth to the community and in that way garnering solid support for telehealth use.

Allen Anderson, Business Manager and CFO
Kim Anderson, RN, CEO, Nurse Administrator

We would like to tell you about the telemonitoring program we have established at Rural Health Care Advantage Inc. We are in a very rural elderly area of the state of Iowa. The population is aging and resources are very limited in our region. We have had a need for registered nurses in our area for quite some time and telemonitoring has helped with this issue. We have been interested in this technology since before its inception and have always felt that we should be able to monitor our patients via technology to get the best possible care. This technology became available to us in 2002.

We have utilized a vital statistics gathering system offered by Honeywell HomMed that gathers information that allows us to monitor the daily condition of our patients. We did not utilize any grants or up front capital to acquire this system. We had determined that the value of an additional R.N. was well exceeded by the efficiencies offered by the program. One nurse is now able to case manage 40 to 50 patients with better outcomes than we were able to prior to implementation.

Cost is a big factor, of course. However, we feel that the investment in telemonitors has saved our agency not only the cost of additional personnel, but has saved in the associated costs of insurance, payroll taxes, wasted time and mileage, etc.

Could we obtain outside funding, we wondered, initially. In sitting in a meeting talking with people from Dept of Human Services among others, the Dept representative mentioned that he did not mind paying for the service but felt that the Dept should not have to buy the equipment. We also failed to receive any funding for establishing a homecare computer network system with software to maximize all the things they promise. Faster reimbursement, better scheduling, etc.

By that time, we became attuned to the idea that telehealth simply needs to be incorporated in your “normal operating budget.” Funding for telehealth should not be expected, in other words. Nobody paid for the stethoscopes or blood pressure cuffs that our RNs use, or the scale that is used to detect variations in weight. Telemonitoring is a tool that can either be embraced or ignored. With the World Wide Web being a part of society, the public is more educated than ever on their condition and want service that is high tech also. Research shows that technology has made our life simpler and more efficient. This is not a trend, it is the future.

We feel that the telemonitoring offers not only a competitive advantage in the increasingly difficult home care arena, but it offers what the customers want. We would personally want the additional service if we were patients and if it were available with the same basic service price with no additional cost to us. Our results have been very much what the public wants. We have used telemonitoring to adjust medication levels in as little as a week whereas everybody knows the basic routine, “Take this medicine and make an appointment to see me in two weeks.” In one case, we monitored the vitals to see if that medicine was working, and when it did not, we consulted with the physician who upped the dose. That did not work either, so we consulted with the physician who ordered a different medicine that did work. Total time 10 days. We have also used the monitor to troubleshoot a diagnosis where a physician was addressed with the problem of someone short of breath. The physician referred the patient to a heart specialist (appointment in two weeks if you are lucky, 6 weeks in our case), but our telemonitored readings showed a consistently low blood oxygen level (SpO2). We had the readings to qualify the patient for Medicare Oxygen, and the readings guided the physician to send the patient to a pulmonary specialist. This was accomplished in less than a week.

We have used the monitor in hospice with very good results. While every patient does not want it, patients and families that utilize it have noted considerable peace of mind knowing that the nurse is looking over them daily. We have been able to track trends over time to see decline in conditions. This has been used to notify families and caregivers that death may be imminent. We have caregivers that have called us stating that their loved one is not doing well. After gathering current (maybe a mid-afternoon retest) vitals showing abnormally low readings, we have been able to send personnel to address their concerns and care for them during what may be the final stages of life.

As to funding for these many improvements we report: Many banks and capital companies offer long-term leasing contracts that give you the equipment on a monthly payment plan. While that worked for us, many home care agencies are writing for grants but you have to be in the right spot at the right time for that. Also you don’t need to buy a quarter of a million dollars of equipment to implement the program. For $75,000 to $100,000 an agency can get a program started and build on that.

Once a program is started, variations of telemonitoring are very marketable. We have established a chronic disease-monitoring program at the local senior meal site. Results from this program have been very good. 50% of the participants have had medications adjusted. All participants have become more educated about their disease and the disease process. It has also strengthened the bond between patients and their physicians. Telemonitoring is very much used in assisted and independent living facilities for assisting with chronic disease management. This keeps people healthy and where they, their caregivers, and families want them to be, home.

Case 4: Beverly Gillund, of Hendricks Community Hospital Home Health Agency (Hendricks, MN) provides yet another view of garnering community support—in this case, the support of the home care agency/organization community, by providing in-service training on telehealth to extend their own reach in rural Minnesota.

The Hendricks Community Hospital Association (HCHA) engaged implementation of home telemonitoring services in 2002 to be on the leading edge of home and hospice care service delivery. But we were buying more than machines. Once we invested in the technology and with the assistance of our telehealth vendor, we developed a proactive model of care. This cultural shift is absolutely key to impacting improved patient care outcomes and agency success.

A challenge in using the technology in this way, however, has been in helping practitioners to understand why it's needed and to realize and get excited about the clinical value. With telemonitoring, nursing practitioners have ready access to seven-day a week information in their agency office as opposed to being dependent on retrieving clinical information when in the home on a patient visit schedule. On another note: Consumers are more knowledgeable today. They expect more services inclusive of "state of the art" resources, equipment and efficiencies in the care that is delivered. It makes good business sense to learn how to please our clients and meet their expectations of exceptional care delivery.

We're are also currently using our resources for telehealth to work toward a bigger vision beyond our agency service area and into our surrounding communities and throughout the state of Minnesota and into South Dakota. I have worked toward mentoring colleagues in telehealth at other local agencies. Beyond this, as a strong advocate for telehealth in Minnesota, I've facilitated the first area Medi-sota Telehealth Users' Group Meeting for a network consortium of home health care providers in SW Minnesota. We believe in the the merit of telehealth integration into the health care continuum and are committed to keep momentum about home telehealth on the horizon of conversations. We'll be working further with the Stratis Health-Minnesota's Quality Improvement Organization for Medicare, Minnesota Home Care Organization, Minnesota Telehealth Association, Minnesota and South Dakota Department of Human Services, and the Minnesota and South Dakota Hospice Organization to meet this goal. Becoming recognized as leaders of excellence in innovative technology strategies to positively impact health care delivery is a credible goal for us.

And so, from an initial and visionary funding plan of action, HCHA has moved well beyond adding telemonitoring machines and counting "saved" in-person visits in our Home Care agency. With telehealth technologies, we are positioned to meet nationwide initiatives in home care and impact health care delivery in additional arenas in the health care continuum all motivate to improve patient care and satisfy consumers. Technology implementation provides this opportunity to shift to a proactive care model and achieve and excel with improved patient outcomes across the continuum of care.

Case 5:

Mary Beth Rutkowski and her team, of the Eddy VNA (Troy, NY), report on how they've covered all the bases needed for home telehealth success, including: securing funding from diverse sources, educating staff on telehealth's value, and assigning a full-time Telehomecare Coordinator to keep the staff's momentum high and the program growing.

Mary Beth Rutkowski, RN, MSN
Director of Patient Services

The Eddy Visiting Nurse Association, based in Troy, NY, acquired funding for its Telehomecare Program through several sources: the Verizon Foundation, legislative funding from NYS Senate Majority Leader Joseph Bruno, local and regional banks, private contributions, and a grant from the NYS Department of Labor.

HMOs that cover Telehomecare visits are BSNENY (Blue Shield of Northeastern New York), CDPHP (Capital District Physicians Health Plan) and MVP(Mohawk Valley Plan).

The Eddy VNA attributes its success with its Telehomecare Program, in part, to the great deal of education its staff does on the benefits of the technology for patients, families, physicians and payers. The agency has assigned a Telehomecare Coordinator who is fully dedicated to the program. Her efforts have also contributed to the significant growth of the program.

Currently, Eddy VNA is expanding its Telehomecare Program into more community housing sites, with the addition of Telehomecare kiosk monitors for residents. The agency anticipates adding monitoring units to several housing sites this summer.

For more information on the Eddy Visiting Nurse Association or its Telehomecare Program, please contact Johanna Lupoli at (518) 270‑1377, or via email at lupolij@nehealth.com.

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