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Why not home telehealthcare and continuous contact and education now? They’re not routine yet. And, the norm, since Medicaid was enacted more than 40 years ago, has been serving the senior Medicaid population in nursing homes and similar institutions.

But it’s not the only way. Hear what Kim Anderson urges us to consider for providing long-term, community-based care to the elderly living with chronic disease and living on Medicaid.

Currently, the entire state of Iowa is being covered by agencies using telehealth with Medicaid patients living with chronic diseases and conditions. Most home health agencies in Iowa are using a comprehensive program with good outcomes. Of importance beyond this result, however, is in using telehealth in the chronic Medicaid population to keep them well and maintain their independence. “Chronic” is just what it implies: this population will always have episodes of acute flare-ups, but if you can monitor them daily and prevent that acute episode and keep them healthy and safe at home and vibrant in their communities again we all win!!  

We are following a different path in healthcare service delivery. Our medical system has always waited for the catastrophe to take place and then fixed it after it has happened with this population costing our system millions of dollars. Everyone knows that a low percentage of the population falls into this category and they cost the medical system the most money. However, you can disease manage this population very easily with the use of telehealth and prevent that catastrophic event and save the system millions in dollars. Obesity, high blood pressure, congestive heart disease, coronary artery disease, diabetes are all on the rise at younger ages. This is the chronic population that needs diseased management to stop the spending and adjust our thinking to prevention. Disease management is for the long haul--this is the solution, not a band-aid over the bleeding. The medical profession is ready for the future in Home Care and beyond; now if the funders and legislators can catch up we may get somewhere. We can only hope!!!!

Because we should say at the outset: these recipients--the chronic Medicaid population-- is a very needy population, one often having more than one morbidity and a low social economic standing as well as often low education level. Education with a capital "E" is everything with this population and needed on a daily basis. However, educating through telehealth is still cheaper than our traditional system is now. By monitoring the patients daily with easy-to-use data collection tools and by having the patient and family involved in the education and use of the telehealth system, they become more proactive with their own care. If they do not submit the data on a day-to-day basis, they know the nurse will call them and do a telephonic visit and educate them on signs and symptoms to watch for and report. They know that if they don't take that water pill, it will show up in their daily weight as a gain and the nurse will call them and educate on the importance of medications and side effects of taking or not taking them. They know that if they eat a lot of salt that it will show up in their blood pressure and their weight.  

Trended data is key; viewing it is when clinicians will pick up problems, and it’s that accumulation of problems that causes the catastrophic event and lands the less compliant patients in the hospital. As a result of this closer tracking, however, the patient becomes more proactive with his/her own care due to more telephonic visits and education, but also the innate need to not be a part of the nurse’s day. The patients want her to do good, and they want to be independent, and so if the patient knows that the nurse will be calling, then he/she will do what he/she can to prevent that and take the lasix, and reduce the salt intake and so on, on their own. In fact some of our most difficult, non compliant patients are the most compliant with the telehealth program because they can do it on their own without the intrusion of a medical person, yet they know they have to be compliant to accomplish less visits from the medical team. So again it is a win-win for the patient, family, medical team all at the same time saving the system millions. Telehealthcare really is the answer. Should Medicaid pay for home telehealthcare? Here are my views: Some insurance companies such as Medicaid don't want to be the first to pave the way for telehealth to be reimbursed. They would rather sit and see how it goes. Or wait till technology catches up in the other areas of medicine such as laser surgery. However, the homecare setting is a beast of its own, and to wait till the other areas of service delivery catch up is insane when you look at the cost savings that can be achieved now by utilizing a telehealth program in homecare and hospice arenas today. This waiting is a waste of time, in my opinion-- we already have so much data on home health and telehealth and savings to agencies and decreased hospitalizations and emergency room visits, and on its effectiveness in rural areas.  

Today, in Iowa, our goal is to keep people out of the facilities and have good outcomes. It just makes good common sense. We will continue to keep the fight going in Iowa to make a difference in the way good quality care can be delivered in the patients’ homes using telehealth to achieve good outcomes safely and independently even in the face of high gas prices, shortage of caregivers, and stringent regulations and reimbursement policies that the government should be ashamed of for home health care providers in Iowa. I own my own business and between offering my employees health insurance, retirement and paying mileage and workers compensation and so on to meet the government regulations, it is getting harder and harder to do a quality job when I receive only 60% reimbursement of what it cost me to do business. I'm afraid the small rural agencies will have to adjust to the new 2008 regulations and reimbursement in Iowa in out of the box ways to survive and produce high quality care that we all strive for.

Telehealth and the Iowa Medicaid population. We’re getting there. As the president for the Iowa Association for Home Care, one of my objectives was to work with DHS, Dept of Elder Affairs, and Iowa Medicaid Enterprise to be visionaries in the arena of telemedicine for the chronic population. Since the fall of 2006 a committee of representatives from both the IAHC and IME met weekly and sometimes bi-weekly on Medicaid reform issues and one of the topics as you can quess was telemedicine. A proposal was submitted Nov. of 2006 to add onto Medicaid as a recognized billable service, telehealth.  

Since then we have been in contact with legislation, DHS, IME and worked diligently for the cause. What is the cause? Telehealth and Home Care are the answer to the medical budget crisis with the chronic population. We can reduce skilled visits, have better outcomes with this population and keep them out of the emergency rooms and hospitals, isn't that what it’s about!! It works: monitor a chronic patient daily collecting biometric and subjective data and trend that data, then forward it to the proper disciplines and you can manage a chronic patient indefinitely with good outcomes and quality of life. No institutional care needed. The system is so institutionally minded that it is hard to shift our train of thought, but once you begin to see the results of these telehealth programs you realize the insurmountable cost savings to the government, communities and business. Using home telehealth is a win! win!  

Our medical arena in Iowa needs to look at all the providers such as Nurse Practitioners, Physician Assistants, Home Health, Hospice, Telehealth to assist in this new age of baby boomers who demand to stay home and to be taken care of using the high technology of today. The demands on the provider are growing with baby boomers, new rules and regulations, new payment structures where you will be reimbursed on your outcomes and penalized for bad outcomes. If you keep you chronic well and out in the communities contributing to the well being of the social structure we all win. We are currently in a battle to get funding for telehealth, but we have made many strides forward. New funding is being set aside for technology and the impact it will make on this new generation of chronic and acute patients ( more demanding, and outcome based). IME is at this time not funding the service telehealth, but has not taken it off the table for negotiation. There are some Iowa Medicaid Waiver programs that at this time do cover telemedicine under the specialized medical equipment service. So a Home Health Agency would have to be a provider of DME to be able to bill for the monitor. My agency has a contract with a local DME company that sells the monitor with a nursing service. It has worked well. But we intend to go further than this with Medicaid funding that’s, needless to say, very much needed for our elderly populations at home.

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