Nancy Dereng, Executive Director of Hospice, Interim Hospice, Spartanburg, SC

Our home health division is very active in the telemonitoring system. I am responsible for the hospice program and have been researching the applications for telemonitoring in the hospice/palliative care setting.

One of the concerns I have is that so often, the family just needs someone to give them a reassuring visit and some individualized attention (hugs included!) that may be a bit of a challenge in the high touch hospice arena. That said, I do believe we have a large group of chronically ill/terminal patients who just are not ready for hospice yet and they would not always meet the criteria for skilled home care. Those are the folks that need to access palliative care and yes, I do believe there is a significant role in telemonitoring in these cases. I can think of at least a dozen patients that we have discharged or not admitted to hospice in the last few months, that would benefit from such a link to a healthcare professional.

Of course, the concern is always how this is funded and in our area, those who need this the most are probably more commonly in the low income bracket. Being a not-for- profit hospice, we have a foundation that provides for uncompensated care but the other issue is that if you "give away" services of value, you could be determined to be out of compliance with the anti-kickback statutes.

In general, it is very difficult for patients with chronic disease to access palliative care for a number of reasons. There is not a funded program for palliative care under the current Medicare program as most of these patients do not require the skill of a RN on an intermittent basis and many are not at the point of being homebound and most of them have had all of the teaching and monitoring allowed in the current home health reimbursement structure. Many hospice and palliative care programs are hiring physicians and nurse practitioners to perform home visits for palliative care disease management and can be reimbursed for that physician/nurse practitioner visit but that is on a very limited scope. Most of the chronically ill patients end up in the ER for exacerbations and then even more frequently are hospitalized unnecessarily because they have not had chronic disease management from a professional in the home.

I can see the incredible impact the telemonitoring program would have on reducing inpatient and ER care at our hospitals--especially when those patients are often in and out of the hospital frequently in the last year of their lives. The cost of the telemonitoring system and a physician visit one time a month in the home, I believe, would have a significant impact on our hospital utilization.

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