July 10, 2020 – With the world stuck in the midst of a pandemic, health systems are looking to telehealth to shift the balance of care out of the hospital or clinic and into the home.
That strategy is shining a spotlight on the home health care industry, which has long balanced connected and in-person care but – faced with a shortage of providers and a growing surplus of patients – could use more of the former and less of the latter.
COVID-19 aside, home health care providers are looking to push the envelope on care management and coordination. They’re using telemedicine technology, ranging from mHealth apps and connected devices to remote patient monitoring and smart home programs, to provide a continuous care experience, and one that balances clinical support with self-management.
The pandemic has certainly helped that strategy, with a record number of care providers using telehealth to bypass crowded or closed hospitals and clinics and offer care at home. But while federal and state regulators have enacted a slew of emergency measures to expand telehealth access and coverage, the home health care industry has seen few benefits.
How the industry has used telehealth, and how providers are positioning themselves now to embrace more virtual services, may well sway lawmakers and policy wonks to give home healthcare providers more freedoms in the future.
Banner Health’s home healthcare program has been using telehealth for roughly three years, giving nurses a virtual window into the home lives of some of the Arizona health system’s most frequent healthcare users.
“It’s good to have that extra visual touch on them,” says Mandy Johnson, senior manager of Banner Home Care’s post-acute care coordination program. “And it gives us information in real time that we need” to improve care.
Johnson says Banner’s program, which partners with New Jersey-based Health recovery Solutions (HRS), gives telehealth kits with Bluetooth-enabled devices free of charge to patients who have been identified as at a high risk for hospitalization, newly diagnosed with a chronic condition or recently discharged and at a high risk of rehospitalization.
The kits allow care providers to connect virtually with patients to monitor vital signs and collect other data on a daily or weekly basis, and to see how patients go about their daily lives – a key factor in determining how to manage and adjust their care.
A cupboard or refrigerator filled with sugary snacks might not be the best thing for a person living with diabetes, and a few pets in the house might affect the treatment plan for someone with asthma or other breathing issues.
“The hospital is a stable environment,” Johnson says, “so we want to see the patient at home, and use that home environment to teach them” how to care for themselves and improve their health and wellness.
Patients are very receptive to the program, she says.
“They want to stay home – that’s where they’re happy.”
Johnson sees a future for more telehealth in home care, especially as mHealth sensors and connected devices become more sophisticated. Bearing in mind that the health system finances the program, she’d like to see a bring-your-own-device program put into place, giving patients the freedom to use their own devices.
“BYOD is a great option to scale” the program upwards, she says, “as long as it can be made affordable for the patient. It would help us, and you’d be using the infrastructure that the patient already has.”
At Detroit’s Henry Ford Health System, an ambitious home health care program tracks a wide range of patients, including those with chronic conditions like heart failure and COPD, cancer patients undergoing chemotherapy, those recovering from thoracic cardiovascular surgery and patients who have had heart or lung transplants.
Mary Hagen, who manages the health system’s e-Home Care program, says the program, in place for serval years, focuses on reducing the readmission rate – a troubling statistic that can cause providers to lose valuable federal funding through penalties.
The program, which sends patients home with tablets and wireless devices, enables care managers to check in with patients on a regular basis, and tracks their health through vital signs and surveys. The idea is to give providers a daily snapshot of a patient’s health, allowing them to adjust care management and spot downward trends before they become health concerns.
Hagen says the key to developing a successful program lies in not anticipating results or buy-in, but going in with an open mind.
“You can’t predict how anything will go,” she says. “You just have to try it out on every person that you can, then go from there. Once you get the (technology) in place and people start using it, you find the benefits that you never saw before.”
Hagen says providers weren’t too enthusiastic about the program at first.
“I just couldn’t figure out how they didn’t think it was cool,” she says.
Then COVID-19 hit, and “it hit home for them” – literally.
“Suddenly everyone was seeing the benefits of care at home,” she says, noting the program added another 60 telehealth kits to the 170 it had to meet demand. “This changed everybody’s thinking and allowed us to look at (home health care) differently.
As with Banner, Hagen says she’d like to see more mHealth devices introduced to the program, giving provider the ability to track more metrics at home. She’d love to track spirometry, EKG, even activity and exercise, and monitor medication adherence through connected pill bottles or other digital health tools.
“And I’d much rather the patients use their own devices,” she adds, noting the costs associated with providing telemedicine technology to the home. “There’s so much out there that we could be using” if it were supplied by patients.
She’d also like to see a home health telehealth program contained inside a health system’s electronic medical record, instead of bolted on or existing alongside the EMR. Many a program lives or dies in the ability to integrate data into a patient’s medical record, avoiding gaps in care and the challenges of accessing soiled information.
“We have a good program that’s growing like crazy,” Hagen says. “It’s really showing us the possibilities of delivering care at home. Now we need more (opportunities) to use it.”
While many home health care programs are using telehealth and mHealth tools and services in some form or another, widespread adoption has been minimal, primarily due to limited Medicare reimbursement and a reluctance from the Centers for Medicare & Medicaid Services to recognize telehealth as a legitimate service.
Home health care advocates were heartened a few years back with the development of bundled payment programs that supported telehealth services delivered in the home setting, but some of those programs have since been discontinued or modified in such a way that telehealth is restricted.
“Telehealth has actually been around for quite a while in home health – a couple of decades at least,” says William Dombi, president of the National Association for Home Care & Hospice (NAHC). “But it hasn’t worked well from a business sense.”
Medicare does allow some telehealth use in its bundled payment program for home health services as an episode of care, but those reimbursements run up against strict guidelines on who can prescribe a telehealth service and how many in-person visits are required.
With the onset of the coronavirus pandemic, federal and state regulators loosened many of the rules around telehealth access and coverage, giving providers more freedom to use different tools and platforms and expanding reimbursement opportunities.
Home health care providers, however, saw few benefits from those relaxed rules.
CMS currently does not recognize the home health care provider as a telehealth provider – instead, it allows primary care providers to prescribe telehealth services in the home, and manages the services provided by home health care companies. In other words, doctors and other practitioners can prescribe and bill for telehealth services furnished, but home health care providers can’t.
In addition, telehealth visits do not count toward a home health care providers’ low-utilization payment adjustment (LUPA) threshold, which sets a minimum number of in-person visits that a care provider must complete. As Dombi notes, a provider can use connected health channels – mHealth apps and devices, telehealth visits, even phone calls – to accomplish dozens of care management goals, yet still must visit the patient to meet CMS mandates.
“We’ve got all kinds of technology in the home setting now that could be put to use,” he says, noting that a recent survey found roughly 40 percent of home health care providers are using telehealth in some form. “We fully expect that telehealth has a strong future in home health … but right now we’re just not there yet.”
But they are moving in the right direction.
As part of the federal government’s response to COVID-19, CMS is allowing home health care providers to use telehealth and mHealth tools as long as those services are part of the patient’s care plan and they don’t replace in-person visits.
“The use of technology may not substitute for an in-person home visit that is ordered on the plan of care and cannot be considered a visit for the purpose of patient eligibility or payment; however, the use of technology may result in changes to the frequencies and types of in-person visits as ordered on the plan of care,” the agency states in its notice to make that change permanent. “This rule also proposes to allow HHAs to continue to report the costs of telecommunications technology as allowable administrative costs on the home health agency cost report beyond the PHE for the COVID-19 pandemic.”
Some states are relaxing the rules around Medicaid coverage for home health care services. A new law recently enacted in Colorado, for example, allows home health care providers to prescribe and manage telehealth services.
Dombi says NAHC has had some discussions with CMS over expanding telehealth coverage and access for home health care providers, though some of those provisions would have to be handled by Congressional action.
“This is the perfect time for telehealth,” says Dombi. “We need their support.”
Ideally, he says, CMS should be integrating telehealth into the model of care for homebound patients, and it should be expanding the categories of patients who qualify for home health care, to include a wider range of people who would benefit from receiving telehealth services at home. In addition, he says, CMS should recognize home health care programs as being capable of prescribing and managing telehealth services.
Both federal officials and healthcare providers are anticipating that telehealth adoption will continue to increase in the wake of the COVID-19 emergency, through better federal and state regulations and an interest among providers to expand their platforms.
This includes home health programs, which will get a boost from a surge of interest in remote patient monitoring. Hospitals and health systems, eager to move more services out of the hospital, clinic or doctor’s office and into the home, will be looking to develop RPM platforms. And they’ll be looking to home care providers to facilitate those services.
“People are getting comfortable with home care, and they’re realizing they’re more than can be done at home than in the hospital,” says Johnson, at Banner Health. “Besides, every time you have to go back to the hospital, we have to start all over again. We want to get away from that as much as we can.”