The Alliance for Integrated Care of New York (AICNY) oversees the healthcare needs of roughly 6,200 dually eligible Medicare and Medicaid beneficiaries with intellectual and developmental disabilities (IDD). Many AICNY beneficiaries reside in group homes and use Federally Qualified Community Health Centers.

THE PROBLEM

A large number of the beneficiaries present multiple complex chronic health conditions with a high coexistence of mental health conditions making the coordination of care more complex and inefficient.

Visibility into centralized accountable care organization (ACO) data across AICNY’s network from its population health vendor, HealthEC, revealed extraordinarily high emergency department utilization rates among the organization’s IDD patients living in certified residences. A substantial portion of that ED use was unnecessary or avoidable, but also had a high correlation to inpatient admissions.

"The savings that result from telemedicine versus an office visit for the long-term care supports and services provider that operates IDD residences is significant."

Duane Schielke, Alliance for Integrated Care of New York

“What we found is the doctors who were on-call after hours were covering IDD patients living in residences were family practice doctors who only had access to limited information on the present issue and thus struggled to triage patient care more effectively,” said Duane Schielke, executive director of the Alliance for Integrated Care of New York. “It resulted in high ER utilization which was also associated with limited access to alternative clinical support resources after hours and on weekends as many urgent care centers do not accept Medicaid.”

PROPOSAL

AICNY thought that if it added telemedicine kiosks to IDD patients’ residential homes and engaged providers with triage expertise, it could more effectively manage people’s medical services “after hours” and on weekends and reduce avoidable ER visits.

“Our goal was to leverage the on-site kiosks to better triage patients via a web-based connection to ER doctors,” Schielke explained. “Station MD, our telehealth vendor, was providing similar telemedicine triage service to nursing homes on Staten Island that housed medically frail residents. The results showed a significant reduction in the number of ER visits.”

To secure funding for the project, AICNY applied for and was approved for a grant from the Staten Island Delivery Service Reform Incentive Payment Program (DSRIP) Performing Provider System that was funded by an 1115 Medicaid Waiver.

MARKETPLACE

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MEETING THE CHALLENGE

Once funding was secured, AICNY piloted the telemedicine kiosk program in two patient residences on Staten Island housing individuals who are medically frail. The kiosks include a pole-cart on wheels with a wireless tablet with touch-screen, high-definition camera, Eko Duo Bluetooth stethoscopes enabling physicians to see a graphical representation of stethoscopes readings, and an ECG option for simultaneous ECG and heart sound tracings. These all provide insight into cardiac function and two-way live voice and video.

“The Direct Support Professional (DSP) staff utilize the telemedicine kiosks whenever there is an occurrence involving a resident’s wellness,” Schielke said. “Unless it is a full-out emergency requiring immediate transfer to the ER, they refer the matter to the on-call RN nurse case manager. If warranted, the nurse will recommend an assessment by telemedicine triage with the telemedicine triage provider, StationMD.”

Using the tools available on the kiosk, the triage provider assesses the situation and makes a recommendation for transfer to ER and contacts the ER; prescribes medication; recommends other home treatment, for example, a nebulizer; and sends a post-visit note.

“Another important aspect of the project includes an interface between three software programs,” Schielke noted. “One is the medical record from eClinicalWorks utilized by the health center that is a participant member of the AICNY ACO. The second is precision care that is utilized in long-term support and services programs to record habilitation plans and activities.”

The third is HealthEC’s Population Health Management platform, which sits in the middle and acts like a hub to aggregate, send and see virtually any information on the patient. HealthEC corrals a large amount of unstructured data received from outside medical providers and adds it to the structured claims data received from CMS.

“Precision care data is refreshed in HealthEC daily to include the eMAR (electronic medication administration record), and medical event tracking of BP, BM, seizure activity, menses, behavioral data and anything requested to be monitored by the patient’s primary care physician,” Schielke explained. “Azara, a population health tool that is a repository for data from eClinicalWorks, updates HealthEC weekly with any new data or information that has been entered into patents’ eCW records.”

In addition to providing a means to manage all of the health information electronically, one of the prime purposes of HealthEC’s Population Health Management platform is to create a pre-visit referral packet so, in advance of a visit, health centers get an electronic packet with charts and the purpose of visit, he added. All that information is sent from HealthEC to eClinicalWorks. When the physician sees the patient and locks the note, it’s automatically sent back to HealthEC to ensure comprehensive care documentation.

“So, in addition to using health information technology to provide more effective tools to manage complex care, we enlisted providers with different skill sets to take triage calls with access to real-time data and vitals,” Schielke said. “They field the virtual session, write a note of the session and make recommendations. They can prescribe medications 24/7 via the pharmacies available to all the homes. They also offer follow-up treatment.”

The most recent development aligning with the new demands during the COVID-19 crisis is to expand access to the telemedicine kiosks to the health center providers to eliminate travel and community exposure. Further, telemedicine can provide access to some specialists for consults who are not available for typical office visits.

RESULTS

Over three quarters of 2018, AICNY inpatient expenditures saw a 6% reduction. As a result of tele-triage kiosks installed in IDD group homes, ER visits dropped by 11% and admissions were reduced by 7%. 80% of the time, patients do not go to the ER if they engage telemedicine kiosks. Data used to risk-stratify patients resulted in a $2.4 million reduction in total costs for the ACO.

“The success of our pilot program operating in 106 locations in New York City housing 650 residents with IDD provided the basis for United Cerebral Palsy Associations of New York State (UCPA of NYS), which is the majority owner of AICNY, to apply for an additional grant aimed at helping facilities transform services to provide the right treatment at the right time,” Schielke said. “A five-year, $13.2 million award has allowed us to scale the telemedicine triage kiosk program to 1,000 houses operated by roughly 54 non-profit organizations across New York State operating certified residences that house about 7,000 patients.”

New kiosk versions have a heart monitor component, so one can get EKG information, as well as chest and abdomen sounds.

ADVICE FOR OTHERS

“Ongoing efforts to engage actively in transformational initiatives must include telemedicine in a manner that is most appropriate for the services being provided,” Schielke advised. “In the case of services to patients with IDD, after-hours and weekend triage addressed an area that was wasting resources.”

With a group presenting mental health challenges, telemedicine around medication management and compliance would be a likely match; end-stage renal disease would involve telemedicine around dialysis, he added.

“Telemedicine is here to stay,” Schielke concluded. “We will not return to having the majority of visits face-to-face. The savings that result from telemedicine versus an office visit for the long-term care supports and services provider that operates IDD residences is significant. Fewer office visits greatly enhances the quality of life for the patients with IDD and patients with chronic health conditions.”

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himssmedia.com
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