TRU Community Care, based in Lafayette, Colorado, had a vision for incorporating a telehealth/remote patient monitoring program: to meet the needs of patients in the new Centers for Medicare & Medicaid Services "Seriously Ill Population" (SIP) program.

THE PROBLEM

SIP provides incentives for TRU Community Care facilities to provide interim care for patients who have historically high hospital utilization rates. The goal of SIP is to deliver intensive care coordination for patients to connect them with a primary care physician.

This coordination includes decreasing social barriers to care like lack of transportation, food scarcity and housing insecurities by means of referrals to existing community supports. When barriers are removed, patients are better able to participate in their healthcare.

TRU president and CEO Michael McHale believed telehealth and RPM were the most cost-effective way to meet this new CMS program's needs.

"The only way to ensure high-quality outcomes was to give nurse practitioners, nurses and social workers telehealth capabilities," said Chad Hartmann, director of access and palliative services at TRU Community Care. "It just isn't cost-effective to pay those employees their hourly rate to travel to the patient's home to provide all care."

Payment models like the Medicare Advantage hospice carve-in necessitate a change in care delivery, he added, and telehealth helps ensure affordable, high-quality care.

"Patients have 24/7 access and daily monitoring, and clinical teams can better track disease progression," he explained. "We see RPM and telehealth not as a way to replace our in-home visits, but as an extension of services. TRU spent almost two years testing new technology and ended up partnering with Vivify Health to help identify patient needs through our tele-care program."

PROPOSAL

Palliative care services typically provide specialized treatment with a focus on relieving symptoms for patients with serious illness.

"In a traditional approach, palliative care providers and social workers make a face-to-face visit based on acuity," Hartmann said. "These visits can be weekly, monthly or bi-monthly, depending on the patient's needs. Knowing what is happening with symptoms and illness progression in between these visits is a challenge."

The same is true for hospice patients who, on average, have an RN visit 2-3 days a week, he added.

"With RPM, tablets and Bluetooth-enabled technology [are] provided to patients for in-home use," he related. "RPM tablets come with a blood pressure cuff, a pulse oximeter and a scale. Data is automatically collected and transmitted to the clinical team for review. Abnormal results trigger telehealth RN follow-up."

Based on the patient, the nurse could schedule a provider visit or contact the patient's primary care physician to discuss interventions, he noted. The nurse also could get on a tele-visit with the patient through the capability of the tablet.

"Patients also receive a set of daily questions called a pathway," Hartmann noted. "Pathway questions are related to a patient's illness and can contain educational videos. A patient with COPD would receive a video explaining lung functioning. We consider the program to be a high-touch/high-tech solution to patient care. We didn't want to take away from in-person care, but rather complement and add to the care through technology."

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MEETING THE CHALLENGE

TRU launched its telehealth program on December 15, 2019 with five test patients on its palliative care program. The plan was to have a yearlong rollout of the new platform and give it time to work out all the bugs to have ten patients on the program, and then formally launch the program in January 2021.

"We were in the implementation process for about nine weeks when the COVID-19 pandemic began," Hartmann recalled. "The pandemic accelerated the rollout timeline, and we quickly learned the system capabilities. We went full-speed-ahead with bringing patients into our tele-care program and developed care pathways for managing various conditions via tele-care."

Through the Vivify platform, staff can customize the pathways to fit \each patient's individual needs. Pathways allowed the tele-care nurses to oversee more patients in less time than via in-person visits.

"We supported patients who were having changes in condition or questions regarding their illness," he said. "Our care teams were able to schedule tele-care visits through the tablet platform, and patients were also able to request a tele-care visit if they needed additional support. Not only did the staff need to get up to speed, but we also had to work closely with outside organizations to get them comfortable with remotely admitting patients."

Staff gave tablets to their hospital's referral sources to expedite patient admissions to the appropriate TRU program. Tele-care accepted the patient into the program quicker, and the nurse met the patient and family at their home.

"This approach increased bed availability in the hospital," Hartmann reported. "We also were able to give families time with their loved ones through the tablet when hospitals had visiting restrictions, so that they were able to say their goodbyes if the patient was unable to transfer home and passed away in the hospital. We also have used the tele-care platform by delivering tablets to skilled nursing facilities and assisted living communities."

Many facility residents are the most vulnerable to the severe effects of COVID-19, so it was essential to limit the number of people visiting these facilities.

"We provided the specialized care that TRU is known for through tele-care to help keep everyone safe and allow families to join those visits remotely," he said.

"Another advantage to the tele-care platform is that the TRU clinicians can conference in a patient's specialty physician as needed, rather than having to try and find a convenient time for everyone to meet in person. We found that patients could not see their PCP or specialty providers, so we brought their providers to them remotely."

RESULTS

TRU programs focus on providing better care to patients when staff do not see them every day and on providing more timely care when crisis needs arise.

"We look at the metrics of how many pathway RN assessment questions are being answered," Hartmann explained. "This data shows us how the patients are supported through the program and how compliant the patients are using the technology. From the inception of the tele-care program, we have had more than 84,000 pathway assessments completed."

TRU also is looking at how many patient alerts it is receiving so the patient is getting the care they need when they need it and, in some cases, staying out of the hospital.

"We received 6,000 patient alerts where the staff supported the patient, sometimes even before the patient knew that anything was going on," he reported. "We are in the beginning stages of tracking the program's impact on hospitalizations, but are seeing an effect on keeping patients from having to be admitted to the hospital and receiving care that they need in their homes."

Additionally, TRU is looking at how "timeliness of care" is being impacted for patients, as measured by patient satisfaction surveys through CMS. For TRU programs, perhaps the best evidence of the connected care program's effectiveness has been the individual success stories that staff have received from patients and their families and caregivers, Hartmann said.

"For example, TRU has a patient who lives north of the Denver area receiving care from a large area hospital," he related. "One of the TRU nurses was doing a tele-care call with the patient, who complained about his medication. The nurse was able to conference in the patient's neurologist, who had assumed he would need to increase the patient's medication."

During the call, the neurologist realized the patient required a reduction in medication. The neurologist accomplished this without the patient requiring a visit. The patient also let the nurse know that they also were struggling with remembering to take their medication, so the nurse could put in medication reminder alerts into the tablet that would sound an alarm to remind the patient when it was time for medication administration.

"Both the patient and the neurologist were very impressed by this support," Hartmann said. "A second patient who had enjoyed going to his mountain cabin no longer felt safe venturing far away from his care team due to his disease progression. After that patient became involved in the tele-care program, he once again enjoyed going up to his cabin. He felt safe that someone was watching over him as he completed his daily pathways, and knew he could request a call with a nurse with just a touch of a button."

Another patient offered this statement regarding the TRU tele-care program: "I want you all to know how your tele-care program has changed my life. It has helped me so much. I'm alerting people if I'm not feeling OK, and receiving regular reminders to drink water, which I used to forget to do."

ADVICE FOR OTHERS

"Don't let the unknown of implementing a telehealth program scare you away from bringing a high-touch/high-tech platform into your organizations," Hartmann advised. "Due to the COVID-19 pandemic impact, we built the ship while we were sailing the ocean, and we see the benefits every day for our patients and families."

TRU has come a long way with its program, but staff feel like they have just started to touch upon how this can help TRU give better, timelier and more cost-effective care to patients, he concluded.

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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