Using Telehealth Data to Improve Patient Care

By David Thompson, MD

Understanding what drives patients to seek treatment can help you educate and prepare staff, which improves the patient experience. While you may have a gut instinct as to your patient’s chief complaints, have you ever crunched the numbers? Health Navigator has. We’ve explored approximately 20,000 medical call center patient interactions to identify the top reasons patients called, how urgent their symptoms were, and peak call times.

The analysis included information for patients from all age groups and found the top complaints included: fever, vomiting, stomach pain, cough, and head pain. Patients with the most urgent needs were babies or infants three to twenty-four months old (nearly 35 percent of calls), while the least urgent calls involved children (two to twelve years).

Understanding why and when people contact nurse advice centers allows telemedicine providers to manage staff expectations and prepare for common interactions. This can be accomplished by using a diagnostic telehealth platform that codes the chief complaints. This serves as a starting point to analyze the most common interactions at a hospital or health system.

If healthcare professionals and call center staff know what to expect in the average telehealth experience, they can:

  • Prepare a standardized call flow format and follow-up questions for their system’s top complaints.
  • Calmly and consistently handle patient calls and manage expectations.
  • Plan workflow and staffing needs, based on patient prioritization and time of day.

Diagnostic platforms can also provide data healthcare professionals can use to determine the suggested treatment protocol for common complaints and to enhance staff training, such as to:

  • Teach incoming staff the most common chief complaints.
  • Document follow-up protocol and questions to ask.
  • Prepare educational information about recommended treatments.

Consider the patient who contacts a medical call center about a persistent cough. The responding staff member recognizes this as a common chief complaint and asks follow-up questions suggested by the telehealth platform. This allows staff to consistently communicate the most common treatments for a cough and to provide care instructions for the patient. The telehealth platform can also provide easy access to printable aftercare instructions to share with patients.

This more efficient workflow can ultimately create a more effective environment for staff and contribute to patient satisfaction and retention efforts. The needs of a patient population may change over time, but data about common chief complaints can help understand these cycles and market services accordingly throughout the year.

David Thompson, MD, FACEP is CEO and chief medical officer at Health Navigator. A part-time faculty attending in the Northwestern Memorial Hospital Emergency Department, Dr. Thompson also works as an author and partner with Self Care Decisions, LLC and Schmitt-Thompson Clinical Content, LLC. In a collaboration with well-known pediatrician Dr. Barton Schmitt, Dr. Thompson has developed a comprehensive set of telephone triage protocols that are used in medical call centers and doctors’ offices in the United States and internationally. He can be reached at david.thompson@healthnavigator.com.

Using Mobile Apps to Engage Patients


TriageLogic


By Ravi Raheja, MD

Telehealth and mobile applications are changing the way healthcare is delivered. A recent Pew Research study found that about 77 percent of Americans own a smartphone. Smartphone users spend about 1.8 hours every day on their devices, and 89 percent of that mobile media time is on an app.

Anyone who owns a smartphone has come to rely on mobile applications to quickly access anything from their bank accounts to social media pages, even to that game they are addicted to. As the public relies more on technology, the telehealth field has grown and adapted to meet patients’ need to stay connected and in control of their health.

Mobile apps play a huge role in bridging access from the provider to the patient. However, as with all new technology, medical mobile apps face obstacles and the challenge of regulation. In recent years, there has been an explosion of patientcentered apps to aid in health and wellness.

Healthcare Mobile Apps Help Patients With:

  • Connecting to their physician’s office
  • Researching health insurance benefits or claims
  • Looking up reviews on providers
  • Finding nearby urgent care centers and ERs
  • Managing chronic disease
  • Lifestyle management
  • Smoking cessation
  • Diagnosis
  • On-demand doctors and telehealth

The Patient Behavior: A key issue for brickandmortar providers is to ensure their patients receive continuity of care with their health. However, with so many outside options available through mobile apps, doctors have to find ways to stay in touch with their patients and ensure patients come back to them for health issues. Solutions include providing patients with a service, such as a nurse triage on call, to ask questions about their symptoms when the office is closed. In addition, doctors can have their own mobile app to engage customers and improve access to the office for prescriptions and appointments.

Provider Driven Telehealth Apps: There are many times when a provider can use mobile technology on phones or tablets to assist in patient care. Mobile apps can send notifications or events directly to patients, such as reminders for appointments and tests or even reminders to help with antibiotic compliance.

Some mobile apps, such as My24/7HealthcareTM, allow patients to send messages to practices to request appointments and prescription refills. Additionally, some telehealth apps allow providers to virtually extend their hours, by allowing patients to conveniently access the practice and their nurse triage from their mobile app. A quality mobile app for a practice allows providers to increase engagement with patients, improve patient convenience accessing the office, and extend the hours when patients can get questions about their health symptoms answered.

In another use of mobile applications, patients can use telehealth mobile apps to replace in-office visits with their providers. This is most useful for rehabilitation or post-operative care patients and those with chronic conditions, who require regular follow-up care or monitoring. Many of these patients have transportation issues due to their health conditions. With the use of mobile applications, patients are able to chat or send images of their progress or setbacks, saving patients the time and money it would take to go to the physical office.

Finally, mobile health applications have proven especially beneficial to rural areas with limited access to physical medical facilities. Rural locations tend to have a shortage of specialists. Primary care providers can use mobile technology to access specialists from large institutions to virtually assist in the care of their patients. The primary care doctors themselves can save their patients time and effort to drive to their offices by conducting telehealth visits using the mobile application.

Regulation: As with any communication tool with patients, an important consideration is that all communication between patients and providers has to be HIPAA compliant. For example, text messages must be secure and coded to ensure that only the patient and the provider are able to access the information. In addition, when sharing a family account on a telehealth mobile app one must have a way for the patient to determine what is visible and to whom.

Though many states have passed telehealth coverage laws, there are still many issues with service reimbursement. Currently, there is some controversy over telehealth parity laws, which would require reimbursement by health plans for telehealth services at the same or equal rate as those services performed in person.

Since telehealth mobile apps are a relatively new tool, the medical community is still developing ways to regulate this industry in order to evaluate and prevent potential dangers. The US Food and Drug Administration (FDA) has weighed in on which apps require regulatory oversight and which do not.

Conclusion: Physicians need to acknowledge and embrace telehealth mobile apps or suffer losing patients to those who are able to integrate the needs of the patient. In this on-demand society, it is important for practices to adapt from the traditional model of healthcare.

Telehealth mobile apps have made it easier for the patient to take an active role in their healthcare, while making access to physicians and medical providers more convenient. While mobile technology has changed the way telehealth is practiced, there is still a lot of data that needs to be examined and adjustments made to the different models to figure out the best approach for the future of healthcare.

TriageLogicDr. Ravi Raheja is the medical director of TriageLogic, a URAC accredited, provider of quality triage solutions, serving over 9,000 physicians nationwide. TriageLogic provides software, mobile applications, and nurse triage services. Recently, TriageLogic expanded its offering to provide employee telehealth solutions through Continuwell. For more information contact Amy Smith at 888-TEAMTLC or visit www.triagelogic.com.

Mobile Apps and Telehealth: Another Channel for Reaching Your Audience


LVM Systems

By Sue Altman-Riffel

Healthcare contact centers have acted as the communication and wayfinding hub between their sponsoring organizations and the audiences they serve. In the 1980s, when I started my first hospital call center, there was really just one channel for quick communication: the telephone. It was a landline.

We didn’t give much thought to our audiences’ preferred communication methods back then. The only option of note was whether someone wished to be contacted on his or her home phone or work phone. Later came car phones and cellular phones, more possible options to be considered when collecting callers’ phone numbers.

The typical contact center users: patients, parents, plan members, and prospective community members have not changed much through the years, but their communication options have expanded.

Internet availability brought about health organization websites. The primary advantages of the website are 24/7 availability and no waiting on hold, allowing its audience to quickly find information, download forms, browse physicians and facilities. and register for programs and services, whether a call center was available or not. Contact centers (note the change from call center to contact center) continue to add support to a variety of website functions behind the scenes, but a growing list of transactions can be concluded without human support.

Websites continue to be an extremely important digital platform for healthcare today. Studies show that the user’s viewing device (for websites) can change throughout the day: a smartphone in the morning and while the user is commuting or at lunch, desktop use picks up during the workday and tablet use increases in the evening. But for the last ten years, the communication medium that has outpaced all others is the smartphone.

We Love Our Smartphones: Since the smartphone was launched, we humans have fallen in love with its convenience and offerings. We each have our favorite apps. They entertain, keep us connected, act as a platform for sharing our views, provide us with answers, and support telephone and video communication.

In the US, the average adult spends eighty-seven hours per month on their mobile devices, mainly smartphones. We keep them nearby, often in a pocket or purse. Studies show that 75 percent of smartphone users take their phones to bed with them. (I want to smirk at this, but I remember using my white noise app to fall asleep last time I traveled.) Clearly, we’ve incorporated smartphones into nearly all aspects of our lives, including managing our (and our family members’) health.

Each year, more functionality is integrated into smartphones (effectively hand-held mini-computers). The list of functions will look familiar. At present, hospital apps support many do-it-yourself (DIY) services, such as:

  • Locate facilities, with mapping and directions
  • Find physicians: search based upon specialty, insurance, location, language
  • Check symptom acuity, with self-care advice and connection to care locations
  • Connect to a triage nurse or telemedicine provider
  • Browse health information libraries
  • Look-up dosages; track medications
  • Login to patient portals
  • Engage in social media
  • Pay bills
  • Sign up for a class or event
  • Get reminders, encouragement, and education via push notifications

One of the many advantages offered by mobile is one-tap connections to the next services needed. A symptom check is one tap away from calling one’s doctor, finding an open urgent care (with map), scheduling (online or agentassisted), or connecting to a triage nurse or telemedicine provider.

Have Mobile Apps Replaced Talking to a Real Person? No. Although mobile is becoming the organization’s digital front door, it is not the sole communication vehicle. The choice between mobile versus livevoice is influenced by your audience, the service required, and its complexity.

Audience and Age: First, audience adoption of apps differs by age group. Pew Research regularly studies the adoption of technology by population. In 2015, they found that 77 percent of the eighteen to twenty-nine age group has used their smartphone to seek information about a health condition, compared to slightly fewer (68 percent) of 30-49 year olds.

They also explored the shrinking segment of non-users (13 percent for websites; 20+ percent for smartphones). The shared characteristics are highlighted as age 65+, income below the poverty level, low education (high school or less), and rural. If this describes a portion of your audience, then telephone services will continue to be the main medium for supporting them.

General Movement Away From the Telephone: Recent Forrester research “Your Customers Don’t Want To Call You For Support” tells us adults in the US prefer using web or mobile self-service more than speaking with an agent over the phone. This use increased from 67 percent in 2012 to 81 percent in 2015 among US online adults.

Although calling customer service has steadily decreased over the past six years, it is still used for escalation. Customers prefer to resolve straightforward interactions using selfservice (web and mobile), but still reserve complex issues for a telephone call.

For 10 plus years, contact centers have seen the volume of inbound calls decline—especially in the age group of 18-35 years. Creating a mobile app to engage this audience is a way of keeping their loyalty by respecting their self-service preference. They will connect by telephone when their health needs escalate or exceed self-service.

Applying this to healthcare contact centers, communication preferences are situational. One example is symptom checking (described as self-triage). Young parents may use an app or website to check their child’s symptoms. It will help them understand what action is appropriate: ER, office visit ,or manage at home for now, and offer step-by-step advice for managing symptoms.

But what if the parent has additional questions? A great solution is offering the symptom-checker user an option (within the app) to connect to a triage nurse or request a call back. In many instances, self-service may satisfy users’ needs. But self-service can escalate to a nurse if the situation turns out to be more complex.

Scheduling: Not all desired services can be completed quickly via mobile. Appointment requests are still largely facilitated through voicetovoice communication. In many cases,

  1. the office (or hospital department) needs more information about the patient than can easily be completed using a web or mobile form, or
  2. the back and forth of choosing an appointment time that suits both schedules can be done faster via telephone.

There are exceptions. Many health systems are piloting self-scheduling for certain types of appointments through their patient portal or through apps such as ZocDoc. It appeals to the self-service enthusiasts and rates highly for fulfillment of instant-gettification.

Mobile apps can be a conduit for connecting the user to your organization for appointments. Placing a “request appointment” button (within the symptom checker or the physician finder) in logical areas can funnel new patients to your scheduling center.

Mobile is Another Channel: At its simplest, mobile represents another change. Since the first healthcare call centers, there have been cycles of invention and change:

  • pilot a service based upon a health system objective or unmet audience need
  • fine-tune the process to reduce variation
  • make it more efficient using software or automation
  • reinvest any time saved into growth or starting another service

Communication and wayfinding services will continue to be multi-channel: telephone, video, website, patient portal, and mobile applications. As the mobile experience is demanded by a growing audience, more services will be supported by it. It will interface with additional software and applications, putting more self-service at your audience’s fingertips.

Mobile may connect your organization with a new set of customers: the 18-29 age group who only use their smartphone to place a call as a last resort.

There is an opportunity to leverage mobile to off-load low challenge or low acuity calls. This creates the chance to take on additional business, improve service levels, or shift staff to support new opportunities. Mobile is just another cycle of (re)invention and change.

Sue Altman-Riffel worked as a manager and consultant in the telehealth industry for 28 years. She currently serves as the CEO for two digital companies: Self Care Decisions and AppCatalyst, which support more than 200 healthcare organizations with self-triage and mobile application design and development.

Vendor Spotlight: TriageLogic Expands Telehealth’s Reach to Help Your Employees


TriageLogic


TriageLogic® believes no one should delay care because physicians are unavailable or the ER is too expensive. That is why earlier this year, TriageLogic launched a new product, Continuwell®, to provide telehealth services to a wider market. With Continuwell, TriageLogic tackled the big question that many organizations face: How do they keep healthcare costs down and employees healthy?

This new telehealth product was created to help businesses and organizations decrease employee healthcare expenses and reduce employee absenteeism by providing free, 24/7 access to a qualified, objective registered nurse. It also allows companies to engage employees by placing all services in one platform and send push notifications and messages.

A recent Pew Research study found that 77 percent of Americans own a smartphone. TriageLogic realizes the connection people have with their phones and their desire to be better connected with more aspects of their life.

The American Hospital Association found that:

  • 74 percent of U.S. consumers would use telehealth services.
  • 76 percent of patients prioritize access to care over the need for human interactions with their healthcare providers.
  • 70 percent of patients are comfortable communicating with their healthcare providers via text, email, or video, in lieu of seeing them in person.
  • 30 percent of patients already use computers or mobile devices to check for medical or diagnostic information.

Continuwell is a telephone healthcare service with a network of experienced registered nurses. Continuwell provides nurses on demand to evaluate employees and their family members to determine the appropriate care for their symptoms. Continuwell differentiates itself with its nurse-first model, where nurses use doctorwritten protocols to evaluate callers and determine the care to resolve their symptoms.

Continuwell nurses provide the necessary care without the need of a doctor in three out of four cases, saving the cost of a telehealth doctor visit and making the system affordable for employers and employees.

The Service

Step 1: A member enters their symptoms using a mobile application (app) or website portal.

Step 2: A registered nurse calls back within minutes.

Step 3: The nurse evaluates their symptoms and helps them with the next steps.

The team at TriageLogic has spent years developing a mobile app that would be user friendly, to increase utilization, as well as customizable, to allow employers or brokers to modify content to fit their specific needs. They recognized the challenge of getting employees to download, register, and then remember the benefits available to them through their employer.

The Continuwell platform allows organizations to select the services they want to include and creates a custom mobile app for their employees, where they get access to all of their services in one place. The app even has single sign-on capability to make it even more convenient. The platform is flexible enough that services can be added or removed on demand.

You take care of your patients, but who takes care of your staff? Why not extend a confidential and independent triage service for your staff by making Continuwell part of your employee benefits package? Continuwell is always available to help your staff get back on their feet, no matter the symptom.

Benefits

  • Easy to use, easy to access.
  • Customized with your logo and your own buttons.
  • Single sign-on ability means your employees can seamlessly navigate through all of your services.
  • Announcements and events calendar make it easy to keep information coordinated with all your employees, through push notifications.

Continuwell can place all wellness and health options in one, easy-to-access spot. With so many options available to employees, it is easy for a company’s benefits and programs to get lost. The customizable mobile application places the company’s benefits in employees’ hands, making it easy for them to find the resources they need, when they need them.

The Continuwell mobile app extends the reach of telehealth service to more people and puts them in control of their health. As telemedicine becomes more prevalent, TriageLogic is committed to providing hospitals and practices with the technological tools to meet the needs of their patients and staff. TriageLogic is also committed to helping its clients ensure high-quality care, while decreasing costs and improving patient satisfaction.

TriageLogicFounded in 2006, TriageLogic is a URAC accredited, physician-led provider of high-quality services and software for telehealth. TriageLogic is a leading provider of top-quality triage technology, mobile applications, and call center solutions. The TriageLogic group serves over 9,000 physicians and covers over 18 million lives nationwide. Visit www.triagelogic.com for more information

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Medical Apps and their “Application” in the Clinical Contact or Monitoring Center


LVM Systems


By Traci Haynes, MSN, RN, BA, CEN

Mobile Apps Affect TelehealthMobile technology is growing exponentially. Hardly a day goes by when there isn’t information on a new medical app for mobile devices. Clinicians use them in their practice to increase efficiency in providing patient care and to effectively explain information to their patients. And individuals use them to learn more about their conditions, and then often to monitor their health status. They are also used as a way in which healthcare providers and patients communicate or interact.

The 2016 HIMSS Connected Health Survey reported that more than 50 percent of respondents indicated their hospitals currently use three or more connected health technologies, which positively affect their ability to communicate with patients and to deliver a higher standard of care. The Technology Marketing Corporation (TMC) reports that the global wearable medical devices market valued at $3.7 billion in 2015 is expected to reach $13.5 billion in 2022.

The advancement in technology in electronics and sensors has permitted devices to capture and present data from the number of steps walked to an EKG. Then it transmits that data to the user or healthcare provider by means of remote or wireless communication. TMC reports wearable medical devices are segmented into diagnostic (such as vital signs, sleep, activity, and fetal and obstetric monitors) and therapeutic (which includes pain management, insulin monitoring, respiratory therapy, and rehabilitation devices). Wearables have different sites of application including head strap, wrist, handheld, and shoe sensors.

Remote monitoring programs primarily focus on serious, chronic conditions that can result in repeated hospitalizations. Several studies have been done on pilot programs with discharged patients and their efforts to reduce avoidable readmissions and maintain medical stability. These individuals, based on their diagnosis, were outfitted at home with devices such as a digital scale, blood pressure monitor, EKG recorder, or pulse oximeter, along with a telestation that wirelessly sends measurements taken in the patient’s home to a monitoring center where the information is viewed.

If the patient data is outside the predefined parameters, appropriate interventions can be pplied, such as a medication change, dietary modification, home visit, or physician appointment. Another example is a sensor on an asthma controller inhaler and an emergency inhaler that sends a signal to a cellphone, which then transmits the information to a monitoring center to let them know whether the inhaler is being used as prescribed.

The innovations in technology and remote monitoring continue to expand. BAM Labs developed an FDA-approved sensor mat, to function as a smart bed, that is placed under a mattress to monitor presence, sleep pattern, and heart and breathing rates. The collected data is transmitted to an app viewable on an internetconnected device.

Other examples include eNeighbor developed by Healthsense, which uses sensors placed on the patient and throughout the home to detect falls, wandering, and medication adherence. Independa created a system for monitoring that can include gathering clinical measurements as well as sensors that monitor motion, toilet flushing, and door opening. The data is then reported via an online app.

Some experts say patient monitoring is necessary for hospitals and physicians to evaluate their business. And monitoring programs are tools to help achieve the triple aim: improve access, raise outcomes, and make the healthcare systems more cost effective.

Challenges have included funding, reimbursement, and patient engagement. Some individuals may have to be reminded or persuaded to use the apps, as unfamiliarity with technology can add an additional encumbrance. Other challenges include staffing needs, filtering the important biometric data and integrating it into the EHR, and questions of medical and legal liability.

Is there a return for the health systems that have implemented a remote monitoring program? The answer is “Yes.” An article in Medical Economics written by John Morrissey, published in 2014, indicated improvements in the bottom line over time. Gains were realized from decreased hospital admissions and reduced use of emergency services. Beyond costs savings, the patients benefitted from the assurance they were being monitored, which improved self-management skills, enhanced quality of life, and enjoyed increased satisfaction.

LVM SystemsTraci Haynes, MSN, RN, BA, CEN is the director of clinical services at LVM Systems, Inc

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Health Navigator Partners With ERatHome

Expands access to care and medical information for retail clinics and home-based urgent care services

Health Navigator announced it has partnered with ERatHome, a network of retail clinics and home-based urgent care services, to expand access to providers and control the flow of medical information between patients and clinicians. As part of the collaboration, Health Navigator will support ERatHome’s Hive application, which is designed to share medical records and treatment history among care teams, provide patients with 24/7 access to doctors, facilitate appointment scheduling, send automated reminders and alerts, and share patient education resources.

“ERatHome provides a valuable opportunity to expand access for patients and providers through its Hive application. This partnership will introduce consumers to a new level of care convenience that includes valuable aftercare instructions and resources,” said Patty Maynard, senior vice president of business development, Health Navigator. “Health Navigator aims to enhance the patient experience with easy-to-understand clinical information in plain language, which makes the Hive application an ideal match.”

Patients in the ERatHome network can use the Hive app to call or schedule a virtual visit with a doctor. Doctors use patient information to make a preliminary diagnosis based on symptoms and suggest the next steps to take. Health Navigator provides a diagnostic decision-support platform that features clinical codes, symptom checking intelligence, and process analysis for clinicians. By integrating Health Navigator’s comprehensive set of codes and analytics, ERatHome provides a more accurate, efficient diagnostic process, which can produce improved outcomes.

Moving From “Sick Care” to “Health Care”


LVM Systems


By Mark Dwyer

In 2012 our government enacted legislature that mandated U.S. hospitals reduce re-admissions by emergency departments (ED) admits for the first thirty days post discharge. To force this change in behavior, rather than waiting for hospitals to choose to proactively address the overall health of their communities, the government began penalizing hospitals who had higher than average readmission rates through a deduction in their reimbursed Medicare payments.

This was a radical change in American healthcare as it put the onus of keeping patients well on the hospitals and providers who treated them. No longer could hospitals simply wait for individuals to require hospital care, rather it became their responsibility to proactively manage ED admitted patients for at least the first thirty days post discharge. If they were unsuccessful in providing the patient with the tools and help needed to keep them from re-admitting, they bore the weight of a financial penalty.

Initially, the penalty amounted to 1 percent of the hospital’s total annual Medicare reimbursement. It was tied to three specific DRGs (diagnosis related groups): acute myocardial infarction (AMI), heart failure (HF), and pneumonia. Each hospital was scored against its neighboring hospitals to determine which ones had readmission rates in the highest twenty-fifth percentile of their surrounding hospitals. If a patient who had been admitted via the ED due to one of these three DRGs required readmission within thirty days post discharge, and the hospital’s readmission rate was in the highest twenty-fifth percentile of hospitals in the area, the hospital’s overall annual Medicare reimbursement was reduced by 1 percent. Although 1 percent may not seem like a lot, when it was applied against the hospital’s entire Medicare reimbursement dollars it was significant—especially for hospitals operating with only 2-3 percent profit margins.

But the government didn’t stop there. In year two of the program, the percentage of Medicare reduction was increased to 2 percent of the hospital’s total annual Medicare reimbursement amount. Then in year three, not only was the percentage again increased to 3 percent of the hospital’s overall Medicare reimbursement, but three additional DRGs were added: elective knee replacement, elective hip replacement, and chronic obstructive pulmonary disease (COPD).

At this point many hospitals began paying attention, especially when over 2,200 U.S. hospitals were penalized for failing to reduce their readmission rates. To address this ever-increasing reimbursement reduction, hospitals had to implement programs to manage Medicare patients post discharge for at least the first thirty days. To do so, many home grown programs were introduced with varying success.

A number of healthcare software vendors also began developing and marketing programs to help educate and manage the patients post discharge. Some of these programs involved on-site care management visits, phone calls, reminder texts, and emails. Some also involved extensive motivational programs designed to not only assist the patient in remaining proactive in their care but also the patient’s caregiver. Too often the Medicare patient’s primary caregiver is their elderly spouse who is also battling a litany of health issues. Assisting them and other familial caregivers was determined to play a critical role in the process.

But what about the many patients who suffer from more than one chronic disease? Some vendors realized that many Medicare patients suffer from co-morbidities. It is not unlikely for an individual with diabetes to also be obese or someone with HF to have been admitted with an AMI DRG. Initially, since these various disease states were defined as separate care plans, patients suffering from co-morbidities experienced multiple interactions post discharge to manage all conditions that could possibly result in a costly readmission.

To motivate patients and their caregivers to follow post-discharge instructions regarding medications, to make and attend post-discharge provider appointments, and to integrate with the hospital’s care management or medical call centers, vendors have begun collaborating with leading content developers. By adding patient educational and motivational training content to their software programs, post-discharge programs can enable the nurse or care coordinator conducting follow-up calls to select the specific information needed to address each of the patient’s multiple issues. This co-morbidity program approach eliminates the need for redundant calls to address each of the patient’s healthcare issues. Instead it enables the nurse or care coordinator to select the content, surveys, motivational scripts, and other resources needed to meet all of the patient’s unique needs across a wide array of health conditions.

Future thinking hospitals and providers who see the need for follow-up beyond the initial thirty days post discharge are beginning to take a stand for long-term health management by using customizable co-morbidity programs. This is a real step in the direction of healthcare management. Imagine a future where healthcare generates greater revenues from having empty beds, keeping area residents healthy and at home.

LVM SystemsMark Dwyer is the COO of LVM Systems, Inc. For more information about LVM’s Co-morbidity Care Management Program (CCMP), contact LVM Systems sales at 480-633-8200 x223 or info@lvmsystems.com.

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The Contact Center’s Role in Reducing Readmissions

LVM Systems


By Traci Haynes MSN, RN, BA, CEN

reducing-readmissions-2

Reducing hospital readmissions has been a focus of the healthcare environment for many years. Steven Jencks MD, dubbed by many as the father of readmission research, along with Mark Williams MD and Eric Coleman MD, analyzed medical claims data from 2003-2004 to describe the patterns of rehospitalization and its relationship to demographic characteristics of hospitals.

They learned that almost one-fifth (19.6 percent) of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within thirty days. They also found that 34.0 percent were rehospitalized within ninety days; and that 67.1 percent of patients who had been discharged with medical conditions and 51.5 percent of those discharged after a surgical procedure were rehospitalized or died within the first year after discharge.

Furthermore, of the 50.2 percent of patients rehospitalized within thirty days post medical discharge to the community, there was no bill for a visit to a physician’s office between the time of discharge and rehospitalization. Additionally the average length of stay (LOS) of rehospitalized patients was 0.6 days longer than that of patients in the same DRG (diagnosis-related group) whose most recent hospitalization had been at least six months prior. The cost to Medicare for rehospitalizations in 2004 was $17.4 billion (Jencks, S.F., Williams, M.V. & Coleman, E.A., 2011).

In 2007, the Medicare Payment Advisory Commission (MedPAC) reported to congress that 13 percent of patients rehospitalized within thirty days of discharge in 2005 were for reasons potentially preventable. These readmissions accounted for $12 billion in Medicare spending.

As a result, the Patient Protection and Affordable Care Act (PPACA) of 2010 mandated that the Centers for Medicare and Medicaid Services (CMS) implement a program in which hospitals with higher-than-expected readmission rates for certain designated conditions experience reductions (penalties) in their Medicare payments. Beginning in October, 2012, the hospital readmission reduction program (HRRP) began adjusting hospital payments based on excess readmissions within thirty days of Medicare patients following myocardial infarction (MI), heart failure (HF), and pneumonia hospitalizations.

The maximum penalty at that time was 1 percent of a hospital’s base Medicare reimbursement rate per discharged patient. Beginning October, 2013 the penalty increased to 2 percent and then to 3 percent the following year (2014). The first year more than 2,200 hospitals were penalized for failing to meet standards, with 8 percent incurring the maximum penalty. In addition to the MI, HF, and pneumonia penalties, readmission penalties now include elective knee and hip replacements and chronic obstructive pulmonary disease (COPD).

The healthcare reform mandate required addressing a long-time quality issue. According to Bisognano and Boutwell, the primary reasons for readmission were no physician follow-up visit, medication discrepancies, and communication failure during transitions of care (Bisognano, M. & Boutwell, A., 2009). Eric Coleman MD and others identified poor information transfer, poor patient and caregiver preparation, and limited empowerment to assert preferences as the primary reasons for readmission. Contributing factors include nurses not having time to thoroughly address the needs of both the patients and caregivers upon discharge, the hospital setting not being conducive to education that will drive behavior change before discharge, and the care continuum breakdown between hospital discharge and the hand-off to primary care (Coleman, E.A., Parry, C., Chalmers, S., & Sung-joon, M., 2006).

The uneven impact of the penalties has been a significant concern for hospitals that care for a larger number of low-income patients. They claim it is more difficult for their patients to adhere to post-hospital instructions including payment for medications, dietary modifications, and transportation to follow-up appointments.

To address these challenges some hospitals have implemented measures including discharging patients with medications, home-visits, and follow-up calls. Other interventions include hiring specialty care coordinators and transition coaches to provide follow-up care for patients with multiple comorbidities, providing patients with extensive teach-back for multiple days prior to discharge so they’ll better know what to do once they are discharged. In addition, many include comprehensive medication reviews with a clinical pharmacist.

The contact center can be an integral team player in reducing avoidable readmissions by enhancing the quality of care in the hospital-to-home transition through the combined capabilities of technology and human interaction. While discharge planning should begin upon admission to the hospital and include arranging for durable medical equipment (DME), transfer to step-down as appropriate, home health care, transportation needs, communications with primary care providers (PCPs), and discussions with caregivers, the extended care team which includes the PCP, caregivers, pharmacist, and other members of the interdisciplinary team can be greatly improved by the services of the contact center in helping to comprehensively coordinate the patient’s care.

The patient and their caregivers will also benefit from the reinforcement of information provided, teach-back, appointment reminders, and coordination of services including transportation, as well as medication reconciliation and symptom assessment resulting in earlier interventions and improved outcomes. Extending the contacts beyond the thirty-day penalty period will bring even greater benefits to patients and caregivers that may prolong readmissions indefinitely.

What readmission reduction activities are occurring within your organization? What is your contact center’s role in reducing readmissions? What level of service do you or can you offer?

Some contact centers make one post-discharge call to review the patient’s diagnosis, instructions, medications, education materials, and ensure the patient has scheduled their follow-up appointment with positive results. Others make several outbound calls to the discharged patient including a call within the first twenty-four to forty-eight hours post-discharge.

In addition the call center staff or care coordinator may reach out to the patient again after their first appointment, which ideally occurs within seven days post-discharge. This call typically is used to review the follow-up appointment instructions, any changes in medications, assist in referrals and scheduling with additional providers or resources, and communicate to the interdisciplinary team as appropriate. During this contact, biometric monitoring may also be tracked through technology or as self-reported by patients or caregivers.

Whatever level of service provided, it’s a win-win for the patients, their caregivers, and the organization. Utilizing the contact center to identify and implement communication strategies that effectively engage the patient and their caregivers adds value to the organization and the opportunity of better outcomes for their patients.

LVM SystemsTraci Haynes, MSN, RN, BA, CEN is director, clinical services at LVM Systems, Inc.

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Three Ways Telehealth Can Improve Access, Workflow, and Patient Satisfaction



By David Thompson

Dr. David ThompsonConsumers are increasingly choosing telehealth encounters over visits to the doctor’s office or the ER. In fact, it’s estimated that by 2020, 78.5 million consumers will be using e-Health applications. Why? It boils down to cost and convenience: telehealth encounters are convenient and easy to fit into busy schedules and lifestyles, and they often cost less than a clinic, urgent care, or ER visit.

Telehealth is also growing because it offers a number of benefits for healthcare professionals. These include improving patient access to care, delivering a more consistent workflow, and facilitating better communication between healthcare providers along the care continuum.

Are you not sure if investing in a telehealth strategy is right for your organization? Consider the following ways in which this technology can give your organization a boost:

1) Expand Access to Care: The shortage of healthcare professionals is no secret. About 20 percent of Americans live in rural areas without easy access to primary care or specialty medical services. Hospitals, health systems, nurse advice lines, and medical call centers can use telehealth solutions to:

  • Connect with patients outside clinics, urgent care, or emergency rooms using the patient’s preferred channel of communication, be it text message, web portal, or phone call
  • Provide nurse-led telephone triage of patient symptom calls and nurse-led education for health information calls
  • Deliver physician-led (or advanced practice provider) telemedicine care, such as audio and video encounters with patients in their own homes

Access to care can also affect patient satisfaction, and happy patients are more likely to return to your healthcare system and to you, as a provider of care.

2) Improve Consistency and Safety in Clinical Workflows: Recent e-Health technologies can also drive novel improvements in clinical workflow. For example, telehealth platforms can help your staff:

  • Capture the reason for the visit quickly and accurately: What is the patient’s chief complaint?
  • Prioritize care delivery: Who should the nurse or doctor speak to first?
  • Suggest the most relevant telephone triage guidelines for medical call center nurses: What is the best treatment guideline for the patient’s chief complaint?
  • Identify health information resources: What additional information or Internet resources could be shared with the patient?

Keep it simple. Did you know that e-Health technologies can use natural language processing that takes patient free-text input (“I have chest pain and trouble breathing”) and translate that into data? This natural language processing codes the patient text for chief complaint, acuity, and SNOMED and ICD10 codes.

This pre-process structured data can then be used by a telehealth platform to automatically place patient cases in rank order, based on the severity of the individual’s chief complaints. The telehealth platform can also automatically red flag higher acuity cases for more immediate attention or prioritized follow-up.

A nurse or a doctor can then speak with patients based on their order in the queue, using acuity level, arrival in queue, and time in queue.

3) Facilitate Communication Between Providers Along the Care Continuum: All too often, patient information exists in silos. There are virtual walls between the medical call center nurse, the telemedicine provider, the hospital, and the primary care provider. Successful healthcare organizations and providers are looking for and implementing ways to facilitate communication between providers along the care continuum.

Successful care will be measured by how well healthcare organizations and providers:

  • Capture patient information as data rather than as narrative
  • Store patient information in an organized manner
  • Use patient information to improve medical decision-making;
  • Transmit this data to subsequent providers along the patient’s continuum of care
  • Leverage such data to improve medical care, speed up care delivery and reduce costs: better, faster, cheaper

For Example: John Gomez, a 22 year old, has had worsening ear pain for two days.

  • Pre-process: John calls and speaks with a non-clinical service representative who works with his doctor. She obtains John’s demographic information, transcribes his chief complaint, and assists him in completing an online “rapid medical history” for ear pain. The telehealth platform lists recommended care options based on John’s symptoms, his availability, and his doctor’s preferences. The service representative then arranges a telemedicine encounter.
  • Process: The doctor reviews the rapid medical history, validates this information during the telemedicine encounter, and provides treatment recommendations.
  • Post-process: A nurse in a centralized medical call center contacts John in two days to make sure he is following treatment recommendations, getting better and has no further questions.

Real-world Healthcare: Telehealth technology isn’t a panacea for all healthcare issues, but it can be an effective tool that healthcare organizations should consider for their changing patient and business needs.

Consider the following:

Use of telehealth is growing:

  • Over two thirds (67 percent) of patients using telehealth last year said it somewhat or significantly increased their satisfaction with the care they received.
  • Telehealth is increasingly being promoted by employer-sponsored benefit plans and major health plans as a covered clinical service. In fact, 74 percent of employers said they plan to offer telehealth benefits within their benefit plans this year.
  • The cost of a virtual encounter is significantly less (close to half the cost) than an ER or primary care visit.

Telehealth can support business growth for healthcare companies by:

  • Establishing a more efficient workflow and allowing healthcare providers to do more with fewer clinical resources
  • Allowing health systems to incrementally increase their cash flow
  • Delivering a consistent and accurate diagnostic and care plan experience to patients

Telehealth can contribute to the greater good by:

  • Improving quality of care while reducing costs
  • Helping providers and health systems keep up with the ever-changing healthcare delivery landscape
  • Providing an answer to the existing and future care delivery bubble of physician shortages combined with the influx of baby boomers requiring medical care

As healthcare continues to evolve and as consumers become increasingly engaged in their day-to-day health and the care they receive, telehealth technology is sure to continue its rapid growth. Innovations in care delivery, healthcare consumerism, regulatory standards for providers, and technological capabilities will fuel this growth. Be sure to stay informed and continue to ask the question: how can we use telehealth technology to deliver a better experience for our customers and patients, while improving outcomes and financial performance?

David Thompson, MD, CHC, FACEP is CEO and chief medical officer at Health Navigator. A part-time faculty attending in the Northwestern Memorial Hospital Emergency Department, Dr. Thompson also serves as chief medical information officer for ECI Healthcare Partners and works as an author and partner with Self Care Decision, LLC and Schmitt-Thompson Clinical Content, LLC. Reach him at david.thompson@healthnavigator.com.

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Can Telehealth Save Medicare?

By Charu Raheja, PhD

Currently Medicare is waning under the pressure of much of America’s population living longer than the system can support. With this in mind, the healthcare system is desperately in need of innovative ways to improve healthcare and reduce costs. One possible solution to the problem is the proposed Medicare Telehealth Parity Act of 2015, H.R.2948, sponsored by Rep. Mike Thompson and introduced July 7, 2015. The bill is the beginning of a revamp of Medicare’s approach to treatment and care that could improve American health and lower healthcare costs as a whole. Telehealth allows patients to contact a nurse or physician directly via their cell phone or computer to discuss symptoms and receive care without leaving the comfort of their homes.

Though telehealth as a whole includes many moving parts, one essential component for the success of telehealth is telephone nurse triage. Telephone nurse triage is a system by which registered nurses are available to take patient phone calls and determine the proper amount of care needed in the proper time frame. Nurses use standardized symptom-based protocol guidelines to ensure high quality of care with every phone call.

With convenient access to nurses 24/7, patients are empowered to make the right decisions about their health and what the next steps for their symptoms should be. Patients who better understand their conditions and have a method of self-management, such as access to a registered nurse, are more able to decipher the appropriate level of care, thus avoiding costly ER visits and improving overall patient satisfaction.

An important aspect for the successful use of nurses in telehealth is for the nurses to have direct contact with physicians. In many systems triage nurses communicate patient call information with providers, allowing for better patient relationships with their provider and continuity of care. Nurse triage facilitates the best use of the healthcare workforce by alleviating doctor workload pressure and allowing them to reach the most urgent cases first.

By utilizing telephone nurse triage as an affordable telehealth option, everyone benefits; providers can be assured that their patients are receiving the best care possible. Patients are satisfied with their care and confident in decisions made regarding symptoms they were once unsure of. And the cost of healthcare in America will be driven down by the efficiency and convenience of patient access to healthcare professionals at reduced costs.

Currently most Americans think of telehealth as an option for those living in remote areas where it may be difficult to visit a doctor’s office, but there is infinite value in the use of telemedicine in urban city centers where the emergency room census can be extremely high. Telehealth provides a positive alternative to unnecessary urgent care and emergency room visits, lowers hospital re-admissions—and with the healthcare costs saved—could in fact save Medicare.

Charu Raheja, PhD, is the CEO, chair, and co-founder of TriageLogic. Founded in 2005, TriageLogic is a URAC-accredited, physician-led provider of high-quality telephone nurse triage services, triage education, and software for telephone medicine. The TriageLogic Group serves over 7,000 physicians and covers over 10 million lives nationwide. Charu also serves on the board of Community Health Charities. For more information visit www.triagelogic.com.

(This piece was inspired by Michael Hodin’s post “Saving Medicare” in Huffington Post, October 26, 2015.)

[From AnswerStat December 2015/January 2016]