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Incorporating Telehealth into Home Health Care Part 1: Practical Strategies

By Kenneth L. Miller, PT, DPT, GCS, CEEAA, Kara Gainer, JD and Ellen Strunk, PT, MS, GCS, CEEAA, CHC

on April 16, 2020

Categories: Compliance, COVID-19, Documentation and Billing, Enterprise, Nursing, Occupational Therapy, Physical Therapy, Speech Pathology, Telehealth

Home health care is expected to experience an influx of discharged patients from acute and long-term care hospitals as well as skilled nursing facilities as they reach maximum capacity.

Whether COVID-19 patients or other high acuity patients that can be transferred to other settings, home health agencies must prepare to deliver care to a large number of patients despite a potentially compromised workforce. At the same time, home health leaders must identify strategies to deliver care while maintaining the safety of both their patients and their agency workforce.

As of this publishing, there is no mechanism for home health providers to be paid for telehealth visits; however, telehealth will be necessary to successfully care for patients during the COVID-19 pandemic so as to provide uninterrupted care.

What Is Telehealth?

There are four core categories of telehealth:

Live Video (Synchronous)—Live video-based interactions between a healthcare provider (HCP) and a patient
Store-and-Forward (Asynchronous)—Storing and sending health records such as images or test results to an HCP for later interpretation
Remote Patient Monitoring—Gathering information such as weight or blood pressure remotely, either continuously or in certain time intervals, and transmitting it to HCPs
Mobile Health—Utilizing mobile technology such as MedBridge’s HEP or MedBridge GO mobile app to achieve improved health goals
Remote Therapeutic Monitoring

Why Telehealth?

While telehealth was introduced to help serve patients in remote areas, it provides a variety of services that can help increase access to safe and reliable care, provide a cost-effective channel for patient communication, and improve health outcomes.¹

As there is no current vaccine nor treatment approved for COVID-19, the Centers for Disease Control and Prevention’s (CDC) current strategy for combating the COVID-19 pandemic is to “flatten the curve”—that is, slow down the spread of the virus across the US, through social distancing. Telehealth can contribute to this effort by minimizing face-to-face interactions between providers and patients, while still providing necessary care.

Home health personnel are at the front line of the pandemic alongside other HCPs, and they need resources to help reduce the spread of this virus while at the same time providing appropriate and adequate care to patients under their charge.

Home health agencies will need to understand how to leverage virtual care to supplement their in-person visits so as to safely manage the upcoming influx of patients. How can home health clinicians best use virtual tools to reduce the spread of COVID-19 while providing appropriate and essential care and avoiding adverse events like re-hospitalization?

Now, more than ever, it’s time for the home health community to incorporate telehealth into practice. This will enable more effective advocacy to the Centers for Medicare and Medicaid Services (CMS) about the value of incorporating telehealth into future payment methodologies.

Getting Started with Virtual Care

Operationally, in order to start virtual care, home health agencies must decide on what equipment will be used and then train the in-office and field clinical staff in its use.

The simplest type of “visit” is a telephonic visit, which is not new to either office or field staff. Essentially, these are calls to schedule visits, follow up on patient concerns, contact primary care providers, or check in with patients during the course of an episode of care. For organizations to be able to provide more effective virtual care, several logistical questions need to be answered prior to implementation of virtual care:

What equipment will be required by the field staff/patient?
Will smartphones, tablets, personal computers, or free standing telehealth equipment such as blood pressure cuffs, heart rate monitors, thermometers, scales, or pulse oximeters be used?
Do software or apps need to be installed or upgraded on staff or patients’ personal devices?
Will staff require training or patients and caregivers require education?
What information will be obtained by and shared with the patient? This detail should be standardized for tracking and trending purposes, with the information in question including vital signs, COVID-19 screening questions, signs and symptoms of comorbid conditions, infection control, fall prevention, and oxygen safety.
Will the visits be synchronous or asynchronous? Is video capability required?

The benefit of a synchronous virtual visit is twofold:

Clinicians can verify that patients and caregivers understand the information shared and can follow the care plan.
Patients and caregivers have the opportunity to ask any clarifying questions and verify that the information they have received is accurate.

Asynchronous visits lose this opportunity.

Once the questions above are answered, flow sheets or trigger sheets need to be developed and staff education needs to be provided prior to implementation. It is highly recommended to use the Plan Do Check Act (PDCA) process with virtual visit program implementation in order to determine whether the program is working as intended and to make needed adjustments to improve care delivery. For clinicians and agencies that are new to the provision of virtual care, it is most important that the patient’s needs as identified on the plan of care be met either with physical visits, virtual visits, or both.

To be clear, telehealth visits may be appropriate for both COVID-19 and non-COVID-19 patients as a way to maintain social distancing, self-isolation, and quarantine. For instance, a patient who is on chemotherapy and is currently immunocompromised may benefit greatly from virtual visits to supplement in-person visits as the risk of infection is lower with less contact with others. A patient with COVID-19 during the contagious period may also benefit from telehealth so as to not potentially expose healthcare workers to the virus.

Patient Triaging in Home Health for Virtual Care

Once a patient is admitted to the HHA, all patients should be triaged into low, moderate, or high-risk categories for re-hospitalization based on the comprehensive assessment. This is mandatory for CMS Medicare beneficiaries and is based largely on the OASIS assessment. This risk category should be located in the 485 plan of care for all clinicians to have access. Additionally, patients are classified by priority codes to identify which patients cannot go without physical visits, which can go a day or two without a physical visit, and which could go longer without a physical visit.

Based on the risk category and priority level, agencies could determine which patients may benefit from telephonic visits alone. The purpose of these telephonic visits would be to support questions patients and families have regarding infection control, social distancing, self-quarantine, and isolation with regards to COVID-19. Agencies should also be available to answer questions about other health conditions for which they require home health services, specifically providing instructions and interventions in the plan of care.

For those at higher risk of contracting the virus, telehealth options may be more appropriate:

Asynchronous monitoring of vital signs with a follow-up phone call for vitals falling outside of ordered parameters
Synchronous televisits where the patient and healthcare provider can see and hear each other in real time, allowing clinicians to perform a more comprehensive examination through observation, history taking, and other exam components as well as address interventions on the care plan

Virtual Therapy & Nursing Home Health Care Visits

For therapists, synchronous televisits are most effective with implementation and progression of home exercise programs in addition to providing interventions for functional mobility training. Synchronous televisits are also most effective for nurses to evaluate skin integrity and observe wound care treatments being provided by a caregiver or self-administered by the patient. Nurses may also be able to assess a person’s ability to perform glucose monitoring and insulin injections.

At this point in time, if a patient experiences symptoms, the plan of care could be adjusted to focus on telehealth visits to protect the safety of healthcare workers.

Still, one important operational consideration is that currently, visits provided through telecommunication methods do not count as in-person visits toward the “plan of care.” For example, telehealth visits are not counted toward meeting the LUPA threshold.

Currently, telehealth can be used for:

Certification—Initial physician certification and face-to-face requirements can be completed using telehealth by a physician, nurse practitioner, or clinical nurse specialist.
Initial assessment—An initial assessment for the baseline care plan can be completed over telehealth or by record review.

Currently, telehealth cannot be used for:

Comprehensive assessment and completion of the OASIS—This visit must be done in person, but providers have been given more time to complete it (30 days instead of 5).
In-person visits—Telehealth visits and/or remote contacts can not replace the required visits per the plan of care and are not counted toward the LUPA threshold.

Which patients should be seen with face-to-face visits and which personnel will go to see the patients is a difficult decision, and the CDC guidelines are rapidly changing as this pandemic is a fluid situation with new information being gathered and incorporated moment to moment.

Standard and transmission-based precautions have not changed and remain very clear. It is true that there is a lot of fluidity in recommendations about which specific precautions are recommended and required for the COVID-19 virus, and these are likely to continue to evolve. Understanding that COVID-19 is a respiratory disease spread by direct transmission from person to person and by indirect transmission from contacting a contaminated surface will help reduce the risk of contamination.

Many in the industry discuss telehealth as a monitoring tool, but it is much more. It is a tool that can be used to advance a patient’s treatment regimen, assess parameters and status of health conditions, intervene timely when status changes, provide patient and family education, and update care plans.

Don’t miss part two of this series, Incorporating Telehealth into Home Health Care Part 2: Reimbursement Status.

Disclaimer: The information in this blog post (“Post”) is provided for general informational purposes only, and may not reflect the current law in your jurisdiction. No information contained in this Post should be construed as legal advice from MedBridge, Inc., or the individual author, nor is it intended to be a substitute for legal counsel on any subject matter.

Kenneth L. Miller, PT, DPT, GCS, CEEAA

Dr. Kenneth Miller has been an educator, physical therapist, and consultant for the home health industry for over 20 years and serves as a guest lecturer, adjunct teaching assistant, and adjunct professor in the DPT program at Touro College in Bay Shore, New York. He has presented at the Combined Sections Meeting of the American Physical Therapy Association (APTA), the Educational and Leadership Conference of the American Council of Academic Physical Therapy and Education Section of the APTA, and the Annual Conference of the National Association for Home Care and Hospice on a variety of topics, including objective testing, professionalism, interdisciplinary team modeling, osteoporosis, differential diagnosis of dizziness, documentation, patient engagement, student program development, and home health regulations.

He serves as chair of the Practice Committee of the Home Health Section (HHS) of the APTA. As the chair, he led the development of the Providing Physical Therapy section in the home handbook, third edition; home health student program road map and tool kit; and the home health section objective test toolbox. He is a member of the editorial boards of the GeriNotes publication and Journal of Novel Physiotherapy and Physical Medicine and is a manuscript reviewer for the Journal of Geriatric Physical Therapy and the Journal of Primary Care. Dr. Miller has authored numerous articles for the Journal of Geriatric Physical Therapy, GeriNotes, and The Quarterly Report Newsletters.

Kara Gainer, JD

Kara Gainer joined APTA in 2017 and provides leadership and strategic direction to the regulatory affairs team on key programs, initiatives, and policy development in the federal regulatory space. She has extensive knowledge and experience working on policies related to Medicare, Medicaid, health care reform, and provider billing and reimbursement. Prior to joining APTA, she was a health care consultant with Drinker Biddle & Reath, where she developed and executed comprehensive public policy strategies for her clients that integrated legislative, regulatory, and communications efforts. She also served as an attorney advisor for the US Department of Health and Human Services Office of Medicare Hearings and Appeals, and she clerked with the US Senate Sergeant at Arms. She received her bachelor’s degree in psychology from the University of Montana and law degree from the University of Montana School of Law, and is a member of the District of Columbia Bar.

Ellen Strunk, PT, MS, GCS, CEEAA, CHC

Ms. Strunk specializes in helping clients understand the Medicare prospective payment systems for skilled nursing facilities and home health agencies, as well as the Medicare conditions of participation for rehab agencies and outpatient billing for all provider types. Her experience includes utilizing medical record reviews and data systems to help both inpatient and outpatient therapy providers meet regulatory guidelines and prepare for the shift to value-based care. She has worked with clients on a variety of Medicare/Medicaid payment and certification matters, including substantial overpayment assessments and facilitation of Corporate Integrity Agreements. Ms. Strunk lectures nationally on the topics of coding, billing, and documentation to meet medical necessity and payer guidelines, value based-purchasing, incorporating clinical outcomes into practice, pharmacology in rehabilitation, and developing meaningful exercise programs.

Hicks, S. A. & Cimarolli, V. R. (2018). The effects of telehealth use for post-acute rehabilitation patient outcomes. Journal of Telemedicine and Telecare, 24(3), 179–184.