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Telehealth Beyond-covid
The document discusses the evolution of telehealth in wound care due to COVID-19, highlighting its transformation from traditional in-person visits to remote patient management using technology. It outlines best practices, challenges, and lessons learned in implementing telehealth solutions and emphasizes the importance of training and preparing both patients and providers for a new care paradigm. The future of wound care is projected to involve greater reliance on telehealth, driven by the need for efficiency and improved patient outcomes.
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Telehealth Beyond-covid
- 1. Copyright © 2020Healthy.io Ltd. All rights reserved Transforming Best Practice in Wound Care Telehealth Beyond COVID-19 Sponsored by
- 2. Copyright © 2020Healthy.io Ltd. All rights reserved Turning the smartphone into a medical device Shifting testing from the clinic to the home with no quality compromise.
- 3. CE-marked and FDA-registered Digitizingwound management Creating a flexible, smartphone enabled product to support documentation and create new data based insights The new standard in care and analysis
- 4. Elaine H. Song MD,PhD, MBA Co-Founder, WoundReference Tiffany Hamm BSN, ACHRN, CWS Co-Founder, WoundReference TELEHEALTH BEYOND COVID-19: Transforming Best Practice in Wound Care Catherine T. Milne APRN, MSN, ANP/ACNS-BC, CWOCN-AP Co-owner, Connecticut Clinical Nursing Associates Clinical Advisor, WoundReference Webinar sponsored by:
- 5. Disclaimer The informationin this webinar reflects the best understanding of the information available as of June 2, 2020. We encourage webinar participants to monitor regulation updates pertaining to telehealth in wound care that occur after June 2, 2020.
- 6. The Transformation ofWound Care as a Result of COVID-19
- 7. What is “telehealth”?The basics eHealth •Not only remote Telehealth • Remote • Curative, preventative Telemedicine •Curative CMS telehealth CMS communication-based technology services (CTBS) AHRQ. The Evidence Base for Telehealth: Reassurance in the Face of Rapid Expansion During the COVID-19 Pandemic, 2020 Van Dyk L. A review of telehealth service implementation frameworks. Int J Environ Res Public Health. 2014 Jan 23;11(2):1279-98 Song E.. What is new in 2019 for Telehealth and Telemedicine?, 2019
- 8. What is “telehealth”?The basics Telehealth •Remote •Curative, preventative Telemedicine • Curative, remote Medicare telehealth AHRQ. The Evidence Base for Telehealth: Reassurance in the Face of Rapid Expansion During the COVID-19 Pandemic, 2020 Van Dyk L. A review of telehealth service implementation frameworks. Int J Environ Res Public Health. 2014 Jan 23;11(2):1279-98 Advisory Board . How COVID-19 is transforming telehealth—now and in the future , 2020 Song E.. What is new in 2019 for Telehealth and Telemedicine?, 2019 E-consults Real-time virtual communication Remote patient monitoring Asynchronous store-and-forward Telehealth modalities Patient-to- provider use cases Provider-to- provider use cases Televisits Wearables, home exams Secure messaging E-consults Wound measurement Mobile health (mHealth) General education Medicare communication- based technology services (CTBS)
- 9. Medicare reimbursements fortelehealth Type of Medicare-covered Service Description of the service HCPCS Medicare Telehealth Visits CMS Telehealth. A visit with a provider that uses telecommunication systems between a provider and a patient Commonly used CPT codes include 99201-99215 "Office or other outpatient visits" and others; see https://www.cms.gov/Medicare/Medicare-General- Information/Telehealth/Telehealth-Codes Brief communication technology-based service (e.g. virtual check-in) CTBS. Virtual check-in by physician or other QHP, provided to an established patient HCPCS code G2012 Remote evaluation of recorded video and/or images submitted by an established patient (e.g. store and forward) CTBS. Patient submits a video/pictures to provider, who provides interpretation with follow-up with the patient within 24 business hours HCPCS code G2010 E-Visits: Online digital evaluation and management services or e-Visits for an established patient CTBS. Communication between patient and provider through an online portal CPT 99421-99423 and G2061-G2063 or CPT 98970- 98972 for some commercial payers Interprofessional internet consultation (e.g. e-consults) Provider to provider communication involving assessment and management of a specific patient CPT codes 99446, 99447, 99448, 99449, 99451, 99452 Remote monitoring Chronic care remote physiologic monitoring (e.g, weight, blood pressure, pulse oximetry, respiratory flow rate) CPT codes 99453, 99454, 99457 Shaum K. COVID-19 Reimbursement Depends on What Was Performed: Telehealth or Communication Technology-Based Service? Today’s Wound Clinic, June 3 2020 Song. E. Reimbursement for Telemedicine Services in Wound Care. May 12 2020 CMS Fact Sheet. Medicare Telemedicine Health Care Provider Fact Sheet. March 17 2020 Federal Register. Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. April 6 2020 CTBS: Communication Technology-Based Services (CTBS)
- 10. The rapid shifttowards telehealth Healthcare Dive. Medicare members using telehealth grew 120 times in early weeks of COVID-19 as regulations eased, May 27, 2020 AHRQ, The Evidence Base for Telehealth: Reassurance in the Face of Rapid Expansion During the COVID-19 Pandemic, May 14, 2020 Forrester Research. Healthcare Predictions 2020: Virtual Care Visits Will Soar To More Than 1 Billion In The US,”, March 16, 2020 Temporary waivers New rules CMS’ rapid legislative and regulatory changes to payment and privacy requirements Broadened access and payment for a wider range of telehealth services 11,000 1,300,000 March 7th 2020 April 18th 2020 Number of Medicare beneficiaries receiving telehealth services Estimated number of total U.S. telehealth visits in 2020 1 billion 11,718%
- 11. Medicare drops barriersto telehealth Weigel G. Opportunities and Barriers for Telemedicine in the U.S. During the COVID-19 Emergency and Beyond. KFF, May 11 2020 Updates in privacy, patient and provider eligibility Privacy regulations Audio-only visits possible Access services from home New and established patients Practice across state lines Widespread coverage and reimbursement Technological developments Healthcare workforce training
- 12. What are patientsthinking about telehealth? Sage Growth Partners. As The Country Reopens, Safety Concerns Rise,, May 11 2020 Most patients in the U.S. who tried telehealth are satisfied (Sage consumer survey, May ’20)
- 13. Pre-COVID evidence supportstelehealth AHRQ . The Evidence Base for Telehealth: Reassurance in the Face of Rapid Expansion During the COVID-19 Pandemic, May 14, 2020 Huang Z et al. Efficacy of Telemedicine for Patients with Chronic Wounds: A Meta-Analysis of Randomized Controlled Trials, Advances in Wound Care, May 20 2020 Telehealth is as good or better than usual care Evidence is concentrated in specific uses Beneficial for chronic wounds * Telehealth: televisits combined with in person visits, remote wound expert consultation using store and forward with picture and measurements
- 14. Crisis brings opportunities •Opportunities to better generate evidence and understand: o How to do telehealth in wound care rather than whether to do it o How digital solutions can facilitate clinicians’ and patients’ transition to the new normal Televisits Wound assessment & measurement Point-of-care decision support Automated documentation
- 15. The Impact ofTelehealth in Wound Care Challenges and Opportunities
- 16. Pre-COVID wound managementchallenges Acute Care Long Term Acute Care (LTAC)Primary Care/ Urgent Care/ Community Health Centers Home Health SNF/Short-term Rehab
- 17. Common themes acrosssettings Different techniques, lack of standardization Wound measurements are inconsistent Wound descriptions often subjective Variable documentation among providers Pressure injury staging incorrect Is wound better or worse? What interventions have been employed? May not have efficient “look-back” processes in place Lack of coordination in and between settings
- 18. The New Paradigmaddresses the challenges Save transportation costs Early and right intervention – cost impact? Specialty beds, compression, offloading Less supply waste Improved patient adherence Improved local care Earlier referral to experts Targeted visits Improved documentation Potential telehealth benefits
- 19. Telehealth addresses theseissues expediently • Between settings • Provider to provider • Provider to patient Quick evaluation of wound • Identify challenges each other did not know existed • Provides Teaching opportunities • Assists in Quality improvement Fosters relationships between providers and organizations • COVID-19 • Non-pandemic situations Triages appropriately
- 20. Best Practices forSuccessfully Adopting Telehealth
- 21. Pandemic challenges • Equipment •Processes • Uncertainty and rapidly shifting environment • Staffing changes Rapidity of Lockdown left wound management unprepared
- 22. Overcoming pandemic challenges •Organization • Payors • Liability company • State Practice Acts Know the rules • Work within and between each setting to determine process • Write it down!! • Train, train, train!! • It must be workable in the workflow Establish processes Identify barriers early1 2 3
- 23. For Provider toProvider • Consider this like a patient visit – set date and time • Expect a learning curve • Get as much information up front • Do you need a Business Associate Agreement? • Keep it HIPPA compliant • Document as if you were planning on an audit BEST PRACTICES AND TIPS
- 24. For Patients andCaregivers • Train early and often • Expect a learning curve • Determine technology comfort and identify point person o Is patient comfortable with this? o Is point person comfortable? o Can you use an intermediary provider? • Expect increased time and technical difficulties • Above all set the expectations up front… and its limitations BEST PRACTICES AND TIPS
- 25. If “outside” theorganization… • Run a few test locations within the collaborating organization if needed • Develop your relationships first… • Know what’s available to you o Staff, dressings, adjunctive therapies, etc. • Try a few with the other site in full PPE BEST PRACTICES AND TIPS
- 26. Selecting the rightpatient • Determine the telehealth goal…. o Are you worried about the patient/wound? o Feel the need to “trust but verify”? o“Survey says?” o Urgent but quick intervention? o Patient/family initiated? Patient doesn’t want face-to-face visit Patient concerned Worried well patient/family member oTriage? oSatisfy paperwork requirements? • Efficient for you? BEST PRACTICES AND TIPS
- 27. Lessons learned • Somepeople are early adopters, some out of necessity, some not at all • For most part, you will not save time early in process • You will get the information you need to make decisions…and sometimes more! • Telemedicine visits do not substitute for all visits • You will have to teach wound assessment and dressing change techniques • You will become a better provider…. • Expect the unexpected……
- 28. Case example • 58yo female admitted in January to SNF with Stage 4 ischial pressure ulcer and co-morbidity of multiple sclerosis Pre-pandemic picture at second MRI
- 29. Case example Outcomes • Improvedcommunication • Care coordination • Time efficient for providers • Staff education • Expedient care for patient New wound on right leg
- 30. Implementing telehealth inthe outpatient setting • Telemedicine process implemented at an outpatient wound clinic • Patient volumes dropped by half due to COVID-19 • Delivering care in a completely different manner • Approval from hospital administration • Overcoming obstacles
- 31. Provider workflow: designand implementation • Involvement of the hospital billing and coding department and management • Multiple training sessions were completed with providers to ensure seamless and efficient experience o Sequence of steps on how to conduct televisits • Providers’ feedback was incorporated in documentation templates o Ease of use o Reimbursement requirements o Coding the encounter o Integration
- 32. Provider challenges andsolutions Solution: repetition/training Memorizing steps of the new televisit workflow Use telehealth solution that automatically keeps track of time spent and guides the selection of the CPT code Getting used to time-based codes Diagnosis, description Practice with patient or enlist caregiver Submit pictures before televisit Have patient utilize wound assessment/measurement app if possible Unable to objectively assess/measure wounds Technical obstacles Perform pre-call test Check connectivity in the hospital Check devices, browsers, operating systems Understand communication technology limitations
- 33. Televisit workflow: nursing •Offering televisit • Scheduling • Vetting the patient • Sending the invite • Preparing the patient encounter • Integrating with the wound clinic scheduling • “Rooming” the patient in the provider’s video visit room at the patient’s scheduled appointment time • Helping provider with documentation Before the televisit During the televisit After the televisit
- 34. Lessons learned: clinicianstraining and support • Providers became stressed if the patient was having difficulty • Educate clinicians • Educate patient and caregivers
- 35. Lessons learned: technicalchallenges and solutions • Pre-appointment: oPatient factors oExperience with technology oEquipment oConnectivity • During the video call: o Capturing the image o A new experience
- 36. Lessons learned: patientexperience • We had been focusing on the provider and staff • We didn’t think about the patient’s problems from the onset. • The patient experience is the number one priority. If patients are happy, clinicians will be happy.
- 37. The Future ofWound Care in a Post-COVID-19 World Where Do Clinicians Go From Here?
- 38. Telehealth to become“table stakes” in wound care Gadzinski AJ, and Chad E. “Telehealth in urology after the COVID-19 pandemic.” Nature reviews. Urology, 1–2. 13 May. 2020 Brain, David et al. “Cost-effectiveness analysis of an innovative model of care for chronic wounds patients.” PloS one vol. 14,3 e0212366. 6 Mar. 2019 Advisory Board . How COVID-19 is transforming telehealth—now and in the future, 2020 • Ideal for simple follow-up care • Ideal for televisits between clinicians, to treat patients who cannot come in Virtual-care-first model • Pent up demand: need physical examination, procedures, diagnostic test Increased in-person visits States reopening
- 39. The new normalin wound care: follow up for non-complex cases Communication • Remote follow-up via televisits Remote monitoring • Wound assessment and measurement • First encounters in-person • Patient education: dressing change, compression • Wound care instructions via online patient portal • Monitoring of wound healing Simple venous ulcer Outpatient Gadzinski AJ, and Chad E. “Telehealth in urology after the COVID-19 pandemic.” Nature reviews. Urology, 1–2. 13 May. 2020 Rasmussen BS et al. A Randomized Controlled Trial Comparing Telemedical and Standard Outpatient Monitoring of Diabetic Foot Ulcers. Diabetes Care.;38(9):1723‐1729, 2015 Santamaria N et al. The effectiveness of digital imaging and remote wound consultation on healing rates in chronic lower leg ulcers in the Kimberley region of Western Australia. Prim Intention, 2004
- 40. The new normalin wound care: streamlining wound care and documentation Diabetic foot ulcer Skilled nursing facility Standardized documentation for SNF • Audit-ready • Supports diagnoses • Maximizes SNF per diem rate Increased efficiency for wound consultant • Data collected prior to encounter SNF Clinician • Clinical decision support tools oAlgorithms oWound-specific recommendations oVirtual panel Time is tissue SNF Clinician • Submits intake form, images, automatic wound measures Wound consultant • Televisit with SNF RN • Uses templates to document E/M • Tele-wound rounds Tele-wound care Purcell L. An invited commentary on “Impact of the Coronavirus (COVID-19) pandemic on surgical practice-part 1”. Impact of the Coronavirus (COVID-19) pandemic on surgical practice: Time to embrace telehealth in surgery. Int. J. of Surgery, May 2020
- 41. Are you readyto launch telehealth? Partner with your patient1 • Actively promote virtual visit options • Encourage patients to conduct a virtual visit before coming onsite • Support patients while using telehealth technology Ensure right technology is working properly 2 • Ensure digital solutions that integrate with your workflow are in place • Check bandwidth, connectivity, hardware Support your clinicians3 • Assess licensure status • Offer training • Provide real-time support for issues that arise during a virtual visit Get the legal team involved Providers’ licensure and employment agreements ok? Identify the unmet need, form your team then follow these 3 steps Song E et al. Telemedicine/ Televisit Implementation Playbook – Parts 1 and 2. 2020 Advisory Board . How COVID-19 is transforming telehealth—now and in the future, 2020
- 42. Start off onthe right foot • Likely the first restriction to be restored 1 Non-HIPAA compliant solutions Select HIPAA compliant solutions • Secure, permanent 2 • No specific documentation • Does not fit workflow Non-wound care-specific solutions Select wound care-specific solutions • Workflow integration, decision support, easy to implement Common pitfalls and suggested solutions • Steep learning curve • Barriers to adoption 3 Non-patient friendly solutions Select patient friendly solutions • Easy to use, meets specific needs
- 43. Incorporate telehealth intoyour strategy “There is no going back” Seema Verma, CMS Administrator Telehealth implementation and re-evaluation questions 1. What is your unmet need? 2. Who should be part of the implementation team? Leadership, clinicians, staff, billing, coding, legal? 3. Which digital solutions can meet this need? Are they HIPAA compliant, wound care-specific and patient-centered? 4. How can clinicians and patients be trained/educated on the telehealth processes and solutions? 5. How can progress be measured? Access to care, patient satisfaction, clinical effectiveness, cost savings? CHECKLIST Generating data to support reimbursement parity • Demonstrate how telehealth can help meet payers’ objectives such as: o Budget neutrality o Cost-effectiveness o Improved clinical outcomes, access to care, patient satisfaction Song E et al. Telemedicine/ Televisit Implementation Playbook – Parts 1 and 2. 2020 The Wall Street Journal. The Doctor Will Zoom You Now, April 2020 Advisory Board . How COVID-19 is transforming telehealth—now and in the future , 2020 FUTURE ACTIONS
- 44.