The Prospective Payment System (PPS) for Home Care, a new means of paying for home care services through Medicare funding, will become effective in October 2000, and represents important changes in home care service delivery. No, home telemedicine will not be reimbursed, just like it was not reimbursed before. Televisits will not be paid as conventional 'visits,' no matter how comparable the two interventions may be.
The most notable change required of home care service delivery under PPS is the switch from payment per visit to payment per episode of care. Episodic care is a new way of apportioning care services. Over 60 day periods, episodic care can mean more needs to be addressed per patient, more services delivered, and more time to demonstrate patients' improved health outcomes. Because-and this is entirely new in home care under PPS- payment for services will be dependent on providers' demonstrating and documenting their patients' maintained or improved health outcomes. If providers choose to use telemedicine during these "episodes," they may. "Whatever works," may be the attitude that's adopted before long, under PPS.
This means of getting paid for providing demonstrably needed and effective home care services is a far cry from simply submitting bills to HCFA for individual services rendered. Compared with conventional home nursing visits, new calls for team management of a broader range of care and precisely tracking all care services delivered per patient are obvious new challenges posed by PPS for Home Care. Can telehealth help to meet some of these challenges posed by PPS? More than likely, yes.
Think first of episodic management, and acquiring a longer term view of patients' needs. The most comprehensive telehealth approach to an 'episode' of care that I have ever heard of (and this, long before talk of PPS for Home Care), was from a marketing executive of a telehealth product for obstetrical care, who said: "We follow women from conception to post-partum care." Never mind what exactly his company might do to pinpoint its role in conception. It's more a case of virtually 'being there' for any patient need, and on an as-needed basis.
Telehealth in PPS is very much a part of helping providers to 'be there' during episodes of care. Regular telemonitoring of vital signs transmitted over ordinary telephone lines from patients' homes to their nurses at home care agencies enable providers to precisely track and respond to patients' progress. High glucose levels, for instance, can be addressed in a timely manner. Using the ordinary telephone, patients can be given pointed directives for lowering glucose through diet, exercise, or medication. Contacts like these with providers can help patients, simply, know what to do.
The most basic contribution that telehealth can make toward timely tracking of patients' progress is increased communications. At its most basic, the telehealth tool is the ordinary household telephone. Cautionary approaches to 'buying in' to telehealth have made all the sense in the world when our understanding of telehealth has been a full-scale, often costly workstation for every patient. Initial outlay is far more than most home care agencies can absorb. There is also a great deal of trepidation in the industry today as PPS approaches-accounting practices need to be revamped, procedures re-styled. New purchases are on indefinite hold in many cases.
What about working with materials on hand-namely, the household telephone, as a start? Sharon Jones, COO of the Visiting Nurse Association (VNA) of Cleveland, reports that her agency specifically has chosen 'low-tech tools' to help prepare for PPS. She says: "Given our elderly population and desire for a low-cost option, we felt the telephone was the most appropriate tool for us." Patients are instructed to use the phone to answer 2 to 3 questions 2 to 3 times per week about their health status which they do in conjunction with their in-person nursing visits.
We can appreciate that the telephone will 'work' when it's presented in this way-as a tool for an elderly, low-tech audience, who already own phones and know how to use them. No special training is involved. An additional comment by Jones is of note, however, when we think about the transparency of this ordinary device--for the nurse. She says that the telephonic system "meets our clinical management needs in that no one is tied to a central monitoring system, but instead will be paged automatically if the patient response warrants intervention." Telehealth provision is delivered, then, on an as-needed and more economically prudent basis.
Telehealth equipment can help providers not only 'be there' and monitor patients' progress, but also effect change as well by enabling patient self-management. One key step to successful use of telehealthcare to reach this end is matching a telehealth tool specifically with a particular patient's need.
There's a huge territory of new telehealth tools to be explored beyond the simple rotary phone and before purchasing the full-scale workstation. A patient who needs help with remembering complex medication schedules may find that an automated phone reminder system or a pre-programmed hand-held beeping device works well. That's an easy match and requires tools not too far from the familiar. What about a notoriously noncompliant diabetic with poor eyesight? A match can be made with a tactile-oriented glucometer tailored for blind patients that is now available. Once the match has been made, the next step for this and all other patients is building programs for contact and follow-through by providers. This contact and training can help patients, particularly those with chronic disease, 'know what to do' and enable their self-management routines over a longer term, particularly after their episodes of care under PPS are completed.
In the 6 years that I've researched home telemedicine, the two questions I receive most frequently are: What does home telemedicine cost? And, does it work? Fair questions, but people really want to know: Isn't it a gamble to invest heavily in these new and unproven technologies?
Yes, it is, if you're waiting to see how they work rather than acquiring only tools that match your patients' needs, and then building programs around these tools and the clinicians who work, even on a virtual basis, with their patients. To start, you can lease or rent equipment, to determine what seems to be effective with the patients you know. PPS in effect gives us the opportunity to measure what 'works'- and we need to locate those tools now to see what can "work" now and after October 2000 if we hope to maintain and, even better, improve patient health outcomes, as required by PPS. We also need to locate and use them so that we can begin learning new and needed ways of doing the business of home care in the 21st century.
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