Reducing readmissions: Physician services enabled by telemedicine in SNFs

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John Whitman
John Whitman

When a resident of a skilled nursing facility has an acute event after hours or on weekends, the on-site nurse will generally call the patient's primary care physician. Over the telephone, the nurse will attempt to describe the resident's condition to his or her physician. Then the physician, in the middle of his Saturday at the zoo with his family, or at 3 a.m. (still trying to wake up), has to make a judgment call about whether the resident needs to go to the hospital.

As you can guess, this generally leads to the physician erring on the side of a hospitalization, both to protect the patient, and to protect the SNF and physician from malpractice liability.

Medicare's new hospital readmission penalties, as well as the general trend away from fee-for-service and toward accountable care, provide a strong incentive for hospitals to seek out nursing homes that have demonstrated that they have a good system in place for determining if a hospitalization is actually necessary.  A 3 a.m. phone call that leads to a hospitalization will probably not cut it in this new era of patient care.

 

What's the solution?

In short, the answer is: Physician Services enabled by Telemedicine (“Telemedicine”).  Telemedicine is becoming an increasingly utilized technology in medicine. The American Telemedicine Association defines telemedicine as “the use of medical information exchanged from one site to another via electronic communications to improve a patient's clinical health status.”

What does this look like in practice?  A physician will conduct an actual patient visit enabled through the use of technology. Through a Skype-like video chat, the physician can see the patient and the patient can see the physician, which allows direct communication. 

There is also technology in place that allows the physician to observe vitals and a high-definition camera allowing the physician to zoom in on the smallest details. This allows for a more accurate diagnosis of the patient's condition than a phone call.

Right now, telemedicine is used primarily for providing access to physicians, both primary care and specialist, in rural areas.  Medicare currently only reimburses for telemedicine services when the patient resides in a rural “Health Professional Shortage Area” or an area outside a “Metropolitan Statistical Area.”

However, technology is needed now in nursing facilities because of the large number of readmissions that occur simply because our long-term care system does not currently have a reliable system for differentiating which residents should go to the hospital and which should stay and be cared for in the SNF, especially during nights and weekends. CMS recognizes the promise of this physician service, enabled by technology, and is providing grant funding to prove the viability of this physician service within long term care.

So, how does all this relate to reducing hospital readmissions? eSNF provides one example. eSNF is a physician service company enabled by telemedicine that provides after hours and weekend support to SNFs. The TRECS Institute (Targeting Revolutionary Elder Care Solution) recently completed a Product/Service Review of eSNF and described it as “a timely product with a proven track record of reducing nursing home to hospital readmissions.” 

How does it work?

First, the telemedicine equipment is delivered to a facility and is set up in conjunction with eSNF. The equipment runs on standard WiFi; it needs a wireless signal to reach the patient's room and also a minimum bandwidth to ensure a good quality connection. eSNF's system was designed to need as little training or IT knowledge as possible.

Once installed, the nursing home's first call in the case of an after-hour acute care concern should be to eSNF.  The eSNF physician answers the phone directly (no answering service is used) and after receiving background information from the on-site nurse, he or she will then perform a virtual visit to that patient's bedside. After speaking with and examining the patient, the eSNF physician will call the resident's primary care physician to relay his/her findings and recommendations. Based on that consultation, and when medically appropriate, the eSNF physician may then actively treat the patient on site.   

In many cases, the eSNF physician also calls the family to bring them into the care decision, especially for end-of-life situations where sending the resident to the hospital offers little or no benefit to the patient, even though it tends to be common practice.

In addition, the eSNF physician can also prescribe medications directly to the patient if necessary, and eSNF has comprehensive and effective outcome tracking software that enables eSNF and the facility to track treatment results for management and marketing to their local hospitals. This last point is especially important when it comes to demonstrating your SNF's effectiveness at reducing readmissions, as well as working with any organization that tracks their outcomes with quality metrics.

What are the benefits?

First, every patient treated on site is one that isn't being sent out to the hospital. Every time eSNF saves a resident from going back to the hospital, that means the SNF can continue billing. With current short-stay rates running at $500 a day or more, and the average number of lost billing days from a readmission estimated at eight or more, each readmission prevented through the use of eSNF generates an additional $4,000 or more for the facility, as well as an increased census resulting from fewer hospitalizations. By utilizing eSNF, a facility's gross revenue should increase.

eSNF has a track record of reducing readmissions by as much as 50%. For many eSNF customers, this program can be used to show hospitals that they are committed to treating in place, which has led to meaningfully increased referrals.

eSNF also helps when speaking with new potential residents, who are more likely to select facilities that have physician coverage both during the day and during nights and weekends. 

What's the catch?

Well, the first potential hurdle, as you've probably already guessed, is assuring a facility's IT capabilities are capable of supporting eSNF. The telemedicine system works through standard WiFi, but facilities will need to make sure it is fast enough and covers all of the rooms where patients will be treated. The equipment itself is included in eSNF's monthly service fee. eSNF charges a one-time setup fee that covers a facility assessment, IT integration, staff training, and a launch seminar. They then charge a monthly fee based on the size of the nursing facility.

To be successful, it is critical to get your nurses and primary care physicians on-board. The nurse will play an integral role in the eSNF visit, both in making the initial decision to call eSNF and initiate the visit and in assisting with taking vitals and other tasks during the visit. The primary care physician also needs to be open to communicating with the eSNF physician about their patient. The good news is that eSNF does not in any way impact the physician's income, and no one is trying to steal his or her patients. At the end of the day, the increase in quality that eSNF provides will win over most providers.

One final concern that often comes up is potential malpractice liability for the SNF and the primary care physician. At the outset, it's important to realize that eSNF physicians all have their own malpractice insurance.  If a case arises, the eSNF physician could be named along with the SNF and the treating physician, but the difference is that the case should be much more defensible. Instead of the current 3 a.m. phone call, eSNF provides a comprehensive visit to the patient's bedside, which allows for much more informed care decisions.

In addition to making your SNF more attractive to hospitals and accountable care organizations through decreased readmissions and data packaging, eSNF is also attractive to residents and their families.

Explaining the comprehensive after-hours coverage will make families feel that their loved ones are in good hands. In addition, it demonstrates that your SNF is at the leading edge of technology, and willing to utilize the latest technology for the good of your residents. From a financial perspective, eSNF can also help keep census up. After all, any avoided readmission will keep the resident in the SNF and the economics of that make it a viable decision from day one.

John Whitman is the executive director of TRECS. John Durso is an attorney and McKnight's Ask the Legal Expert columnist. For more about eSNF, contact Susan Riley by email or at (855) 376-3669.  For more information about the TRECS Product/Service review, contact John Whitman by email or at (484) 557-6980.  

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