Telehealth in the Skilled Nursing Facility: An Important Tool to Deliver Care

A hypothetical physician (let's call him Dr. Reyes) sits down at his desk in his home office having completed rounds at three separate skilled nursing facilities (SNFs). He enjoys his position as a medical director and knows each patient’s health condition. At times, though, the 24-hour shifts are exhausting. He doesn't often visit the facilities in the middle of the night, but when he does, the next day is grueling. Often the nurses call with details of a patient’s situation, but the verbal descriptions vary widely.
Recently, one of the SNF administrators approached him about the possibility of using telehealth technology as a more efficient tool to monitor patients across various facilities. Dr. Reyes is open to the idea but is curious as to how it would be deployed.

The SNF as Part of the Acute Care Continuum

Hospitals have historically been viewed as the hub of the care continuum. Accordingly, Medicare has focused a great deal of its transformational healthcare policies and change management tools to address the acute care environment.
Hospitals are under a great deal of pressure to be efficient and focus on the acute patient. They are penalized for inappropriate readmissions and rewarded for quality care and excellent patient experience. Yet, the entire care continuum has been affected by the hospitals’ focus on shorter hospital stays and more efficient acute care. As a result, patients released to the sub-acute environment of a SNF are often more medically complicated and are generally in poorer health than they used to be.
With 1.4 million people receiving care in SNFs, and as payment reform expands into new settings, the Protecting Access to Medicare Act of 2014 added skilled nursing facilities to the list of organizations financially accountable for population health and quality care. Medicare reimbursements are now linked to the SNFs' ability to avoid preventable readmissions. If SNFs are deemed to have lacked appropriate patient preparation for discharge and readmit those same patients, they will face penalties up to 2 percent (or an average of $36,000) of their Medicare reimbursement  
Yet, the Medicare penalties are only part of the story. When patients are transferred back to a hospital setting, the SNF can lose up to $500 per day per empty bed. The overall cost to Medicare is substantial, given the average hospitalization costs $12,000.

Telehealth in the SNF

SNFs, as well as other care settings throughout the care continuum, are investigating innovative ways to improve outcomes, reduce costs, and enhance the patient experience. Telehealth is a powerful tool to assist physicians with clinical assessment and accurate diagnosis while allowing them to extend their oversight across multiple sites.
Typically in the skilled nursing environment, there are fewer physicians managing more patients than in a hospital setting. Nurses or medical assistants provide the bulk of the care. They call the doctor when a change of condition occurs and offer a verbal description of the situation.
A report by the Kaiser Family Foundation found that 30 to 67 percent of hospitalizations among SNF residents could be prevented with well-targeted interventions. Telehealth is one of those interventions.
Telehealth offers physicians another layer of data with which to evaluate patients. It provides a real-time view of the patient and condition that complements the nurses’ description of the issue. Quality telehealth equipment can see details of a patient’s eye dilation, labored breathing, bed wound, and even cognitive impairment.
By supporting the physician’s ability to conduct a patient examination, a telehealth encounter provides a clear view of many health conditions and supports nursing and caregiver efforts. Telehealth can also be used to obtain specialist consults without subjecting the patient to a potentially risky transfer. Increasingly, specialists are conducting their exams using telehealth.

Telehealth is More Than Bedside Video Conferencing

SNFs are using a variety of telehealth interventions. Some use telehealth for its remote monitoring capability. The most critically ill patients are monitored with tools to assess their vital signs and critical measures. Others use telehealth for stroke diagnosis and care. Still others use it to support the coordination of care and communication between healthcare professionals, caregivers, and family members.
When a facility uses the full functionality of telehealth, they often purchase a telehealth cart with peripherals like otoscopes and stethoscopes that support the video assessment.

Telepsychiatry in the SNF

Behavioral health and mental health issues are prevalent in the SNF. Psychiatry is another type of specialty care that can be brought to the patient’s bedside using the telehealth concept.
With telepsychiatry as the second-most-common use of telehealth (after stroke care), the incorporation of telepsychiatry into SNFs elevates the standard of care and supports treating the whole patient.
Reimbursement is lacking at this time, which has hindered telepsychiatry adoption. But as population health management continues to gain ground, the use of telehealth to deliver psychiatric care is a logical next step.

The Business Case

In their 2014 article in Health Affairs magazine, Grabowski and O’Malley studied 11 skilled nursing facilities and found that when telehealth was adopted and actively used, the savings to Medicare per facility was $120,000. They point out that unfortunately, the facility must buy the telehealth system, and Medicare reaps the savings reward. They encouraged a closer alignment between effort and reward.
After seeing telehealth technology in action, Dr. Reyes realizes that it presents a tremendous opportunity to make a difference for patients while improving outcomes and supporting the skilled nursing physician and care team. He feels ready to use telehealth technology to provide an extra layer of information and access to patients — especially after hours.
He believes that technology will make the difference in population health management. Specifically, telehealth will be used to improve patient care, extend stretched resources, and deliver quality care to a growing population of aging adults.