We have put together several videos demonstrating the use of telemedicine in the care of nursing home patients:
Wednesday, April 29, 2009
Friday, April 24, 2009
Reducing 30 day Hospital Readmission rates
The Institute of Healthcare Improvement or IHI, has launched a grant funded initiative for reducing Rehospitalizations. It is supported by the Commonwealth fund. The goal is to reduce the 30-day rehospitalization rate by 30%. Another stated goal is to improve patient and family satisfaction with transitions of care and with the coordination of care.
IHI recommends these 4 elements at the time of hospital discharge:
IHI states that success is dependent on active partnerships with providers across the continuum of care: hospitals, skilled nursing facilities, home health, ambulatory settings and patient/caregiver.
The focus of this project will have implications in healthcare payment reform, so it will be important to follow the progress of this project. There's a strong emphasis on improving care transitions and to identify those important services that will enhance this process. Unfortunately, many of these services are currently not reimbursed. It will require an out-of-the-box thinking beyond the current fee-for-service payment model in order to finally develop solutions that really work.
IHI recommends these 4 elements at the time of hospital discharge:
- Enhanced assessment of post-discharge needs;
- Enhanced teaching/learning;
- Enhanced communication at discharge; and
- Timely post-acute follow up
IHI states that success is dependent on active partnerships with providers across the continuum of care: hospitals, skilled nursing facilities, home health, ambulatory settings and patient/caregiver.
The focus of this project will have implications in healthcare payment reform, so it will be important to follow the progress of this project. There's a strong emphasis on improving care transitions and to identify those important services that will enhance this process. Unfortunately, many of these services are currently not reimbursed. It will require an out-of-the-box thinking beyond the current fee-for-service payment model in order to finally develop solutions that really work.
Monday, April 20, 2009
WSJ writes about the perils of an EMR stimulus
From the opinion page of the WSJ from April 14, 2009: "A competitive marketplace would produce the most innovative medical-records system"
I wrote earlier about the dangers of having the government force physicians into buying the "right" EMR systems. That is, systems approved or certified by the government, possibly CCHIT certification. This may have the unintended consequences of stifling competition and innovation. Can you imaging if the government had mandated that all businesses use a "certified" word processing system or a "certified" search engine? If this was the case, we'd all be using a Wang word processing system and Google may never have been created.
The WSJ puts it very nicely in this opinion piece:
I wrote earlier about the dangers of having the government force physicians into buying the "right" EMR systems. That is, systems approved or certified by the government, possibly CCHIT certification. This may have the unintended consequences of stifling competition and innovation. Can you imaging if the government had mandated that all businesses use a "certified" word processing system or a "certified" search engine? If this was the case, we'd all be using a Wang word processing system and Google may never have been created.
The WSJ puts it very nicely in this opinion piece:
"The ideal system would be an open platform for many developers to write applications that are allowed to succeed and fail, much like Apple's iPhone software. They argue that the key is "allowing competition and 'natural selection' for high-value, low-cost products."
"The stimulus hands the Obama Administration the power to define and approve "certified" records, therefore the power to create a health-tech monopoly. With stimulus money being shoveled out as quickly as possible, doctors and hospitals may end up prematurely investing in the costly systems that happen to have the government seal of approval -- and in the process freezing out an innovative marketplace."
Thursday, April 16, 2009
Medicare Reform: Denying payment for 30 day re-admissions
Connected Health: Expanding its Role to Prevent 30-day Hospital Readmissions
Friday, August 22, 2008 | Allison McDonough, MD
Dr McDonough makes the following Points:- "Connected health can contribute significantly to preventing such readmissions by improving monitoring of patients after discharge."
- "May provide additional benefit by assisting with access to timely ambulatory care for high risk patients."
- "There is ample room for improvement in 30 day readmission rates."
- "In 2005, an average of 18% of patients were readmitted within 30 days of their hospital discharge, with a range of 14% at the 10th percentile to 21% at the 90th percentile (Commonwealth Fund National Scorecard on U.S. health system performance, 2008)."
- "Medicare estimates that 13% of these readmissions were “potentially avoidable,” based on the IPPS rule, with major areas of concern including poor communication with patients at discharge, especially around medications, and inadequate post hospital discharge monitoring."
- "Prevention of these avoidable readmissions could save Medicare about $12 billion per year. (Report on Medicare Compliance, Volume 17, Number 24, June 30, 2008)"
- "Post Hospital Discharge Monitoring: Remote daily measurement of vital signs and symptoms in the heart failure population has shown great promise already in reducing readmissions, through improved monitoring as well as patient education."
- "IT platforms which facilitate interactions with Primary Care Providers will enhance the effectiveness and efficiency of telemonitoring."
- "These interactions may also improve patients’ access to timely ambulatory care, avoiding Emergency Department visits and readmissions."
Great comments made by some readers:
"I would like to also suggest hospital/physician referral's to Skilled Nursing Facilities. Many people still have the idea that a "Nursing Home" is the end of the road of life, however this is no. Most SNF's can handle much higher levels of care post-acute and most offer wonderful rehab programs and all disciplines (PT, ST, OT). It would be nice to develop a "circle" of care. From Hospital to SNF and then home with home health. This would really help deter the emergency room visits and the costs asscoiated with such visits. Also, a way to educate about the Medicare 30 day window, post hospital stay, for patients and the hospital staff would be very beneficial. Most of the hospital case managers and ER staff are not aware of this benefit."
Posted by: Robin Davis
Comments by the Author: Allison McDonough, MD
- "There is clearly a vital role for the visiting nurse in caring for our sickest patients. SNF and Rehab facilities are also an essential part of the continuum of care. However, as you know, many very sick or complicated patients are still not homebound, and do not qualify for VNA services. I see connected health as one way to fill this gap."
- "...dangers patients face in periods of transition, e.g. hospital or SNF to home."
- "Research from Kaiser found that >90% of hospital discharge medication lists contained errors (such as duplicative medication classes, interactions, inappropriate dosing)."
- "Patients often feel, and sometimes are, abandoned."
- "Economic incentives to discharge early mean that patients are frequently sent home while they are still fairly ill."
- "we need to embrace the patient and guide them through the entire continuum of their care"
Friday, April 10, 2009
Nursing Home Care- A Literature review
Here are some interesting articles highlighting some problems related to lack of physician availability to care for nursing patients in the current health care system.
Although this is a blog with a primary focus on health IT, it is important to have a clear understanding of the problems faced by practitioners in order to create an IT solution.
I have listed some key information from my literature search
..."the quality of care in nursing homes remains inconsistent and in many respects suboptimal."
(11. Scanlon WJ. Nursing Homes: Prevalence of Serious Quality Problems Remains Unacceptably High, Despite Some Decline. Testimony before the Committee on Finance, U.S. Senate, GAO 03-1016T, 17 July 2003)
A case for Nursing Home Physician Specialists in the Annals of Internal Medicine, March 2009
1997 Study on Nursing Home Medical Practice
"Physician care positively influences residents' hospitalization rates, functional status, and satisfaction (33–35). Marginal physician involvement impedes communication and integration of the physician into the nursing home culture, with detrimental patient outcomes"
Although this is a blog with a primary focus on health IT, it is important to have a clear understanding of the problems faced by practitioners in order to create an IT solution.
I have listed some key information from my literature search
..."the quality of care in nursing homes remains inconsistent and in many respects suboptimal."
(11. Scanlon WJ. Nursing Homes: Prevalence of Serious Quality Problems Remains Unacceptably High, Despite Some Decline. Testimony before the Committee on Finance, U.S. Senate, GAO 03-1016T, 17 July 2003)
A case for Nursing Home Physician Specialists in the Annals of Internal Medicine, March 2009
Marginal physician involvement impedes communication and integration of the physician into the nursing home culture, with detrimental patient outcomes (36–38).
Nursing home practice is only 4% of work time among the 20% of physicians who practice in a nursing home, one third of whom are internists (12). Often rooted in reality, perceptions among nursing home physicians of excessive regulation, paperwork, professional liability, and lack of nursing support remain barriers to developing a widespread nursing home specialist culture (13). Perhaps more important, many physicians still find it difficult to overcome logistic challenges (for example, caring for a sufficient number of patients while traveling from one facility to another), even though reimbursement for nursing home visits has increased. Without salary derived from administrative duties associated with being a medical director, many practitioners find nursing home care untenable. Waning interest in primary care and geriatrics (14), coupled with few credible role models (15), further constrains physician involvement in nursing homes. In a survey of graduating residents, fewer than 15% felt "very prepared to provide nursing home care" (16). .
1997 Study on Nursing Home Medical Practice
RESULTS: Most (77%) physicians reported spending no measurable time caring for nursing home patients
CONCLUSIONS: With increasing numbers of older and frailer residents, nursing homes will continue to be integral components of the future healthcare system. However, physicians currently spend minimal time caring for nursing home patients, with physician characteristics best predicting involvement. Questions remain about the future of nursing home medical practice and how to best recruit, staff, and train future cadres of physicians to provide sufficient quality care for nursing home patients in an evolving health care system.
Physician involvement in nursing home patient care is important in decreasing needless hospital admissions and in improving outcomes:
"Physician care positively influences residents' hospitalization rates, functional status, and satisfaction (33–35). Marginal physician involvement impedes communication and integration of the physician into the nursing home culture, with detrimental patient outcomes"
Sunday, March 15, 2009
EMR and the Stimulus Bill
There are many opinions regarding the effects of a government subsidy for EMR adoption. As I blogged earlier, my fear is this may just end up promoting older technologies and "establishment" vendors, potentially preventing smaller, innovative players from entereing the market. There also implications for open source EMR community as well.
Austin Merritt has some interesting thoughts in his article, Get Ready for EHR Failures, But Don’t Blame the Software.
He expresses concern that a free or overly subsidized EMR will not lead to meaningful use by physicians since people tend not to value somthing they did not pay for. I generally agree with this premise. However, if the "free EMR" is trully indispensible to the physician in terms of efficiency, workflow, care quaility, and is easy to use, then it will not matter if the EMR is free- it will be adopted by phyicians.
Austin Merritt has some interesting thoughts in his article, Get Ready for EHR Failures, But Don’t Blame the Software.
He expresses concern that a free or overly subsidized EMR will not lead to meaningful use by physicians since people tend not to value somthing they did not pay for. I generally agree with this premise. However, if the "free EMR" is trully indispensible to the physician in terms of efficiency, workflow, care quaility, and is easy to use, then it will not matter if the EMR is free- it will be adopted by phyicians.
Tuesday, March 10, 2009
Addressing Long Term Healthcare worker shortage
Legislation H.R. 468 was introduced in order to expand opportunities for long term care workers to obtain additional training and education in care of our growing geriatric population. It is now well known that there will be a shortage of physicians and nurses in the near future, especially in long term care.
There's a need to widen the educational opportunities for the existing pool of long term care providers.
I'm looking for practical examples of the implications of this bill. Hopefully we will see more educational programs being offered to our nursing homes. Nurses in these facilities are over burdened by the increased complexity of today's long term care patients and often lack clinical support. Educational programs for nurses that can be offered on site at nursing homes in the practical aspects of patient care would be of great value.
Perhaps telemedicine can help fulfill this need by bringing experts remotely via video conferencing to the nursing homes and allowing all facilities equal access to quality education despite their location.
Below is an excerpt from the bill describing their findings:
Text of H.R.468 as Introduced in House
See also for more information:
See below for Information of Geriatric Education Centers (taken from above H.R.468)
There's a need to widen the educational opportunities for the existing pool of long term care providers.
I'm looking for practical examples of the implications of this bill. Hopefully we will see more educational programs being offered to our nursing homes. Nurses in these facilities are over burdened by the increased complexity of today's long term care patients and often lack clinical support. Educational programs for nurses that can be offered on site at nursing homes in the practical aspects of patient care would be of great value.
Perhaps telemedicine can help fulfill this need by bringing experts remotely via video conferencing to the nursing homes and allowing all facilities equal access to quality education despite their location.
Below is an excerpt from the bill describing their findings:
Text of H.R.468 as Introduced in House
Retooling the Health Care Workforce for an Aging America Act of 2009
SEC. 2. FINDINGS.Congress finds the following:
(1) The United States will not be able to meet near-term demands for chronic, geriatric, and long-term care without a workforce that is prepared for the job.
(2) Between 2005 and 2030, it is estimated that the number of adults aged 65 and older will almost double from 37,000,000 to over 70,000,000, increasing from 12 percent of the population of the United States to almost 20 percent of the population.
(3) Because the overall size of the population of older adults in the United States will increase rapidly, the number of older adults in the United States who are disabled will soar in the coming decades. Between 2000 and 2040 the number of older adults who are disabled will more than double, increasing from an estimated 10,000,000 to an estimated 21,000,000.
(4) A 2008 report by the Institute of Medicine of the National Academies, entitled, ‘Retooling for an Aging America’ concludes that the health care workforce will lack the capacity, in both size and ability, to meet the needs of older patients in the future unless action is taken immediately.
(5) Inadequate training in geriatrics, gerontology, chronic care management, and long-term care is known to result in misdiagnoses, medication errors, and inadequate coordination of services and treatments that result in poor care and is costly for the health care system as a whole.
(6) Currently, only 1 percent of all physicians (approximately 7,000) in the United States are certified geriatricians, even as the population of older adults is on track to double by 2030.
(7) Inadequate amounts of time devoted to geriatric training are reported by 1/4 of graduating medical students, and close to 1/2 of graduating medical students say they are unprepared to care for residents in nursing homes.
(8) Less than 1 percent of all nurses are certified gerontological nurses. Absent any change, by the year 2020, the total supply of nurses in the United States is projected to fall 29 percent below requirements, resulting in a severe shortage of nursing expertise relative to the demand for care of medically complex, frail older adults.
(9) Estimates suggest that there are currently only 700 practicing geropsychologists in the United States, falling far short of the current need for 5,000 to 7,500 geropsychologists.
(10) The Bureau of Labor Statistics of the Department of Labor predicts that personal or home care aides and home health aides will represent the second and third fastest-growing occupations between 2006 and 2016. Yet personal or home care aides are not subject to any Federal requirements related to training or education, and States have very different requirements for personal or home care aides.
(11) Research shows that inadequate training is a major contributor to high turnover rates among direct care workers and more training is correlated with better staff recruitment and retention rates.
(12) An estimated 44,000,000 family caregivers are being asked to provide increasingly complex medical services to frail and elderly loved ones wishing to live at home. Multiple surveys have documented that basic training and access to other targeted services are necessary for family caregivers to provideSee also for more information:
Bill would expand education, training for workers in LTC
Democrats file bill addressing geriatric provider shortageSee below for Information of Geriatric Education Centers (taken from above H.R.468)
TITLE I--AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT
Subtitle A--Health Professions Education Related to Geriatrics
SEC. 101. GERIATRIC EDUCATION CENTERS.
Section 753 of the Public Health Service Act (
‘(d) Grants To Expand and Improve Geriatric Education Centers-
‘(1) IN GENERAL- The Secretary shall award grants or contracts under this subsection to entities that operate a geriatric education center pursuant to subsection (a)(1).
‘(2) APPLICATION- To be eligible for an award under paragraph (1), an entity described in such paragraph shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.
‘(3) USE OF FUNDS- Amounts awarded under a grant or contract under paragraph (1) shall be used to--
‘(A) carry out the fellowship program described in paragraph (4); and
‘(B) carry out 2 of the 3 activities described in paragraph (5).
‘(4) FELLOWSHIP PROGRAM-
‘(A) IN GENERAL- Pursuant to paragraph (3), a geriatric education center that receives an award under this subsection shall use such funds to offer short-term intensive courses (referred to in this subsection as a ‘fellowship’) that focus on geriatrics, chronic care management, and long-term care that provide supplemental training for faculty members in medical schools and other health professions schools with programs in psychology, pharmacy, nursing, social work, dentistry, public health, or other health disciplines, as approved by the Secretary. Such a fellowship shall be open to current faculty, and appropriately credentialed volunteer faculty and practitioners, who do not have formal training in geriatrics, to upgrade their knowledge and clinical skills for the care of older adults and adults with functional limitations and to enhance their interdisciplinary teaching skills.
‘(B) LOCATION- A fellowship shall be offered either at the geriatric education center that is sponsoring the course, in collaboration with other geriatric education centers, or at medical schools, schools of nursing, schools of pharmacy, schools of social work, graduate programs in psychology, or other health professions schools approved by the Secretary with which the geriatric education centers are affiliated.
‘(C) CME CREDIT- Participation in a fellowship under this paragraph shall be accepted with respect to complying with continuing medical education requirements. As a condition of such acceptance, the recipient shall agree to subsequently provide a minimum of 18 hours of voluntary instructional support through a geriatric education center that is providing clinical training to students or trainees in long-term care settings.
‘(5) ADDITIONAL REQUIRED ACTIVITIES DESCRIBED- Pursuant to paragraph (3), a geriatric education center that receives an award under this subsection shall use such funds to carry out 2 of the 3 activities:
‘(A) FAMILY CAREGIVER TRAINING- A geriatric education center that receives an award under this subsection shall offer at least 2 courses each year, at no charge or nominal cost, to family caregivers that are designed to provide practical training for supporting frail elders and individuals with disabilities. The Secretary shall require such Centers to work with appropriate community partners, including family caregivers and family caregiver organizations, to develop training program content and to publicize the availability of training courses in their service areas. All family caregiver training programs shall include instruction on the management of psychological and behavioral aspects of dementia, communication techniques for working with individuals who have dementia, and the appropriate, safe, and effective use of medications for older adults.
‘(B) DIRECT CARE WORKING TRAINING- A geriatric education center that receives an award under this subsection shall offer at least 2 courses each year to certified nurse aides, home health aides, personal or home care aides and other types of direct care workers on ‘best practices’ for working with frail elders and individuals with disabilities, including individuals with dementia, urinary incontinence, and problems with balance or mobility, and raising awareness of medication issues for older adults.
‘(C) INCORPORATION OF BEST PRACTICES- A geriatric education center that receives an award under this subsection shall develop and include material on depression and other mental disorders common among older adults, medication safety issues for older adults, and management of the psychological and behavioral aspects of dementia and communication techniques with individuals who have dementia in all training courses, where appropriate.
‘(6) TARGETS- A geriatric education center that receives an award under this subsection shall meet targets approved by the Secretary for providing geriatric training to a certain number of faculty or practitioners during the term of the grant, as well as other parameters established by the Secretary, including guidelines for the content of the fellowships.
‘(7) AMOUNT OF AWARD- An award under this subsection shall be in an amount of $150,000. Not more than 24 geriatric education centers may receive an award under this subsection.
‘(8) MAINTENANCE OF EFFORT- A geriatric education center that receives an award under this subsection shall provide assurances to the Secretary that funds provided to the geriatric education center under this subsection will be used only to supplement, not to supplant, the amount of Federal, State, and local funds otherwise expended by the geriatric education center.
‘(9) AUTHORIZATION OF APPROPRIATIONS- In addition to any other funding available to carry out this section, there is authorized to be appropriated to carry out this subsection, $10,800,000 for the period of fiscal year 2011 through 2013.’.
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