Learning Objectives. Disclosures. Definitions. Welcome to So-Cal. CMS Telehealth Practitioners 13/04/2014

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1 Learning Objectives IRSG 49th Annual Conference Moving Beyond Disability: Bridging the Gap for the Future of Rehabilitation Telemedicine and Telehealth in Physical Therapy April 8, Define telemedicine and telehealth in physical therapy 2. Describe telehealth opportunities in physical therapy 3. Review telehealth challenges in physical therapy Assoc Prof Alan C. Lee Mount St. Mary s College, Los Angeles, CA allee@msmc.la.edu Disclosures NIDRR Department of Education, Grant #H133E D3 Telerehabilitation Implementation Projects: TIP-5: Telerehabilitation to support international rehabilitation service learning. Collaborators: Parmanto B., Sapporo A., Schein R., and Lee AC. No financial interestor relationship with the manufacturer(s) of any commercial product(s) ATA Telerehab SIG Secretary Definitions Telehealth is a collection of means or methods for enhancing health care, public health, and health education delivery and support using telecommunications technologies For purposes of Medicaid, telemedicine seeks to improve a patient's health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment Telehealth (previously called telemedicine) is seen as a tool in medical practice, not a separate form of medicine. There are no legal prohibitions to using technology in the practice of medicine, as long as the practice is done by a California licensed physician Telerehabilitation is a term used to describe the provision of rehabilitation services at a distance using telecommunications technology as the service delivery medium Welcome to So-Cal CMS Telehealth Practitioners Physician Nurse practitioner Physician assistant Nurse midwife Clinical nurse specialist Clinical psychologist Clinical social worker Registered dietitian 1

2 Live Video, Store-and-Forward, Remote Patient Monitoring Telehealth in Physical Therapy Image Courtesy of Clay Brown, PT, DPT Copyright American Heart Association Silva G S et al. Stroke 2012;43: Telemedicine The platform of video conference used during the home cardiac telerehabilitation by American Physical Therapy Association Scalvini S et al. PHYS THER 2013;93: The hourly cost of operating the teledermatology practice was lower than that of the conventional clinic ($274 versus $346) TELEMEDICINE AND e-health V13, 2, Actual cost ($4.75) Actual cost ($12.50) 2

3 Remote Diagnosis of musculoskeletal disorders Indian Health Services, AK MSK referral sources 11 Family practice physicians- Village Travel Orthopedic Referrals- Field Clinics Post-op patients from Anchorage hospital Technology used Polycom VSX 7000 Rolling Cart Telehealth in Physical Therapy Benefits & Barriers By moving information rather than people, telehealth streamlines facility costs, improves provider efficiency, extends access to care to remote patients Reduce travel costs Maintain societal roles Telehealth doesn t work for every patient Manual intervention may be necessary Hands-on examination If not pleased with outcomes Logistics Weather Reimbursement Indian Health Services, AK Telehealth Network, GA Integument wound management since 2004 Hub and spoke sites to 5 rural counties small hospitals swing bed facilities nursing homes home health agencies 3

4 Benefits & Barriers Benefits & Barriers Expands integumentary knowledge & advanced specialty care to patients and health care providers In a manner that is cost effective timely efficient Reduced ambulance use & provider travel costs Covered by GA rural health initiative Is not possible to Palpate wound or periwound tissue probe for bone Measure the wound for depth/undermining Detect odor With PT/PTA/nurse at remote site to carry out assessments, all information can be obtained Financial Savings Regular employee vs. agency therapist Regular employee traveling from distant location Travel time/mileage savings Compliance savings Fines, paybacks, contracts Rapid Adoption Providers & patients Superior outcomes Consistent care and progression of treatment plan Technical Loss of connectivity Equipment failures Onsite visit as needed Reimbursement Licensure portability in near by states Sub-Acute Rehab, WA Telehealth in Physical Therapy Re-evaluation & PTA Supervision RCW Board of Physical Therapy wrote this rule, it was their intent that reevaluation means that the licensed physical therapist must at a minimum lay eyes on the patient. Technology used Global Media i5770 Camera Initial hardware -$2,000 (not including computers, internet) Monthly software cost -$150 Typical Episode of Care Telehealth in Physical Therapy Mount St. Mary s College to HIC, Mexico Examination Evaluation Treatment Plan Onsite PT Visit PTA Visits Daily onsite encounters with patient Observe Patient & PTA in 5 th visit Record encounter in EMR PT modifies plan/goals PT Re-evaluation by Telehealth PT Onsite Every 10 th Visit Arrangements made for onsite PT visit sooner if needed Patient safety & outcomes are priority 4

5 Technology Used VISYTER Portal Informed Consent The therapist talked to you about speech therapy on your computer. We will use a computer and a camera. This equipment connects to the internet. Service is available to you here in Belfast. You can stop the telepractice session at any time. If you are a Medicaid client, MaineCare will pay for transportation to therapy as needed. We will tell you when to turn on your computer. We will show you how to connect the equipment. We connect with a secure connection. This makes sure your privacy is protected. The equipment used will be your home computer. It is equipped with a camera and internet connection. Anytime during a computer treatment, you can request that we stop. You can have treatment here in Belfast if you want. MaineCare will pay for the transportation. We will schedule a visit for you in Belfast at a good time. Your privacy is important. Laws about medical information are called HIPAA. You received information about HIPAA from our center. You were told about your privacy and signed permission forms. The online connection we use meets privacy standards. The only person present during your treatment will be authorized therapist. The therapist is in a private room during treatment. The screen cannot be seen by unauthorized people. You should be aware of who can see your computer. Don t place it were someone else can see or hear it. Telehealth in PT Telehealth Challenges in PT Licensure uniformity & portability Reimbursement Practice, Research, and Education Documentation Time in Time Out What telepractice needed What the therapy is Patient information provided usual procedure Quality of connection & impact on treatment Any breaches People present/role Typical progress note Source: Michael Towey, CCC-SLP Licensure Compacts & Telemedicine License 5

6 PT State Licensing Boards Medicare Reimbursable Services Tele-consults in ER or Initial inpatient Follow-up inpatient (hospitals or SNFs) Subsequent care: 1 telehealth visit/3 days SNF subsequent care: 1 telehealth visit/30 days Individual & group assessment & intervention Psychotherapy Diabetes self-management Medical nutrition therapy Smoking cessation Transitional care management services PT Interstate Compact? Federation of State Boards of Physical Therapy (FSBPT) is moving forward with investigating this concept. APTA is part of the FSBPT Committee. Technology hurdles have gone down, and demand for telehealth services will likely increase with legislation More state regulatory boards are exploring telehealth (MD, GA) Medicare Telehealth Services Calendar Years Medicare Reimbursement Live video only reimbursed GT modifier Originating site must be located in County outside MSA Rural health professional shortage area Demo projects (AK, HI) Originating Sites Physician or practitioner offices Hospitals Federal (health and rural health clinics) Renal dialysis centers (hospital based) Skilled nursing facilities Mental health centers Source: Center for Connected Health Policy 6

7 2014 Rural HPSA Payment Analyzer Remote Patient Monitoring 12 States have some form of coverage (AK, AL, CO, KS, MA, MN, NY, PA, SC, SD, TX, WA) 10 states reimburse for Medicaid remote patient monitoring (AK, CO, KS, MN, NY, UT, WA; three within dept. of aging PA, SC, SD) New S-code (S9110) Have a GT modifier Bill for eligible practitioner Code is not uploaded in Medicaid FFS Medicaid Overview Alternate definitions Telehealth or Telemedicine Reimbursement 5states that do not pay: Connecticut, Iowa, New Hampshire, New Jersey, Rhode Island 45 states for Live Video, 7 states for store and forward (GQ modifier), 12 states for patient remote monitoring, 18 states for home telehealth Informed Consent 4 states require it via law and Medicaid policy: KY, NE, OK, TN Licensure 9 states with special licenses or certificates: Alabama, Louisiana, Montana, Nevada, New Mexico, Ohio, Oregon, Tennessee, Texas Private Insurance Coverage 20 states with telehealth parity laws Law makers in Connecticut, Iowa, Illinois and West Virginia are the latest to introduce telehealth parity legislation Source : ATA & CCHP - This is information only and is not authoritative. Consult program administrators Medicaid Programs CMS reimbursement policy: States may reimburse for telehealth under Medicaid so as long as the service satisfies federal requirements of efficiency, economy, and quality of care. CCHP: states comprehensive scan PT mentioned in AZ, KY, MN, NE, NM, WA IN does not pay for PT telehealth In 2004, HI, LA, MN, NE (Palsbo, 2004) 2014 Private Payer Telehealth Reimbursement in the United States Antoniotti NM et al. Telemed e-health 2014;20:

8 2014 Private Payer Telehealth Reimbursement in the United States Telehealth Provider Checklist Contact telemedicine & telehealth networks What can I do now? Consider telehealth Resources Consider liability Licensure, Insurance Consider telehealth standards & guidelines Establish informed consent Antoniotti NM et al. TeleMed e-health 2014;20:1-5 Telehealth Consumer Checklist Clay Brown Tim Esau Nancy Henderson Mike Billings Pat Mcaddo Todd Davenport Nicholas Ferlatte Anang Chokshi Alan Lee Bob Nithman Jim Cavanaugh James Kurt Armbrust Carey Chris Peterson Judith Deutsch Jean HowardMJ Geyer Katie Stout Jennifer Schmit Janice Kuperstein Deydre Teyhen Matt Elrod Mike Muscarella Joseph Ashburn Tiffany Shubert Harriett Loehne Sarah Davidson Sandy Davis Gina Musolino Keith Myers Dorian Rose Donald Shaw Is the provider licensed? Contact information? What should I look for? Is actual visit option available? Patient/Provider Relationship Telehealth Networks How are emergencies handled? What are the fees? How is my health data protected? Is there evidence that telehealth works? Clinical and experimental research validates telerehabilitation solutions Resources Kairy D, Lehoux P, Vincent C, Visintin M. A systematic review of clinical outcomes, clinical process, healthcare utilization and costs associated with telerehabilitation.disabil Rehabil. 2009;31(6): Outcomes at least similar to or better Johansson T, Wild C. Telerehabilitation in stroke care-a systematic review. J Telemed Telecare. 2011;17(1):1-6. High levels of satisfaction from patients and providers Hailey D, Roine R, Ohinmaa A, Dennett L. Evidence of benefit from telerehabilitation in routine care: a systematic review. J Telemed Telecare. 2011;17(6): More detailed, better quality studies needed on routine and cost of care 8

9 Key Takeaways Thinking It Through All telehealth is not the same Evidence is emerging for telehealth in PT Practitioners & stakeholders should establish standards of care Outcomes should drive value for connected telehealth Thank You 9