Telemedicine and Nursing Home Hospitalizations

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1 Telemedicine and Nursing Home Hospitalizations David Grabowski, PhD A. James O Malley, PhD Harvard Medical School Supported by Commonwealth Fund

2 NH Hospitalizations are Frequent (and increasing over time) Costly Often preventable (~40%) Often associated with negative health outcomes Risk of delirium Falls Incontinence Dehydration Adverse drug events Nosocomial infections

3 MD Coverage in Nursing Homes Evening and weekend MD shifts at NHs are typically covered by a large group practice If a medical issue arises, the on-call physician can: Address the issue over the phone Come to the facility to see the patient Recommend a transfer All too often, the on-call physician sends the patient to the ER

4 Telemedicine provides real-time medical consultation directly to patients and their families via two-way video conferencing Medical call center with MD, NP, RN, medical secretary May prevent costly hospital transfers Telemedicine

5 Objective To examine the effect of off-hour telemedicine MD coverage on hospital transfers

6 Study Design Study team partnered with a regional for-profit NH Chain and a telemedicine company NH chain signed contract with telemedicine provider to introduce service in 11 Massachusetts facilities Service covered calls on weeknights (5-11pm) and weekends (10am-7pm) Both companies agreed to randomly stagger introduction of telemedicine to allow study of pre-post effect of intervention on hospital transfers Differences-in-differences design

7 Study Design (cont.) Facilities were randomized using block design primarily based on their CMS 5-star rating and secondarily on their size (number of beds, total admissions) Six facilities received intervention in summer/fall 2010; other five facilities were delayed to begin in Fall 2011 Pre-period: Nov 2009 Sept 2010 Post-period: Nov 2010 Sept 2011

8 Data Telemedicine provider database: # of calls by NHmonth Nursing home s electronic health record: # of total hospital transfers by NH Hospital transfers only recorded if stay crosses over midnight

9 Telemedicine Calls by Facility Total Sept-11 Aug-11 July-11 June-11 May-11 April-11 Mar-11 Feb-11 Jan-11 Dec-10 Nov-10 Facility A Facility B Facility C Facility D Facility E Facility F

10 Telemedicine Calls by Facility Total Sept-11 Aug-11 July-11 June-11 May-11 April-11 Mar-11 Feb-11 Jan-11 Dec-10 Nov-10 Facility A Facility B Facility C Facility D Facility E Facility F Two facilities within the chain barely used the intervention!

11 Pre-Post Hospital Transfers/Day: Telemedicine vs Control 1% -1% -3% -5% -7% -9% -11% -13% -15% -9.6% Treatment (N=6) -5.2% Control (N=5)

12 Pre-Post Hospital Transfers/Day: Telemedicine vs Control 1% -1% -3% -5% -7% -9% -11% -13% -15% -12.0% Treatment Engaged (N=4) -5.3% -5.2% Treatment Not Engaged (N=2) Control (N=5)

13 Cost-Effectiveness? Tx vs Control Engaged Tx vs Control Annual Medicare Savings/NH Annual Telemedicine costs/nh $81,818 $117,273 $30,000 $30,000 Difference $51,818 $87,273

14 Key Question Why doesn t every nursing home with inferior MD/NP off-hour coverage have telemedicine?

15 Disconnect on ROI NH invests in telemedicine service Medicare reaps the hospital savings

16 Disconnect on ROI NH invests in telemedicine service Medicare reaps the hospital savings Indeed, the telemedicine intervention was never fully implemented in the control NHs due to Medicare SNF payment cuts!

17 How do we bridge this disconnect? Payment reform: capitation, bundling, ACOs, readmission penalty, etc. Example: One Medicare Advantage Special Needs Plan covers telemedicine cost for their enrollees in Massachusetts NHs Medicare direct coverage of telemedicine Example: Medicare currently covers rural telemedicine services

18 Study Limitations Generalizability: 11 NHs in a single FP chain in a single state Inability to tease out effects by time of day Our study examines overall effect (direct + indirect) Inability to examine ER transfers Need to look at other outcomes: Quality of care Staff retention Resident/staff satisfaction

19 Summary Telemedicine in nursing homes has great potential to lower hospital rates/spending However, disconnect between investment and savings will limit adoption Future interventions will need to ensure strong engagement by NHs. E.g., Designating a telemedicine champion among the NH staff Check-in calls at the start of each shift

20 Thank You

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