Telehealth Initiative: A Partnership between Two Healthcare Organizations

 Technology 

Agency
Visiting Nurse Association of Somerset Hill, Basking Ridge, New Jersey.

Agency Description
The Visiting Nurse Association of Somerset Hills (VNASH) is a non-profit organization, founded more than a century ago, providing home and community health services to the residents of Morris and Somerset counties. It is accredited by the Community Health Accreditation Program (CHAP), certified by Medicare and licensed by the New Jersey Department of Health and Senior Services.
The VNASH's mission is to provide individuals and families with comprehensive, high quality, cost-effective home and community health care services, regardless of ability to pay, using partnerships where appropriate. This mission is carried out through the delivery of a variety of services, including home health care, hospice, adult day care, and community health programs developed over a century of service.

Population Impacted
The population impacted by this project were Summit Medical Group (SMG) outpatients with congestive heart failure (CHF) or chronic obstructive pulmonary disorder (COPD), determined "at risk" for hospitalization. These patients resided in the central New Jersey area and were able to use a telehealth monitor with or without caregiver assistance. Other criteria included: 1) CHF patients admitted to a hospital or Urgent Care Center (UCC) within the past 12 months and on a loop diuretic, or 2) COPD patients admitted to a hospital or UCC within 12 months and on home oxygen, or 3) SMG physician endorsed and provided patient-specific standing orders.

Strategic Partners
Summit Medical Group (SMG) is the largest and oldest physician-owned multi-specialty practice in New Jersey. In addition to the main campus, SMG has satellite offices in five counties and employs more than 325 clinicians and 1,500 staff addressing 76 medical specialties and services. SMG first opened its doors 85 years ago to focus on a patient-centered approach to care. Funding was provided by SMG in the form of a monthly management fee and equipment rental fee consistent with services rendered and the equipment being provided.

Project Description
VNASH partnered with SMG to reduce hospitalizations and emergency department visits, improve quality of care, improve coordination and transitions of care, increase patient self-management skills, reduce overall health care costs, and provide an alternate revenue stream for the home care agency. Twenty-four heart failure and three COPD patients were admitted to the joint telehealth program. The program included 90 days of daily monitoring and education modules. Clients were instructed in the use of a "zone" tool to identify symptom severity and report to the same telehealth nurse. Standing orders set frequent communication between the telehealth nurse and advanced practice nurses employed by the practice, allowing for proactive outreach and early intervention for symptomatic patients. Twenty-two patients completed the program. Retrospective chart reviews were used to compare previous hospitalization rates with program rates at 30, 60, and 90 days. Additionally, participants completed a satisfaction survey, which included questions regarding the ability to self-manage their disease. 

Results
The year-long project yielded zero 30-day readmissions for these patients and high patient satisfaction. A conservative estimate of $10,000 per hospital admission demonstrates significant health care cost savings.

Outcome Measures
The impact of this project was that the number of hospitalizations decreased when comparing hospitalizations pre-and post-intervention. The VNASH/SMG Telehealth Program had no hospital admissions within 30 days for the entire year-long program. When looking at all patients who completed three months on the program, there were 20 admits pre-intervention and four post-intervention; at six months (for all patients who completed six months post intervention) there were 28 admits pre-intervention and 12 post-intervention; at 12 months (for all patients who completed 12 months post-intervention) there were 20 admits pre-intervention and six post-intervention. There were zero hospital admissions within the first 30 days patients were on the program, three admissions within the period of 31 to 60 days on the program, and one admission in the period of 61 to 90 days on the program. 
Fifty percent of patients in the program demonstrated improvement in their ability to manage self-care. In addition, 21 patients completed the final satisfaction survey, and 91 percent of the patients strongly agreed or agreed that "Overall, I was satisfied with the telehealth program." The other two patients answered neutral on this question. 
Potential cost saving estimated annually, using the Center for Medicare and Medicaid Services (CMS) average costs per hospitalization of potentially avoidable hospitalizations for 12 months totaled $109,844.
 
Barriers to Implementation
There were many barriers to the successful implementation of this program. The first barrier was the small study sample size due to limited and inappropriate referrals. Another barrier was the need for increased marketing to physicians and patients to help drive enrollment in the program. In addition, the selection criteria excluded patients expected to have limited benefit from the program based on multiple co-morbidities. Lastly, patient activation measurement/satisfaction tools did not allow patients to answer surveys anonymously.