Digital innovation is a cornerstone of UMass Memorial Health’s strategy, garnering the health system impressive accolades including HIMSS Stage 7 certification for EMR adoption, CHIME’s Most Wired Level 8 certification, and Epic Gold Stars Level 10 status.
Dave Smith, Senior Director of Digital Innovation for UMass Memorial Health, attributes his organization’s competitive edge to a physician-led leadership team that truly embraces digital transformation. UMass Memorial has been delivering hybrid care for the better part of 20 years through its flagship eICU and tele-stroke programs. The throes of the pandemic and ensuing challenges related to patient safety, capacity management, patient flow, and staffing shortages reignited interest in hybrid care innovation, leading the health system to pursue additional programs like hospital at home, remote observation, and remote patient monitoring (RPM) in recent years.
In the enlightening session “Hybrid Care Innovation: The ROI of Bedside Virtual Care at Scale,” part of Becker’s Healthcare’s 2024 Digital Health and Telehealth Virtual Event, Smith sat down with Caregility President and COO Mike Brandofino to share compelling insights into the transformative hybrid care initiatives his organization is pursuing, how his team approaches ROI, and what it takes to scale new hybrid care models.
Hybrid Care’s Return on Value
UMass Memorial’s Hospital-at-Home program is a great example of how health systems are bringing resources to bear to improve outcomes, efficiency, and the experience for patients and clinicians. Patients receive twice-daily visits at home, supported by EMS partners working in collaboration with UMass doctors and nurses. They also have immediate access to virtual nursing support. The health system employs a four-to-one ratio for field nurses and a 30-to-one ratio for virtual nurses.
By bringing acute care to the patient’s home, the team has been able to expand capacity. “In our first year of operation, we saved over 3,000 bed days at our busiest hospitals,” shared Smith.
“With our eICU program, we monitor 150 critical care beds around the clock with intensivists on any given shift and the aid of a pharmacist at night,” Smith said. Since its inception in 2006, UMass’s eICU program has seen a 27% reduction in patient mortality and fewer patient complications, reducing care costs.
“For programs like tele-stroke and tele-psych, the ROI is really about improving access,” Smith continued. “But also, community hospitals see the ROI because they don’t have to hire and retain a full-time specialist. Instead, they buy professional services from a tertiary health system like UMass Memorial.”
The health system’s remote video monitoring (RVM) program has shown the strongest direct labor-cost ROI by enabling a single care team member to support six patients instead of conventional one-on-one observation ratios. “To take advantage of the full 12-patient panel, we assign each observation tech six primary patients and six backup patients for a total of 12,” Smith shared. “For every remote observation tech, we save $300,000 a year in direct labor costs.”
The health system is also leveraging AI solutions for radiology, ophthalmology, and ambient dictation to save providers valuable time. “I don’t think AI is going to replace doctors anytime soon, but I do think the ones who embrace it will probably surpass the ones who don’t,” noted Smith.
Scaling Hybrid Care Innovation
Smith sees digital health innovation as “the cost of doing business for healthcare systems that want to innovate and remain competitive.”
“We're in the process of building a new 72-bed inpatient facility that will open about a year from now and every bed will be wired with Caregility technology. We'll use the technology for a variety of use cases like virtual rounding, remote observation, specialty consults, patient/family communication, and even tele-ICU level care. And the funny thing is, it was an easy sell to hospital leadership because they understand the importance of hybrid care and balancing staffing demands. I just think hybrid care is the new standard.”
Dave Smith
Senior Director of Digital Innovation, UMass Memorial Health
Smith champions platforms that can be leveraged across the enterprise over point solutions. “To do anything at scale, it cannot exist in silos and pockets that are scattered throughout the organization,” he shared. “A good example is our commitment to building a digital medicine hub. We’re taking most of our virtual services and putting them under one roof. By doing so, not only will it be a showcase for our health system of the future, but we’re expecting to find operational synergies by having these virtual care teams collaborate in the same physical space. So, teams like eICU, transfer center, RVM, RPM, interpreter services, and virtual nursing will all be working alongside each other.”
“We’re also investing in a new digital innovation team to support rapid scalability. Digital health and especially AI is evolving so quickly that we need to operate at a faster pace to keep up. I’ll be leading a new multidisciplinary team to focus on emerging technologies that support our system initiatives and foster collaboration with our care teams. The whole idea is to identify opportunities, experiment with proofs of concept, fail fast, if necessary, iterate, and then deliver a solution or look at alternatives.”
“People are embracing technology in ways never thought possible and it’s making hybrid care models not only plausible but also practical.”
Telehealth News Roundup: The EASE Act, H@H Risk, and ViVE
Here is a glimpse into some of the latest headlines grabbing attention in the world of digital health and telehealth news:
The Equal Access to Specialty Care Everywhere Act
On January 30, 2024, the Equal Access to Specialty Care Everywhere (EASE) Act was introduced by a bipartisan group of US House representatives. The proposed legislation advocates for the creation of a virtual specialty network to expand access to specialist care for Medicare and Medicaid beneficiaries, using Center for Medicare and Medicaid Innovation (CMMI) funds earmarked to “test models and innovations that support access to integrated specialty care across the patient journey,” as Anuja Vaidya reports.
Might this be a step towards a national framework for virtual care access that extends beyond state borders, similar to what’s seen in Veterans’ care?
Meanwhile, the clock is winding down on Acute Hospital Care at Home funding, slated to run out at the end of 2024. Designed to free up bed capacity by allowing select Medicare and Medicaid patients to recover at home, Hospital at Home is one of the few levers providers have to offset emergency department overcrowding. Concern about the future of the program is giving providers pause on implementing the solution. NBC reporter Erika Edwards notes that growing interest in the program may garner it a two-year extension or even permanency by the end of this year.
Last but not least, the 2024 ViVE conference is officially a wrap, with recaps from the conference pouring in. Telehealth was a recurring theme in HealthLeaders editor Eric Wicklund’s write-up of five key takeaways from healthcare’s flashiest tradeshow. What do nurses in need of help, the call for more care at home, and health AI enablement all have in common? You guessed it: virtual care.
The surging senior population in the U.S. stands in stark contrast to the declining number of medical doctors specializing in geriatric care. According to a recent JAMA Network viewpoint from UMass Memorial Health geriatrician Dr. Jerry Gurwitz, the number of geriatric specialists in the U.S. has fallen almost 40% over the last decade.
Meanwhile, skilled nursing facilities (SNFs) and nursing homes are grappling with the same nurse staffing shortages plaguing other healthcare organizations. The Department of Health and Human Services (HHS) recently announced a proposed rule that would establish minimum nurse staffing levels for nursing homes. CMS estimates that roughly three-quarters of nursing homes would have to strengthen staffing in their facilities in order to comply, amplifying workforce demand in a system already strained by staff deficits. As facilities struggle to maintain target staffing ratios, rural and disadvantaged nursing homes face the threat of additional closures, leaving senior care at risk.
These industry-wide staffing shortages mirror issues playing out in inpatient care. And the parallels don’t stop there. Long-term care facilities can expect to encounter similar outside disruption from retail health organizations as Aging-in-Place technologies introduce in-home alternatives to traditional care. With seniors expected to represent about 20% of the U.S. population by 2030, inpatient, post-acute, SNF and long-term care settings alike will see senior patient volumes rise.
The Domino Effect on Hospitals
The lack of open nursing home beds is already marooning some patients in hospitals. Growth in the senior population, coupled with evolving expectations set by Aging-in-Place technologies, will significantly influence how hospitals strategize and deliver care. As seniors grow accustomed to enhanced virtual care and in-home services, they’ll expect similar accessibility and convenience when transitioning from SNFs to hospitals or vice versa. We’ll likely see accelerated adoption of Hospital-at-Home and other advanced home care models as a result.
Healthcare organizations will grapple with not only an influx in senior patient volumes but also a higher degree of care complexity, as comorbidities become more prevalent in an aging population. Multidisciplinary care coordination will be vital to effective care delivery. One could even posit that in the not-so-distant future, the lines distinguishing SNFs, home care, and hospitals may blur, giving rise to a more fluid, patient-centered healthcare delivery model. Accountable Care Organizations, which emphasize value over volume and coordinated patient care across different providers, may serve as a precursor to the evolving landscape.
Telehealth’s Place in Senior Care
Just as hospitals are reimagining care delivery in response to staffing shortfalls, burnout, and evolving patient expectations, senior care must similarly innovate to get ahead of compounding trends. By embracing models that leverage virtual care, SNFs and other senior care providers can not only better compete but also enrich patient experiences and elevate care delivery standards.
1) Democratizing Access to Scarce Geriatric Specialists
By establishing remote access to the limited pool of geriatricians, SNFs can traverse geographic boundaries. Virtual care ensures seniors, especially those in regions most affected by staffing deficits, aren’t left in the lurch by bringing expert care to them on-screen, anytime, anywhere.
2) Enabling Bedside Teams and Emerging Care Models
Hybrid care models like Virtual Nursing help alleviate pressure on limited bedside staff and improve patient experience by introducing remote support resources to care models. These programs also help establish workflows that lay the groundwork for remote, in-home service expansion.
3) Seamless Care Coordination Connecting Clinical Teams, Patients, and Families
Virtual care fosters collaboration between disparate multidisciplinary care teams, patients, and their families. Recognizing that family members often shoulder caregiving responsibilities for relatives, virtual care facilitates intergenerational support. This is particularly helpful when managing chronic conditions.
As we stand at this crossroads, the increasing importance of tech-enabled care cannot be overlooked. Although virtual engagement won’t be a panacea in senior care, where technology adoption rates may be weaker, it does introduce new ways to better support aging patient cohorts and their care teams. This impending transformation underscores the need for healthcare organizations to be agile, forward-thinking, and willing to embrace change – not just as a response to shifting demographic trends, but as pioneers redefining what comprehensive care for seniors truly entails.
Virtual Nursing for Post-Acute and Transitional Care
Virtual nursing programs continue to make headway as health systems look for new solutions to the ongoing staffing crisis. Many of the virtual workflows sprouting up in inpatient departments have applicability in post-acute and transitional care, as well, where the impact of workforce shortages is also being felt.
Here is a look into how virtual nursing can support transitional care management, home care, population health, post-acute care, and hospital-at-home models.
Transitional Care Management
A patient’s discharge signals the start of a 30-day period where Medicare pays for services to help the patient transition from inpatient services to a community-based setting. Patients are typically moved to either a home, long-term care, or assisted living facility.
Many of the processes to prepare patients for care transitions can be fielded virtually. Providers are required to contact the patient within two business days of discharge, followed by a face-to-face visit within 14 calendar days of discharge for moderate-complexity patients and within 7 days for high-complexity patients. Supportive services provided by a virtual nurse can include:
Coordinate follow-up visits, durable medical equipment delivery, etc.
Educate the patient and/or caregiver on self-care, activities of daily living, etc.
Support adherence to the treatment plan, including medication management
Provide access to community resources and assist with care navigation
Home Health
Traditionally, care has been delivered in person when patients transition to a home setting.
Hybrid “tele-home” care models are emerging where a home care nurse may see a patient in person on the first visit and then virtually after that unless hands-on nursing care is required (i.e., dressing changes, wound vac care, etc.) or in-person visits are deemed necessary.
If practitioner-ordered virtual visits are incorporated as part of the patient’s Plan of Care (POC), the virtual visit must address specific patient needs identified in the comprehensive assessment and incorporate interventions and measurable outcomes identified in the POC.
Many home health agencies provide patients with Bluetooth or wireless devices such as pulse oximeters, blood pressure cuffs, glucose monitors, and scales connected to a tablet. This allows virtual nurses to track patients more frequently, between formal visits, to catch trends and head off deterioration before resulting in an ED visit. A home care aide acting as a telepresenter for the virtual nurse can also be used for virtual nurse visits.
In a study of nearly 1,400 patients with 314 patients belonging to a hybrid model, there was a significant reduction in hospitalizations in both the 30- and 60-day time period for those in the hybrid model. This patient group also demonstrated better clinical outcomes across a variety of measures.
Population Health & Chronic Disease Management
Chronic diseases continue to plague approximately 46% of Americans, with almost 30 million people living with five or more chronic diseases. Leveraging virtual care can dramatically improve outcomes for patients living with difficult-to-manage chronic illnesses.
Employing virtual nursing to support chronic disease management increases patient adherence to their POC. It also provides a quick and easy way to connect with their care team more often for early intervention to prevent unnecessary trips to the ED or hospital.
Remote Patient Monitoring
Remote patient monitoring (RPM) helps achieve chronic disease management goals while reducing patient travel costs and infection risk. Conditions that are appropriate for RMP include hypertension, diabetes, cardiovascular heart disease, COPD, and asthma. RPM tools are sent to the patient’s home and may include scales, digital stethoscopes, blood pressure monitors, pulse oximeters, blood glucose meters, and questionnaires.
Use cases reimbursed by Medicare include remote monitoring of physiologic parameters such as weight, blood pressure, pulse oximetry, and respiratory flow rate, set-up and patient education for equipment use, and treatment management services.
Knowing how to manage risk alerts is a key to success and guides the actions and interventions of the virtual nurse. In this way, patients are informed of self-care interventions, thus improving and reinforcing what they need to know the next time. In addition, alerts from remote monitoring devices help the virtual nurse monitor the maximum number of patients.
Skilled Nursing Facility & Long-Term Post-Acute Care
Telehealth can address over 50% of resident cases typically sent to the hospital, potentially avoiding readmission. To qualify for Medicare coverage, there must be a “qualifying event” that includes a three-night hospital stay that requires skilled nursing or rehabilitation for at least one hour daily, five days a week. Medicare SNF benefits last 100 days without a new qualifying event.
Post-acute workflows that can be performed virtually include:
Provider virtual visits: SNF patients are typically seen by a nursing home provider on admission, then monthly for the first 90 days and every 60 days after, or as concerns present.
Specialty virtual visits: Specialists can be brought in virtually, avoiding patient transport needs.
Ancillary visits: Virtual visits with pastoral care, hospice, family, and friends.
Continuous virtual observation or tele-sitting: Patients at high risk for falls or other safety concerns can be observed continuously and redirected.
Virtual Nursing: Admission, discharge, care planning, chart review, and assessment can be fielded virtually to offset some of the administrative burdens of bedside nursing staff.
Long-term care (LTC) facilities can utilize the same workflows, albeit at a lower frequency given lower patient acuity. LTC facilities provide long-term custodial care that is typically paid for byeither Medicaid, personal finances, or long-term care insurance.The use of a telepresenter is especially helpful within both populations.
Long-Term Acute Care Hospitals
Patients moving to a Long-Term Acute Care Hospital (LTACH) require direct skilled nursing care and have complex medical needs such as ventilator weaning and or complex wound care that can’t be met at a lower level of care. Patients are typically transferred from a hospital’s ICU to an LTACH.
LTACHs must maintain an average length of stay greater than 25 days. For optimal reimbursement, it’s imperative that the acute care hospital discharge patients to the LTACH as soon as feasibly appropriate. Every extra day spent in an ICU instead of the LTACH hinders LTACH reimbursement by minimizing LTACH length-of-stay (LOS), increasing costs and LOS for the acute care hospital.
Like other post-acute inpatient facilities, virtual workflows can support a multitude of use cases. Virtual observation can be more broadly used to support workflows beyond fall and safety monitoring by unlicensed personnel. Ventilator-dependent and other complex patients at high risk for deterioration or readmission can be observed continuously or rounded on more frequently by a virtual nurse.
These workflows can help to interrupt deterioration requiring hospital readmission, decrease adverse events, and keep the LTACH’s LOS intact by treating patients in place.
Hospital at Home
The Hospital at Home (HaH) care model has shown promise for reducing cost, improving outcomes, and enhancing the patient experience. HaH offers hospitals more flexibility to care for patients in the comfort of their own home.
Programs vary based on hospital capacity and patient population needs, but may include:
Medium-acuity patients who need hospital care but are considered stable enough for home
Patients with defined treatment protocols such as pneumonia, COPD, diabetes, etc.
A combination of in-person visits, virtual visits, and continuous biometric monitoring
Diagnostic studies (electrocardiograms, echocardiograms, X-rays), treatments (oxygen therapy, IV fluids, IV antibiotics, and other medications) and services (respiratory therapy, pharmacy, virtual nursing)
The combination of in-person and virtual nursing visits provides patients with 24/7 access to care. If necessary, the patient can visit the acute hospital for treatments that cannot be provided in the home (i.e., CT scan, MRI, etc.). The patient is discharged when stable.
Conclusion
When we think about keeping patients out of high-cost care settings and preventing unnecessary use of the ED and inpatient settings, virtual nurses are key players. They can advise multiple patients during their shift, provide timely care, perform competent assessments, document results in the EMR, and guide patients to the most appropriate level of care.
Nurse triage and advanced practice nurses do what they can to alleviate the pressure on providers who are in short supply and overtaxed. By providing sound care advice to patients on-demand, any time of the day or night, virtual nurses enable physicians to direct their expertise to patients who are high-risk, have chronic diseases, or are in the most fragile condition.
From the hospital bedside to Hospital-at-Home, virtual nursing programs across the care continuum are helping clinical teams improve patient care, reduce readmissions, and better manage costs.
Learn about the practical application of virtual nursing in post-acute preparation and care in the second installment in our webinar series, “A Guide to Virtual Nursing: Post-Acute Settings.”
Caregility nurses Donna Gudmestad and Heidi Steiner address ways virtual nursing helps overcome staffing challenges, streamline care transitions, and improve patient outcomes in post-acute care.
Want to learn more?
Set up a call with our clinical workflow experts to explore virtual nursing for your health system’s unique needs.
HTLH 2021: Healthcare’s Future: Evolving to a Hybrid Model of Care
On-Demand Webinar
Healthcare’s Future: Evolving to a Hybrid Model of Care
In 2020, telehealth became a household word as an unprecedented number of providers and patients turned to virtual care as a vital component of healthcare delivery. At the same time, healthcare providers and hospital systems experienced rapid transformation, creating a hybrid delivery system of in-person and virtual care to best serve the needs of their patients.
This session explores clinical use cases from organizations and solution providers helping to move toward a hybrid model of care delivery, one that places the patient first – yet establishes equilibrium for the provider for better decisions in triaging.
Discussion Topics:
What is the pathway for healthcare organizations to grow?
How has hybrid care grown to include remote monitoring, acute care, shared services, and hospital at home?
What are lessons learned and potential opportunities ahead?
Featured Panelists:
Moderator: Kristi Henderson, SVP, Center for Digital Health, Optum Health, & Chair-Elect, ATA
Zenobia Brown, MD, VP & Medical Director, Population Health, Northwell Health
