Exploring Critical Success Factors for Telehealth Implementation Deb LaMarche, PI, Program Director Northwest Regional Telehealth Resource Center [email protected]www.nrtrc.org Kathy Chorba, Executive Director California Telehealth Resource Center [email protected]www.caltrc.org Mei Kwong, Executive Director Center for Connected Health Policy National Telehealth Policy Resource Center [email protected]www.cchpca.org
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Exploring Critical Success Factors for Telehealth Implementation
Deb LaMarche, PI, Program DirectorNorthwest Regional Telehealth Resource Center [email protected] www.nrtrc.org
• Critical success factors within each of the five elements of the Telehealth Implementation Roadmap
• Assess• Establish• Define• Implement• Improve
• Policy and reimbursement landscape updates
• Introduction to the Telehealth Resource Centers and free resources and technical assistance available for program development, implementation and sustainability
• Q&A
Introduction To Telehealth and Telemedicine
Deb LaMarcheNorthwest Regional Telehealth Resource Center
NRTRC
Telehealth or Telemedicine
What’s the difference?
TelehealthTelehealth is global term, which includes telemedicine and other uses of communication technologies
• Health professional education• Public health• Consumer education
TelemedicineTelemedicine is direct clinical care provided from a distance using electronic communication to provide or support clinical care.
See also: Virtual Care, Telepractice, Tele-X (specialties like telepsychiatry), Connected Care, Digital Health, Home Health, Remote Patient Monitoring, eHealth, eVisits, eConsult, etc.
Store and ForwardStore & Forward electronically transmits patient information between primary care providers and medical specialists. Information could include digital images, X-rays, video clips and photos.
• Utilizes low bandwidth, transmitting patient information, still images and video clips
• Best used in Dermatology, Ophthalmology, Pathology, Radiology
• Exploring new avenues in Psychiatry, Endocrinology, Hepatology, Orthopedics and many more specialties via eConsult
Home Health and Remote Patient Monitoring
Remote patient monitoring uses telehealth technologies to collect medical data from patients in one
location and electronically transmit that information to health care providers in a
different location, either real-time or store and forward.
Use cases include hospital emergency departments, intensive care units, and at-
home management of patients with chronic conditions.
Telehealth Equipment
Telemedicine Carts
Off-the-Shelf for providers and consumers
Peripherals
Telehealth Implementation Roadmap
Kathy ChorbaCalifornia Telehealth Resource Center
CTRC
Great Ideas
Telemedicine … Where
do I start?
Planning, implementation and integration requires a multidisciplinary team to be involved throughout each phase of the
project.
On the following slides, look to the left for team category suggestions!
Lead
ersh
ip *
Clin
ical
* T
echn
olog
y *
Ope
ratio
ns
Assess
Clinical and Administrative Service Needs
Leadership Support
Clinical Provider Buy-in
Relationships with Specialty Providers
Technology Infrastructure and Equipment Inventory
Ope
ratio
ns
Facility Information
Assess
Establish
Define
Implement
Improve
Ope
ratio
ns
and
Clin
ical
Current or Previous Telehealth Experience
Why is this information important?
• May be able to leverage existing program staff / equipment for expansion activities
• May be able to address barriers or adjust the approach to get the program back on track
Assess
Establish
Define
Implement
Improve
Lead
ersh
ipGo Live Expectations /
Timeline
Do you have a target date for go-live?• Having a target date for go-live is important for planning
purposes. • Milestones to incorporate into project plan:
– Policy and Procedure & workflow development, staffing allocation– Provider contracting– Data and connectivity infrastructure enhancement – Equipment procurement, installation, testing – Staff training
Assess
Establish
Define
Implement
Improve
• What are the unmet healthcare needs
• Specialties • Volume• Delivery Method
• Don’t rely on data alone –Ask your clinical team!
Ope
ratio
ns
and
Clin
ical
Clinical and Administrative Services
Assess
Establish
Define
Implement
Improve
Ope
ratio
ns
and
Clin
ical
Clinical Services
• What services do you wish to provide and how will you provide them?
• How is this information useful?• Specialty service provider selection & negotiation• Equipment, software and broadband consideration
SpecialtyAdult (Vol/mo)
Peds (Vol/mo)
Technology Model
Live Video
Store & Forward
Remote Patient Monitoring
Provider & Patient to Specialist
Provider to Provider (eConsult)
Direct to Consumer
Dermatology 20 x x
Endocrinology 30 5 x x
Mental Health 60 10 x x
Primary Care 50 75 x x
Assess
Establish
Define
Implement
Improve
• Program financing• Grant funding? For what, how much and how long?• Institutional funding commitment
• Staffing allocation• Program design, management and day to day operations
• Ongoing program support• Staffing, technology, change management
Lead
ersh
ipLeadership Support
Assess
Establish
Define
Implement
Improve
• Understand the value of telehealth to patients and clinical practice
• Willing to incorporate telehealth into daily practice• Patient identification and referral• Patient presentation and follow-up
Clin
ical
Clinical Provider Buy-in
Assess
Establish
Define
Implement
Improve
• In-house• Within your organization, practicing at a different location
• In the community• Providers in your referral network that would benefit from enhanced
services provided via telemedicine• Statewide / Nationwide
Clin
ical Existing and Potential
Relationships with Specialty Providers
Assess
Establish
Define
Implement
Improve
• Tele-communications• Secure, medical grade broadband in the staff meeting and clinic exam
rooms? Is it wired or wireless?• Equipment and peripherals
• Videoconferencing equipment• Peripherals (exam camera, stethoscope, otoscope)• Computer with webcam, microphone, speakers• Store and forward software, digital camera
Tech
nolo
gy Existing Technology Infrastructure and Equipment
Goal: Program efficiency, patient and provider satisfaction
Technical Support
Telecommunications network planning and
maintenance
Equipment selection, installation, training and
troubleshooting
Equipment reliability and functionality – video
conferencing, store and forward software & medical peripherals
Goal: Maintain, user-friendly, reliable
technology
Telehealth Team
Assess
Establish
Define
Implement
Improve
Partnering with Specialty Service Providers
1. Specialties Available
2. Payment Model
3. Rates
4. Appointment times
5. Credentialing policy
6. Specialist bio / qualifications
7. Established referral guidelines
8. Staffing requirements
9. Direct patient care or consultation only
10. Medication refills
11. Specialist continuity
12. Turn around time for chart notes
13. Cancellation/no show policy
14. Patient double-booking
15. Back up plan for tech failure
16. Technical support available
17. Non-consult communication policy
18. Method of communication during consult
19. Post-consult correspondence policy
20. Onboarding process
Assess
Establish
Define
Implement
Improve
• Equipment and peripherals• To accomplish the administrative and clinical service goals
established by the needs assessment and specified by the specialty consultant
• Secure medical grade broadband to clinic and conference rooms
• Sufficient to support the equipment and/or software
Tech
nolo
gyTechnology Infrastructure
Assess
Establish
Define
Implement
Improve
Price Snapshot
• Simple Telemedicine cart with PC -$2,000 -$10,000
• Telemedicine cart with Pan/Tilt/Zoom camera, CODEC and peripheral capabilities -$18,000 -$30,000
Assess
Establish
Define
Implement
Improve
Price Snapshot
• General Examination Cameras• $3,000 -
$11,000
• Bluetooth Enabled Electronic Stethoscope• $500 -
$4,000
• Nasopharyngoscope• $6,000-$20,000
Assess
Establish
Define
Implement
Improve
• Payer credentialing and contracting• Research and understand your payer environment• Develop payer reimbursement chart indicating for each major payer if
they reimburse and which codes to submit• Financial modeling and Pro Formas
• Forecasting cost of program is critical for sustainability• Create a pro forma that estimates the monthly cost of the program over
the first year as both utilization and payer reimbursements mature
Busi
ness
&
Sust
aina
bilit
yRevenue Cycle
Management Program
Assess
Establish
Define
Implement
Improve
• Key pro forma data points• Payer mix of patient population served• Anticipated volume by specialty• Estimated payer reimbursement• Physician compensation and service fees• Technology platform and recurring infrastructure costs• Staffing costs• Related financial benefits to the facility
Busi
ness
&
Sust
aina
bilit
yRevenue Cycle
Management Program
Assess
Establish
Define
Implement
Improve
This is a very basic, yet illuminating tool
What this will do• Provide a high level, VERY BASIC overview
of how specialty provider selection decisions and other variables are likely to affect sustainability
What this will not do• Calculate for:
• sliding fee or commercial health plan payments
• Appointment slots filled by double booking
• Provide an accurate, detailed profit/loss statement for clinic financial modeling
NOTE: Clinic collection revenue on this form is based on PPS Medi-Cal patient billable visits only. Other payment sources cannot be predicted or calculated using this simple tool.
Appointment type: time (min) # of visits total hoursInitial #VALUE!Established #VALUE!Total number of visits per block of time purchased #VALUE! #VALUE!
CTRC Sample Telehealth Sustainability WorksheetThis worksheet is provided as a basic tool to assist in business model development for
FQHC/RHC/IHS and is based on the model of purchasing blocks of timeInstructions: Insert your data in to the blue cells. All remaining cells will be automatically
populated based on the information entered.
Patient VolumeSpecialist hourly rateSpecialty cost per block of time reservedClinic collection rate per encounter (PPS rate)Amount clinic collects if 100% billableAverage No Show rate for clinic (or specialty)
For more information or assistance with this spreadsheet, please contact us! California Telehealth Resource Center, www.caltrc.org
Clinic uninsured rate
Staffing and overhead per hourStaffing and overhead per block of time purchasedVarianceNote: This calculation does not include sliding fee or private pay collection
To download this interactive worksheet, visit:caltrc.org/knowledge-center/best-practices/sample-forms/
Assess
Establish
Define
Implement
Improve
Busi
ness
&
Sust
aina
bilit
y
Appointment type: time (min) # of visits total hoursInitial 40 12 8.00Established 20 0 0.00Total number of visits per block of time purchased 12 8.00
12200.00$
1,600.00$ 165.00$
1,980.00$ 15%
1,683.00$ 5%
1,598.85$ 20.00$
160.00$ (161.15)$
Clinic uninsured rateAdjusted clinic collection (after uninsured calculation)Staffing and overhead per hourStaffing and overhead per block of time purchasedVarianceNote: This calculation does not include sliding fee or private pay collection
Clinic collection minus No Show rate
CTRC Sample Telehealth Sustainability Worksheet
Illustration of the start-up phase (typically months 1-3)This worksheet is provided as a basic tool to assist in business model development for
FQHC/RHC/IHS and is based on the model of purchasing blocks of timeInstructions: Insert your data in to the blue cells. All remaining cells will be automatically
populated based on the information entered.
Patient VolumeSpecialist hourly rateSpecialty cost per block of time reservedClinic collection rate per encounter (PPS rate)Amount clinic collects if 100% billableAverage No Show rate for clinic (or specialty)
Assess
Establish
Define
Implement
Improve
Busi
ness
&
Sust
aina
bilit
y
Appointment type: MinutesNumber of visits Hours
Initial 40 9 6.00Established 20 6 2.00Total number of visits per block of time purchased 15 8.00
15200.00$
1,600.00$ 165.00$
2,475.00$ 15%
2,103.75$ 5%
1,998.56$ 20.00$
160.00$ 238.56$ Variance
Illustration of the growth phase (typically months 4-8)This worksheet is provided as a basic tool to assist in business model development
for FQHC/RHC/IHS and is based on the model of purchasing blocks of timeInstructions: Insert your data in to the blue cells. All remaining cells will be
automatically populated based on the information entered.
Note: This calculation does not include sliding fee or private pay collection
Patient volumeSpecialist hourly rateSpecialty cost per block of time reservedClinic collection rate per encounter (PPS rate)Amount clinic collects if 100% billableAverage No Show rate for clinic (or specialty)Clinic collection minus No Show rateClinic uninsured rateAdjusted clinic collection (after uninsured calculation)Staffing and overhead per hourStaffing and overhead per block of time purchased
Assess
Establish
Define
Implement
Improve
Busi
ness
&
Sust
aina
bilit
y
Appointment type: time (min) # of visits total hoursInitial 40 4 2.67Established 20 16 5.33Total number of visits per block of time purchased 20 8.00
20200.00$
1,600.00$ 165.00$
3,300.00$ 15%
2,805.00$ 5%
2,664.75$ 20.00$
160.00$ 904.75$
Clinic uninsured rateAdjusted clinic collection (after uninsured calculation)Staffing and overhead per hourStaffing and overhead per block of time purchasedVarianceNote: This calculation does not include sliding fee or private pay collection
Clinic collection minus No Show rate
Illustration of the maintenance phase (typically months 9 & beyond)
This worksheet is provided as a basic tool to assist in business model development for FQHC/RHC/IHS and is based on the model of purchasing blocks of time
Instructions: Insert your data in to the blue cells. All remaining cells will be automatically populated based on the information entered.
Patient VolumeSpecialist hourly rateSpecialty cost per block of time reservedClinic collection rate per encounter (PPS rate)Amount clinic collects if 100% billableAverage No Show rate for clinic (or specialty)
Assess
Establish
Define
Implement
Improve
Busi
ness
&
Sust
aina
bilit
y
Define
Policies and Procedures
• Clinical guidelines • Referral forms• Process for patient consent• Workflow• Specialty services billing/payment• Exchanging medical information• Clinic scheduling• Patient insurance billing• Credentialing & privileging
Ope
ratio
nsPolicies and Procedures
Assess
Establish
Define
Implement
Improve
Ope
ratio
ns
Clinical guidelines for specialty referral
Policies and Procedures
Assess
Establish
Define
Implement
Improve
Process for Referral Request
Ope
ratio
nsPolicies and Procedures
Assess
Establish
Define
Implement
Improve
Process for patient consent
Ope
ratio
nsPolicies and Procedures
Assess
Establish
Define
Implement
Improve
Workflow
Ope
ratio
nsPolicies and Procedures
Assess
Establish
Define
Implement
Improve
• Clinical guidelines• Referral forms• Process for patient consent• Workflow• Specialty services billing/payment• Exchanging medical information• Clinic scheduling• Credentialing & privileging• Patient insurance billing
Ope
ratio
nsPolicies and Procedures
Assess
Establish
Define
Implement
Improve
Implement
Technology
Staff Training
Provider Orientation
Community and Patient Education
Go Live with Patient Consults
• Hardware, software, peripheral equipment and telecommunications configuration and testing
• And testing … and testing … and testing
Tech
nolo
gy
Technology
Assess
Establish
Define
Implement
Improve
• Who should you include in the staff training process?• Telemedicine coordinator, clinical staff, technical staff, billing, coding
and compliance staff
• What should be included in the staff training?• Referral protocols• Equipment usage and troubleshooting• Patient presentation techniques• Coding and billing• Medical records• Patient consent• Process flow
Ope
ratio
ns
Staff Training
Assess
Establish
Define
Implement
Improve
• Equipment demonstrations• Video meet and greet sessions with specialty providers to
discuss referral requirements and patient presentation techniques
• Place telehealth on the agenda at medical staff meetings to review patient selection and process flow
Clin
ical
Provider Orientation
Assess
Establish
Define
Implement
Improve
Equipment demo * Appointment fliers * Web site
Ope
ratio
ns
Community and Patient Education
Assess
Establish
Define
Implement
Improve
Ope
ratio
nsGo Live with Patient
Consults
Assess
Establish
Define
Implement
Improve
Improve
Revenue Cycle Analysis
Provider Satisfaction
Organizational Culture
Program Diversity
• Review and update the financial model based on the key data points used to establish the initial pro forma:
• Payer mix of patient population served• Anticipated volume by specialty• Estimated payer reimbursement• Physician compensation and service fees• Technology platform and recurring infrastructure costs• Staffing costs• Related financial benefits to the facility
Busi
ness
&
Sust
aina
bilit
yRevenue Cycle Analysis
Assess
Establish
Define
Implement
Improve
• Review claims and payments for potential areas of process improvement
• Assign a telemedicine lead or expert to own the process and ensure all codes are entered appropriately prior to submission
• Mine and analyze all denials received and continually update the billing policy based on new payers or change in existing payer policy
• Management reports• Provide and track monthly productivity, income and expense reports to
show trending over time
Busi
ness
&
Sust
aina
bilit
yRevenue Cycle Analysis
Assess
Establish
Define
Implement
Improve
• Are your specialty providers getting the information they need to provide patient care?
• Are your clinical providers getting the information they need to provide patient care?
• Are your clinical providers satisfied with the relationship with and services they are receiving from the specialty provider group?
• Is the technology adequate, reliable and easy to use?• Are there any changes to be made to the clinic flow process?
Clin
ical
Provider Satisfaction
Assess
Establish
Define
Implement
Improve
Clin
ical
Organizational Culture
Assess
Establish
Define
Implement
Improve
Ope
ratio
ns
Program Diversity
Assess
Establish
Define
Implement
Improve
Repeat the Process with Every New Initiative
“It takes 6 months to implement a program …
… and 10 years to become an overnight success!”Dean Germano, CEO Shasta Community Health Center, Redding CA
Resources discussed in this presentation are available on www.caltrc.org
Needs AssessmentStaff Roles and Job Descriptions
Considerations in Developing Partner RelationshipsContracting Model Pros and Cons
Credentialing GuidelinesBilling Guidelines
Sample Referral GuidelinesPatient Consent
Clinical and Operational WorkflowOvercoming Integration Barriers
How to Develop a Telehealth Marketing PlanAccess to Free Telehealth Implementation Workshops
June 2015 CENTER FOR CONNECTED HEALTH POLICY Mario GuttierezExecutive Director
TELEHEALTH IN A COMMUNITY HEALTH CENTER SETTING
NACHC FOR/IT CONFERENCEOctober 25, 2019
877-707-7172cchpca.org CENTER FOR CONNECTED HEALTH POLICY
Mei Wa Kwong, JDExecutive Director, CCHP
June 2015 CENTER FOR CONNECTED HEALTH POLICY Mario GuttierezExecutive Director
DISCLAIMERS• Any information provided in today’s talk is not to be regarded as
legal advice. Today’s talk is purely for informational purposes.
• Always consult with legal counsel.
• CCHP has no relevant financial interest, arrangement, or affiliation with any organizations related to commercial products or services discussed in this program.
June 2015 CENTER FOR CONNECTED HEALTH POLICY Mario GuttierezExecutive Director
MEDICARE – Technology & CHCs
CENTER FOR CONNECTED HEALTH POLICY
However, services that utilize telehealth technologies but are not labeled “telehealth” MAY be provided by CHCs• Chronic Care Management (CCM)• Transitional Care Management (TCM) • Virtual Communications
CCM services furnished between January 1, 2016 and December 31, 2017, CCM services can be billed by adding CPT code 99490 to an RHC or FQHC claim, either alone or with other payable services. Payment is based on the Physician Fee Schedule (PFS) national average non-facility payment rate for CPT code 99490. For CCM services furnished on or after January 1, 2018, CCM services can be billed by adding the general care management G code, G0511, to an RHC or FQHC claim, either alone or with other payable services. Payment is set annually at the average of the national non-facility PFS payment rate for CPT codes 99490 (20 minutes or more of CCM services), 99487 (60 minutes or more of complex CCM services), and 99484 (20 minutes or more of general behavioral health integration services). For CCM services furnished on or after January 1, 2019, CCM services can be billed by adding the general care management G code, G0511, to an RHC or FQHC claim, either alone or with other payable services. Payment is set annually at the average of the 3 national non-facility PFS payment rate for CPT codes 99490 (20 minutes or more of CCM services), 99487 (60 minutes or more of complex CCM services), CPT code 99491 (30 minutes or more of CCM services furnished by an RHC or FQHC practitioner).
TCMTCM services furnished on or after January 1, 2013, TCM services can be billed by adding CPT code 99495 or CPT code 99496 to an RHC or FQHC claim, either alone or with other payable services. If it is the only medical service provided on that day with an RHC or FQHC practitioner it is paid as a stand-alone billable visit. If it is furnished on the same day as another visit, only one visit is paid.
June 2015 CENTER FOR CONNECTED HEALTH POLICY Mario GuttierezExecutive Director
MEDICARE – Virtual Communications
CENTER FOR CONNECTED HEALTH POLICY
Effective January 1, 2019, RHCs and FQHCs can receive payment for virtual communication services when at least 5 minutes of communication technology-based or remote evaluation services are furnished by an RHC or FQHC practitioner to a patient who has had an RHC or FQHC billable visit within the previous year, and both of the following requirements are met: • The medical discussion or remote evaluation is for a condition not related to an RHC or FQHC
service provided within the previous 7 days, and • The medical discussion or remote evaluation does not lead to an RHC or FQHC visit within the next
24 hours or at the soonest available appointment.
• Code used is G0071 but is not paid at the PPS rate.
June 2015 CENTER FOR CONNECTED HEALTH POLICY Mario GuttierezExecutive Director
FEDERAL TORT CLAIMS ACT
CENTER FOR CONNECTED HEALTH POLICY
• Does not specifically address telehealth• Last policy update 2014• Potential problems when using telehealth – Physician/Patient relationship exists only when
the patient comes to the health center site. If the patient is not at the health center, would FTCA cover? For example: when CCM is used?
• If the FQHC has a contract with a provider, will FTCA cover that person?• Performs at least 32.5 hours of service/week for the period of the contract• If less than 32.5, provider must be licensed or certified in family practice, general internal medicine,
general pediatrics or OB/Gyn• Does not include psychology/psychiatry
June 2015 CENTER FOR CONNECTED HEALTH POLICY Mario GuttierezExecutive Director
OPIOIDS/SUBSTANCE USE DISORDER
CENTER FOR CONNECTED HEALTH POLICY
• The SUPPORT for Patient and Communities Act required CMS to adjust their reimbursement policy of telehealth for treating individuals with SUDs or a co-occurring mental health disorder.
• Removed the originating site geographic requirements for telehealth services on or after July 1, 2019 for any existing Medicare telehealth originating site (except for a renal dialysis facility).
• Home was made an eligible originating site for purposes of treating these individuals, however the home would not qualify for the facility fee.
• Within 5 years a report of the impact of telehealth services on SUD must be submitted by the Secretary
June 2015 CENTER FOR CONNECTED HEALTH POLICY Mario GuttierezExecutive Director
THANK YOU!
Where can you go to learn more about telehealth?
Deb LaMarcheNorthwest Regional
Telehealth Resource CenterNRTRC
The National Consortium of Telehealth Resource Centers (NCTRC) is an affiliation of the 14 Telehealth Resource Centers funded individually through cooperative agreements from the Health Resources & Services Administration, Office for the Advancement of Telehealth. The goal of the NCTRC is to increase the consistency, efficiency, and impact of federally funded telehealth technical assistance services. This presentation was made possible by 14 Telehealth Resource Centers and administered through grant #G22RH30365 from the Office for the Advancement of Telehealth, Federal Office of Rural Health Policy, Health Resources and Services Administration, Department of Health and Human Services.
TRC Fact Sheets
These are just a few!87
There’sMore!
• The NCTRC website houses additional fact sheets on policy, reimbursement, FDA approved technology, and more.
• We also have a collection of guides and research resources (catalogues and webliographies) from various TRCs to help your telehealth program.
• There are a wide variety of resources we can provide.
• Get in touch!
NCTRC Webinar SeriesEvery 3rd Thursday of the month from 11 AM – 12 PM (PST), the National Consortium of Telehealth Resource Centers provides a free webinar for those interested in telehealth.
• Schedule
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The TRCs have an expansive network of professionals in the field of telehealth.
The monthly topics encompass various topics ranging from policy, business models, clinical workflow, telehealth program development, etc.
Content
Don’t worry.We record them.
Can’t make the live webinars? No problem! We record all webinars and post them on our YouTube page within 1 business day.
Find more educational webinars:https://www.youtube.com/c/nctrc
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Hands-On Training Networking
RegionalConferences
TRCs host conferences year-round. Let’s look at what’s coming up in your region!
Education
Key Takeaways
1. TELEHEALTH IS AN EMERGING FIELD. Telehealth is a rapidly changing field, we’re expecting many changes in 2019.
2. CONNECT WITH US. Shoot us an email, give us a call, visit the website, or even better, register for our regional conferences. We’d be glad to chat, but even happier to meet you.
3. OUR RESOURCES. DIY kind of person? We have numerous resources and a reliable network to get your answer. We’re federally funded so our information and resources are at your disposal.
4. THE CONSORTIUM. Keeping development in mind, TRCs are prepared to connect with you and morph your telehealth program.