IN THE EARLIER DAYS OF health care, the physician’s house call was common. Many people received medical care at home, and it was just expected that doctors would travel – black bag filled with various instruments and equipment in hand – to care for people where they were.
But as medicine has evolved, fewer physicians make house calls. The amount of equipment many doctors now need to care for patients won’t fit in a tote bag, and the time required by the doctor to travel to each individual patient wasn’t efficient. Instead, patients travel to a clean, bright office for care.
For some patients, however, traveling to see a doctor can be a challenge – so what if there were a middle ground? Particularly for older adults who face transportation challenges, health care delivered via technology from a doctor off-site may be the future of making sure seniors get the health care when and where they need it most. The concept of telehealth has evolved over the past several years and might become part of the solution for an aging population that needs more care than the current system is expected to be able to handle.
“Telehealth is basically the use of technology to deliver care remotely,” says Joel White, executive director of Health IT Now, a nonprofit healthcare advocacy organization. Where once this meant a phone call between doctor and patient, now the term, sometimes phrased as digital health or telemedicine, can encompass any number of technologies and devices, including smartphone apps, remote appointments, biofeedback sensors and other connected devices that track and share information about a patient with a physician off-site. “It’s a consumer-centric view of bringing the expertise that’s available now around the world via telecom and the internet into the patient’s home or physician’s office,” White says.
Hal Wolf, president and CEO of the Healthcare Information and Management Systems Society, a global health care nonprofit focusing on improving efficiency and quality, says that the terms telehealth and digital health “are the same thing. We used to talk about them in a restricted manner, but people use them interchangeably to talk about all aspects of electronic or digital capability and communications” used in the delivery of health care. This can run the gamut from electronic health records to a video-chat appointment with a physician.
Patrick Pilch, managing director and national leader of The BDO Center for Healthcare Excellence & Innovation, a clinical and financial advisory organization, says that the idea of telehealth or digital health care today is growing to include a constellation of devices and tools to not only treat medical conditions, but to foster wellness and increase communication with health care professionals. He cites the example of Google’s Alexa device, which users talk to, as offering an opportunity to monitor a person’s state of well-being. As such, these sorts of devices might be able to “detect whether you’re having some issues, such as slurring of speech, that could signal a stroke.” It might also pick up on changes in a person’s behavior that could signal other problems. “All of those things are focused on the ability of the individual to interface with some type of electronic interface” to monitor how a person is behaving and looking for clues of a health problem. If an issue develops, these sorts of devices could send an alert to a doctor or other health care provider and trigger additional care and support as needed.
For example, Wolf asks “what happens when a person isn’t moving with the same regularity they have in the past? Are they are spending a lot more time in the bathroom than they would normally? Those could be triggers that would give us an indication that something might be wrong and get to them before an emergency has happened, before they’ve realized they need to pull the (emergency help) cord.” For older adults living at home or in an assisted living communityor another long-term care facility, the applications of digital health can be especially appealing for helping them live fuller lives with less interference from caregivers. “It’s a great application in the senior living space as it is for literally every aspect of the health and medical model,” Wolf says.
In addition to helping stop emergencies before they start, telehealth technologies might also be able to address some of the “worker shortages that exist,” Wolf says. “The encounter-based paradigm of one doctor to each patient is at risk because the numbers don’t add up. We’re in the midst of a silver tsunami as thousands of baby boomers are turning 65. So how do we support the health of individuals,” especially seniors who on average are managing more chronic conditions, like diabetes. The Centers for Disease Control and Prevention reports that “1 in 4 Americans has multiple chronic conditions, those that last a year or more and require ongoing medical attention or that limit activities of daily living. That number rises to 3 in 4 Americans aged 65 and older.”
These statistics have an important financial impact, the CDC reports. “Approximately 71 percent of the total health care spending in the United States is associated with care for the Americans with more than one chronic condition. Among Medicare fee-for-service beneficiaries, people with multiple chronic conditions account for 93 percent of total Medicare spending.”
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Wolf, who says he’ll be turning 65 in a few years, says baby boomers “want to be in a position of knowing we’re doing well and being supported at the level that’s needed. Not every senior needs a nurse following them around.” But at the same time, a little help managing chronic conditions could help seniors live more productive, enjoyable lives. “What digital health allows us to do is remain connected to support mechanisms and do so in an unobtrusive way.” He says keeping intrusiveness to a minimum and maintaining privacy is important in helping seniors retain their freedom to live the life they want for as long as possible.
But can high-quality health care be delivered remotely? White says yes, based on Medicare analysis of programs currently using this approach. Telehealth offers a “value-based model,” he says, which means that quality is a factor in determining whether services are effective. Health IT Now’s senior director of government affairs, Catherine Pugh, adds that for some patients, telehealth might actually offer better outcomes than being moved to a hospital setting for care. Especially for seniors dealing with dementia and other cognitive issues, “moving them from these facilities is disruptive” and disorienting, and can result in them not getting medications on the right schedule, “which is a huge problem.”
Although limited research has investigated how difficult some telehealth solutions might be for seniors to use, Pilch says many seniors have already shown an eagerness to adopt these technologies and a growing willingness to talk about health care options later in life, but adds that the focus needs to be on improving quality of life rather than simply extending life. “They want care focused on maximizing the quality of life. They’re also comfortable with modern technology. Two years ago, 76 percent of seniors were using mobile phones and 64 percent were using computers. They want to not have to go to the hospital to get care,” if that can be avoided. Because hospitalization is so expensive, it makes sense to reserve its use only for those who truly need it. Pilch says that BDO has found that “home health models that are supported by telemedicine reduce hospital spending” and readmission. That allows seniors to “remain in their homes for longer,” and may increase quality of life.
This hospital readmission question is one that telehealth seems well suited to address, particularly for seniors living in nursing homes and other long-term care facilities. In an effort to address this issue, members of the House of Representatives introduced bipartisan legislation, titled the “Reducing Unnecessary Senior Hospitalizations Act of 2018,” or the RUSH Act, that seeks to allow qualified physician group practices to offer telehealth services in skilled nursing facilities under Medicare. The act seeks to reduce unnecessary hospitalizations by connecting seniors in nursing homes with physicians via telehealth technologies to determine whether that senior actually needs to be transported to a hospital for additional care.
“The problem is bigger than you might think,” White says. “There’s about 1.3 million transfers from the nursing home to an emergency department” each year. The Centers for Medicare & Medicaid Services estimates that about 45 percent of those hospital admissions are unnecessary, amounting to “about $40 billion every year,” White says. “That’s a huge opportunity to put an innovative solution into the mix, and that’s what the RUSH Act would do,” he says.
The bill would address both cost and care concerns in this population, Wolf says. “When a first responder comes on site with a mobile diagnosis, they can make a much better decision about whether this person needs to be transported to the hospital. “When you roll an ambulance it’s very expensive, and when you take the person out of their environment,” it’s very disruptive, so getting an accurate diagnosis before those moves are made could reduce cost and disruption while reserving hospital care for those who need it most. “It’s a heck of a lot more efficient,” Wolf says.
If it seems surprising that there’s not already a doctor on site at most nursing homes, it shouldn’t – this is why they’re called nursing homes, not hospitals. “The skilled nursing model is a nursing model, not a doctor model,” White says. For patients who need ongoing care from a doctor, a long-term acute care hospital would provide that. For those who need skilled nursing care, which is less intensive, an assisted living facility or nursing home would be a better fit and are “a step down from the more severe institutional settings.”
White says he thinks the RUSH Act will pass because it has strong bipartisan support and addresses a real need in society. It also has “a lot of support from outside groups and technology companies.” But Pugh notes that the RUSH Act “is very targeted toward the use of telehealth to treat people at the time of emergency. It’s not a broad-reaching bill for telehealth in nursing homes.” She says that this legislation is just “the tip of the spear that can pave the way for other legislation,” and perhaps an expansion of the use of – and insurance coverage for – technology in delivering care to people when and where they need it.
Despite the high hopes for telehealth innovations, Pilch says it’s important that people continue to have in-person encounters with doctors and other health care providers. “You can’t live in just the physical world or just the digital world. It’s going to be a combination,” and using technology to bridge the gaps in direct care availability may help improve health care for seniors with less disruption.
As Wolf puts it, the hope for telehealth for seniors is: “The right care, at the right time, with the right person when it’s needed.”