The SNF/IRF Telehealth Model, Explained

By Elena Muller, MPH


In researching this blog, I sat down with Jenni Gudapati RN, MBA, Value-Based Healthcare Program Director at Boise State University. During our conversation, Jenni shared her insight into the value of utilizing telehealth in Skilled Nursing Facilities (SNFs) and Inpatient Rehabilitation Facilities (IRFs). Our conversation is reflected in this blog post.

SNFs & Telehealth - the Value

Across the country SNFs are starting to leverage telehealth to improve both clinical and operational outcomes. Telehealth provides patients with the necessary tools to engage in their own health and equips providers with the tools they need to monitor and remain engaged with their patients. 

Telehealth can provide a huge value to SNFs - reduced readmissions, shortened length of stay, improved patient outcomes and satisfaction, increased caregiver engagement, decreased unnecessary patient transports/ED visits, and boosted staff morale.

As our industry continues to move towards value based care, health systems, ACOs, and insurance providers, will strive to partner with organizations that can provide the tools necessary to drive successful outcomes for their patients, while lowering risk and reducing unnecessary costs. SNFs, by leveraging telehealth, a tool that improves outcomes and saves costs, will finally be invited to the table to join-in on these conversations.

Remote Patient Monitoring & the Transitionary Period

The use of remote patient monitoring (RPM) can help SNFs reduce and avoid hospital readmissions, ED visits and acute disease exacerbation - factors that are essential to decrease within an effective value-based care program.

SNFs play a crucial role in ensuring patients transition smoothly from the hospital to the home and there is huge opportunity for SNFs to utilize RPM in a transitionary model, to ensure that once the patient leaves the SNF they are able to manage their care from home.

How does the transitionary period model work? At the beginning of the patients stay in the SNF, they are enrolled in the telehealth program, and telehealth training is incorporated into their therapy routine or care plan. Throughout their stay, the patient gets educated on their condition and the benefits of telehealth, learning how telehealth can benefit their health and their providers.

The patient is taught how by looking at trends closely, abnormalities can be caught quickly, reducing their chance of increased sickness and resulting in faster healing. Throughout repeated practice, the patient learns how to engage with the platform (how to take Bluetooth biometrics, how to do a virtual visit, symptom surveys, education, etc.), beginning their journey towards proactive health and wellness.

While at the facility, the patient’s family or caregivers also learn about tracking data and which trends to watch, and how they can be helpful with their loved one’s care plan adherence.

At discharge, the patient takes the telehealth platform home. Introducing the telehealth program during the patients’ stay in the SNF ensures that when the patient is home, they are comfortable with the program and understand how to use it correctly and confidently.

In many cases, this transitory model can reduce length of stay, as it enables patients to understand their health and adopt the necessary behaviors to have control over their individual health outcomes. Another added benefit to incorporating RPM into the inpatient care plan is it illustrates a clear picture and start of patient specific trends and norms that the patient’s provider can study to identify early variances in condition.  Through alerts and early intervention, acute events can potentially be avoided. By starting the telehealth process a road map to recovery is created and the health care team learns to work simultaneously with the patient to see what works and what doesn't. 

Engaging the Caregiver in The Telehealth Program

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Telehealth brings the caregiver into their loved one’s care plan. During the COVID-19 pandemic especially, where family members are not able to visit their loved ones, telehealth can be a great resource to ensure that the patient and their caregiver(s) are continuously connected.

HRS’ CaregiverConnect mobile application, for example, incorporates the caregiver directly in the patients’ care. The caregiver is able to gather valuable insight, track their loved ones progress and see in real-time if they are improving, or not. Additionally, the Caregiver can be included in conversations with the clinician and their loved one through video visits, directly from the application. The caregiver application allows the family members to check in on their loved one and follow the care plan in real time, without having to get in contact with the SNF staff every time an update is needed. This a low cost option that can provide immense value to the patient and the family.

SNFS & Value-Based Care

Telehealth has the ability to improve patient outcomes and caregiver engagement, while also improving the SNF’s financial stability. When a SNF incorporates telehealth into their workflow it impacts their bottom line by reducing Medicare penalties associated with readmissions and decreases lost days, while also enabling the SNF to qualify for value-based care and risk-share partnerships. RPM increases communication and teamwork between providers and helps create a team-based approach that further develops relationships, trust, and mutual success.

The COVID-19 pandemic has accelerated our industry into the era of telehealth. With this shift, SNFs have seen how valuable telehealth can be for their patients and clinicians. SNFs treat the most vulnerable patient populations, which comes with a need for the highest level of patient care. Telehealth platforms have enabled staff to treat patients more effectively, reduced the need for hospital transports, and ensured that once the patient leaves the facility, they are equipped with the tools they need to continue their recovery safely at home.

As we continue to shift towards value-based care, more and more SNFs will proactively turn towards telehealth to aid in reducing hospitalizations, improving staff morale, involving the caregiver, and ultimately, improving the outcomes of their vulnerable patient population.

 

 

Tags: disease management, cost savings, skilled nursing

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