Utilizing Innovative Solutions to Achieve Value-Based, Long-Term Care

For many of us, our childhoods were filled with Saturday morning cartoons watched on 1 of 3 channels on a television firmly planted in our living rooms. One popular cartoon at that time was The Jetsons. In one episode, little Elroy is attempting to get out of school by pretending he is sick. His mother calls on their physician who makes a televisit.¹ This virtual medical visit occurred some 50 years ago in a cartoon, yet now it is a regular part of our work in long-term care (LTC). 

While the televisit in The Jetsons is certainly an interesting demonstration of innovative possibilities, in today’s environment, investments in innovation—both in terms of dollars and time—require a clear appreciation for what it can deliver. For LTC, these types of innovations have the ability to impact occupancy and payments through the improvement of clinical and financial outcomes, for example, as shown through resident/caregivers’ enhanced quality of life and through reductions in total cost of care via less emergency room visits and hospitalizations.

There are several financial models and programs that focus on this need to improve the value LTC providers’ care delivery, with more value-based models to come in the near future. These include accountable care organizations (ACOs), bundled payments, and readmission penalties. The Centers for Medicare & Medicaid Services describes ACOs as “groups of doctors, hospitals, and other health care providers who come together voluntarily to give coordinated high-quality care to their Medicare patients.”² Coordinated care helps ensure that patients, especially the chronically ill, get the right care at the right time with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program.  

The Bundled Payments for Care Improvement (BPCI) initiative is comprised of 4 broadly defined models of care, which link payments for the multiple services beneficiaries receive during an episode of care. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care.³ Bundled payment models are growing in use as private physicians utilize the services of sophisticated bundled payment managers to assist them in functions typically requiring large health systems. This is expanding use of this model.

The Hospital Readmission Reduction Program (HRRP), which financially penalizes hospitals with relatively high rates of Medicare readmissions, is currently focused on readmissions occurring after initial hospitalizations for selected conditions—namely, myocardial infarction, congestive heart failure, pneumonia, chronic obstructive pulmonary disease, elective hip or knee replacement, and coronary artery bypass graft.⁴

All of these models encourage LTC providers to reduce the total cost of care through reducing emergency room visits and hospitalizations, resulting in innovative care approaches to accomplish these tasks. The following are a few examples of innovative solutions to consider for your LTC practice.

Services at the Bedside

Many available innovations apply to care at the bedside, whether that bedside is in an LTC facility or in the community. Several of these opportunities are emerging from our smart phones, which now have the ability to do everything from a single-lead electrocardiography to ultrasound to an inner ear exam. Previously, the use of these diagnostic tools often required patients being transported to a hospital or specialist clinic. But now these tools can be used right at the patient’s bedside, increasing time to diagnosis and reducing the burden and potential complications of transporting a patient.

Similar benefits can be realized through the use of eConsults, which are electronic consults with specialists. Like the smart phone tools, eConsults can increase the speed of diagnosis at the bedside.⁵ Imagine getting a referral report in the chart from a dermatologist within 24 hours of simply sending a photo of the lesion. It is the high-tech equivalent of doing informal telephone consults, which we have been employing for years with our colleagues to get an answer to a clinical question. This formal process provides the specialist the chart, specific question, and related information, all without having the patient leave their room.

As a result of readmission penalties for congestive heart failure and myocardial infarction, LTC providers are increasing their scope of cardiac care. Two innovations in this area are the use of remote telemetry monitoring and cardiac vests. Gone are the days when telemetry patients required monitoring by facility nurses who stared at a bank of monitors 24/7; instead, these patients can be monitored by a team far outside the facility. This allows facilities to manage telemetry patients in a more efficient and effective manner. Another piece of cardiac innovation is a wearable vest that can noninvasively assess a patient’s volume status, and it can provide recommendations on the use of diuretics far in advance of weight gain, leg edema, or shortness of breath.

Another group of innovations are in the areas of paramedic-delivered acute care and hospital-at-home services, allowing hospital-level care to be provided at the bedside. Dialysis and blood transfusions are also being brought into facilities by teams equipped to provide these services bedside in any facility and leave without any impact on facility or staff. 

All of these services can be provided not only in LTC facilities but also in patients’ homes. This is an important detail as LTC providers are increasingly becoming responsible for care transitions to the home as well as delivering long-term services and supports in the community.  A primary need for many older adults to remain safe at home is effective medication management. Innovation in this area is providing devices that can help older adults take their medications correctly through prompts and electronic delivery of their medications. This can ensure that as-needed medications are only provided within the appropriate timeframe, for example, by preventing a forgetful patient from taking several sleeping pills because they forgot they already took it. In addition, medications such as warfarin, which may require a dose being held because of an elevated prothrombin time/international normalized ratio, now can be securely managed by LTC providers remotely, who can make sure that these changes will be applied and not need to rely on a patient or caregiver remembering. All of this can be managed by the LTC provider, allowing older adults to remain safe in the community and to have better quality of life.

Communication and Beyond

The need to provide timely information to all members of the care team from primary care providers, nursing staff, specialist, and families is increasingly critical. There are several innovations to provide secure texting and messaging to enhance communication with all parties. Whether those communications are between nursing staff and providers or between the entire team and a family, these tools can improve shared decision-making, access to information, and outcomes. 

Of course, communication needs go beyond these and include the very real need to communicate with our emergency and urgent care colleagues who often fail to appreciate LTC facilities’ scope of care. With the growth of urgent care centers, LTC residents can be sent for a rapid assessment and initial treatment (RA+IT) and then sent back to the facility for completion of that treatment. This innovative approach requires the receiving team to be knowledgeable and fully engaged in this process. If you are attempting this process with your local emergency department and they are not fully aware, they will default to admitting that resident. The success of the RA+IT program is based on effective communication.

Safety

There are several innovative solutions coming available to address some of the major safety concerns in LTC from falls, elopement, wounds, and staff safety. These include such devices as fall belts, which are belts filled with air bags that can sense a traumatic fall, activate, then provide a cushion to an otherwise traumatic hit to the floor. However, these are similar to combination hockey pants, which have been proven effective but which no one wants to wear.⁶ 

Other innovative devices on the safety front for LTC patients include monitors to prevent elopement and others that sense increased and prolonged pressure to move a patient in an effort to prevent pressure lesions. 

But LTC staff are also in need of safety assistance—one of the areas is in lifting patients. Japan has actually invented a nurse robot that can lift and move patients safely avoiding harm or injury to patient or staff.⁷ Tangentially, these robots are not only serving as nurses but pets too. Several versions of robotic pets are available to provide companionship for older adults, helping to lower anxiety and the use of sedative medications. ⁷

Conclusion 

If we look beyond our textbooks and journals for answers to where the future innovation will take us, perhaps we will catch up to the world of self-driving cars and artificial intelligence—2 phenomena that are arriving sooner than we thought. For us in LTC, the key will be incorporating innovation in our practices when and where the model will support it, so that we are not so far ahead that the costs, both from a financial and administrative perspective, fail to realize any benefit. Embracing innovation will help LTC providers be successful in positioning their facilities on those very important preferred provider lists and in providing long-term services outside of the LTC facility in homes and other settings far from the nursing home. 

References

1. troyrnmba. Jetsons – HealthNation. YouTube. www.youtube.com/watch?v=WP2y_bpnZDw. Published February 5, 2012. Accessed October 29, 2018.

2. Centers for Medicare & Medicaid Services (CMS). Accountable Care Organizations (ACOs). cms.gov website. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/. Updated May 3, 2018. Accessed October 29, 2018.

3. Centers for Medicare & Medicaid Services (CMS). Bundled Payments for Care Improvement (BPCI) Initiative: General Information. cms.gov website. https://innovation.cms.gov/initiatives/bundled-payments/. Updated October 25, 2018. Accessed October 29, 2018.

4. Centers for Medicare & Medicaid Services (CMS). Readmissions Reduction Program (HRRP). cms.gov website. https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions-reduction-program.html. Updated September 27, 2018. Accessed October 29, 2018.

5 Mann S. eConsults reduce need for specialty referrals. AAMC News. May 23, 2017. https://news.aamc.org/patient-care/article/econsults-reduce-need-specialty-referrals/. Accessed October 29, 2018.

6. Chen A. This $800 belt has airbags to protect your hips. The Verge. January 7, 2018. https://www.theverge.com/2018/1/7/16860374/hipair-elderly-tech-health-fall-prevention-wearables-ces-2018. Accessed October 29, 2018.

7. Hamstra B. Will These Nurse Robots Take Your Job? Don’t Freak Out Just Yet.