Maine Nursing Home Telehealth Network

3. Maine Nursing Home Telehealth Network High fraction of elderly residents�17% for project counties, 14% for Maine, 12% for U.S. High state rates for lung disease and cancer mortality ranks 6th and 4th among states, �99-�02 High ER utilization rates�ranks 5th among states High rates of asthma among elderly�ranks 6th Substantial rural vs. urban health disparities linked to economics and health care access e.g. project county rates of hospitalization for elderly 15-50% above state averages for pneumonia, COPD, asthma/bronchitis, diabetes & heart disease

5. Maine Telehealth Network Primarily ISDN 128-384 kbps Open-architecture IP-based hospital use w/ISDN gateway

7. Maine Nursing Home Telehealth Network Recruiting nursing homes and providers Clinical telemedicine application development Develop distance education program Pilot videophone program for linking patients with distant family members

8. Maine Nursing Home Telehealth Network MDS and facility-specific cost data collectedMDS and facility-specific cost data collected

9. Maine Nursing Home Telehealth Network Patients More timely specialty care Reduction of stressful transports Families More participation in plan of care and clinical visits Relationship maintenance through videophone calls

10. Maine Nursing Home Telehealth Network Nursing Facilities Reduced expenses for transports Improved access & reduced cost for staff education Reduced worker injuries IVC-facilitated training Specialists/Practitioners Improved ability to assess the patient in residential settings Reduce travel cost and disruption of work flow Greater provider collaboration and peer education

11. Maine Nursing Home Telehealth Project Four rural facilities added in northern Maine in Year 1�25-50 skilled beds Another added in Year 2 to replace planned site where ISDN service unavailable A larger facility from southern Maine added late in Year 2�100 skilled beds (city of 20,000 vs. 1,000-4,000 for others)

12. CMS Nursing Home Quality Indicators

13. Install equipment Train Site Coordinators Provide targeted in-service education to nursing home staff Develop primary care telemedicine Develop specialty care applications Implement videophone program Maine Nursing Home Telehealth Network

14. Maine Nursing Home Telehealth Network Establish management and oversight system Set up infrastructure Develop policies, protocols, and procedures Site Coordinator identification & training

16. Maine Nursing Home Telehealth Network Dermatology Geriatric psychiatry Wound care Pain management Mental health counseling Rheumatology Post-op orthopedics

17. Maine Nursing Home Telehealth Network Wound Care Pain Management/addiction medicine Mental Health Developed--not used Asthma/allergy Occupational medicine Available--not used Sign Language Interpreting Endocrinology

18. Maine Nursing Home Telehealth Network Specialty Care Telehealth Activity 86 consults over 30 months--3/month 36 Wound Care, 48 Mental Health, 2 Pain Management Overall provider satisfaction�very=87% Could adequately assess patient�88% Helped with diagnosis, treatment-63, 67% Improved quality of care�75% Helped avoid patient transfer�71%

19. Maine Nursing Home Telehealth Project Patients benefited from not having to be transported�100% Clinical, educational, and administrative uses saves my practice time & money�100% Prevents worsening of patients condition�100% Positive impact on patient care�100% Use can save money for insurers�92%

20. Patient Satisfaction with Clinical ConsultsN=27, 12/-4-2/06

21. Patient Satisfaction with Clinical Consults(continued)

22. Maine Nursing Home Telehealth Network Telemedicine is effective for delivery of specialty care consults for nursing home residents�88% Setting up telemedicine consults is a major barrier to use�only 13% agree Barriers you think prevent some needed telemedicine consults from happening? PCPs work hard to address medical problems themselves�50% PCP and staff are effective at preventing and managing resident pain and wounds�13% Getting doctor to make referral�13% Staff just too busy�13%

23. Maine Nursing Home Telehealth Network 35 cents per mile 2 staff members, wage and bennies $50 per hour35 cents per mile 2 staff members, wage and bennies $50 per hour

24. Maine Telemedicine Network Antibiotic resistant infections Wound care Pressure ulcers Colstomy management Pain management Swallowing disorders Nutrition and diabetes Respiratory infections

25. Staff Satisfaction with Distance Education

26. Staff Dissatisfaction with Education

27. Maine Nursing Home Telehealth Project One PCP used 6 times for patient oversight between Lubec and Machias (30 mi. distance)�reported satisfied with efficacy, but dropped use due to regular in person visits Other PCP providers showed resistance to use-- distances were often not significant and system use was more cumbersome than usual monitoring by telephone calls to staff nurses Pilot use of videophones with one PCP was not perceived as effective

28. Maine Nursing Home Telehealth Network POTS-based home video units placed by staff with distant family and in patients rooms To date, 3 units placed with patient relatives in Florida, Tennesee, Connecticut and 2 in-state

29. Feedback on Virtual Visitation Responses from patients suggested effective in enhancing their sense of connectedness & well-being; in one case, patient dementia hindered use Daughter of 92 yr. old patient: �I loved this�it�s made the holidays so enjoyable. It�s as if we were sitting there for a visit. I use it all the time.� 100% of 8 staff surveyed agreed: �Videophone links between patients and family can enhance the patient�s quality of life�

30. Maine Telemedicine Network Look at acuity of residence and not just rurality of the nursing home Staffing time constraints providing services not previously provided Reimbursement amount needs to be consistent with prevailing rates

31. Barriers to Success of Telemedicine Both primary care and consulting specialist providers are resistant to adopting new technologies or changing their routine mode of practice The high cost of telecommunications, including line charges for ISDN or dedicated T1 lines Additional personnel resources and training are required at both spoke and hub sites Solutions to liability and credentialing/privileging issues must be worked out Reimbursement development in some states is slow: Maine has been forthright in reimbursement