D.28 HT-ops-manual.pdf

VHA Office of Connected Care vaww.telehealth.va.gov www.telehealth.va.gov

Home Telehealth Operations Manual

December 2017

D.28 RFP: 36C25722R0015

Home Telehealth Operations Manual- December 2017 Page i

Table of Contents

1. PURPOSE, DEVELOPMENT PROCESS AND AUDIENCE

1.1 PURPOSE

1.2 DEVELOPMENT PROCESS

1.3 AUDIENCE

2. HOME TELEHEALTH: INTRODUCTION AND HISTORY

2.1 INTRODUCTION TO HOME TELEHEALTH

2.2 DEFINITION OF HOME TELEHEALTH

2.3 THE HOME TELEHEALTH MODEL

2.4 HISTORY OF VA HOME TELEHEALTH

2.5 GROWTH OF HOME TELEHEALTH IN VA

2.6 TELEHEALTH ORGANIZATION AND INFRASTRUCTURE

3. PLANNING AND EXPANDING HOME TELEHEALTH PROGRAMS

4. BUSINESS CASE DEVELOPMENT

4.1 NEEDS ASSESSMENT

4.2 DETERMINING HOME TELEHEALTH ENROLLMENT GOALS AND PANEL SIZE

4.3 SPACE PLANNING FOR HOME TELEHEALTH

4.4 DEPLOYING AND MANAGING HOME TELEHEALTH PROGRAMS

5. HUMAN RESOURCES, KEY POSITIONS, ROLES AND RESPONSIBILITIES

5.1 CARE COORDINATORS

5.2 LEAD CARE COORDINATORS

5.3 FACILITY TELEHEALTH COORDINATOR (FTC)

5.4 HOME TELEHEALTH SUPPORT STAFF

5.5 HOME TELEHEALTH MASTER PRECEPTOR

5.6 HOME TELEHEALTH PRECEPTOR

5.7 HOME TELEHEALTH CLINICAL CHAMPION

5.8 VISN HOME TELEHEALTH PROGRAM MANAGER

6. STAFF EDUCATION, TRAINING AND COMPETENCY

7. ORIENTATION

7.1 NATIONAL IMPLEMENTATION TEAM

8. HOME TELEHEALTH CLINICAL PATHWAY AND CARE COORDINATION PROCESS

8.1 SCREENING AND IDENTIFYING APPROPRIATE VETERANS FOR ENROLLMENT INTO THE HOME TELEHEALTH

PROGRAM

8.2 ONGOING CARE COORDINATION - CARE MANAGEMENT, CASE MANAGEMENT AND MONITORING

8.3 DISCHARGE/ TRANSITION TO OTHER SERVICES

9. HOME TELEHEALTH TECHNOLOGY

9.1 HOME TELEHEALTH TECHNOLOGY PLATFORMS-VA APPROVED

9.2 TELEHEALTH TECHNOLOGY ORDERING, INVENTORY AND SUPPORT

9.3 DENVER ACQUISITION AND LOGISTICS CENTER (DALC)

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9.4 MATCHING TECHNOLOGIES TO CLINICAL NEED

9.5 TECHNOLOGY SUPPORT, MAINTENANCE, INFECTION CONTROL, SERVICE AND REPAIR

9.6 TECHNOLOGY USER GROUP

10. DISEASE MANAGEMENT PROTOCOLS (DMPS)

10.1 DMP TYPES

10.2 DMP PROCESSES

11. DOCUMENTATION STANDARDS

11.1 DOCUMENTATION OF CASE MANAGEMENT ACTIVITIES

11.2 THE HOME TELEHEALTH CONSULT REFERRAL

11.3 INITIAL ASSESSMENT AND TREATMENT PLAN NOTE (ASSESSMENT, REVIEW OF SYSTEMS, GOAL-SETTING AND

PLANNING)

11.4 CONTINUUM OF CARE FORM (CCF) TEMPLATE

11.5 CAREGIVER BURDEN ASSESSMENT TEMPLATE

11.6 TECHNOLOGY EDUCATION NOTE

11.7 INTERVENTION NOTE

11.8 MONTHLY MONITORING NOTE

11.9 PERIODIC EVALUATION NOTE

11.10 HT NOTE

11.11 DISCHARGE NOTE

11.12 RE-ENROLLMENT

11.13 PATIENT PARTICIPATION

12. PATIENT AND CAREGIVER SELF-MANAGEMENT EDUCATION

12.1 VA HEALTH CARE DELIVERY

12.2 PATIENT SELF-MANAGEMENT

13. WORKLOAD CAPTURE AND DATA MANAGEMENT

13.1 CODING AND WORKLOAD CREDIT

13.2 COMPLETING THE ENCOUNTER INFORMATION

13.3 VETERANS EQUITABLE RESOURCE ALLOCATION (VERA) FOR HOME TELEHEALTH

14. QUALITY MANAGEMENT

14.1 CONDITIONS OF PARTICIPATION

14.2 PROCESS AND PERFORMANCE IMPROVEMENT

14.3 DOCUMENTATION/PROCESS OF CARE DOCUMENTATION AUDIT

14.4 QUALITY IMPROVEMENT REPORT (QIR) PROCESS

15. RISK MANAGEMENT

16. INFORMATION OUTREACH

APPENDIX A: RESOURCES AND LINKS .................................................................................................................. A-1

APPENDIX B: ACRONYMS ......................................................................................................................................... B-1

APPENDIX C: ENDORSEMENT OF HOME TELEHEALTH OPERATIONS MANUAL .....................................C-1

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List of Tables Table 1: Resources and Links ...................................................................................................................................................... A-1

Table 2: Table of Acronyms .......................................................................................................................................................... B-1

List of Figures Figure 1: Home Telehealth Active Patient Census (Rounded), EOFY2003-2014

Figure 2: Home Telehealth Clinical Pathway Diagram

Figure 3: Home Telehealth Quality Improvement and Patient Safety

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Acknowledgement We wish to acknowledge the many contributions of the subject matter experts who have provided their technical expertise in order to make this manual possible.

Contributors

VHA Office of Connected Care

Office of Patient Care Services

VISN Leadership

Facility Leadership

Home Telehealth Master Preceptors

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Document Version History Responsible Office

The development and maintenance of this document is the responsibility of the Veterans Health Administration (VHA), Office of Connected Care. Proposed changes to this document should be submitted to Rita. Kobb@va.gov

Document

Revision

Effective Date Page Description

1 April 2011 Initial Document Redevelopment

2 December 2011 Bi-annual Review of Manual

3 April 2012 Bi-annual Review of Manual

4 December 2012 Bi-annual Review of Manual

5 May 2013 Annual Review of Manual

6 April –June 2016 Annual Review of Manual

7 January 2017 Newly Revised Major Version

April 2017

Quarterly Update

Patient Participation 70% requirement at least over

90 days

Employee Education System link not hyperlinked

Co-morbidities for DMPs and category of care for

Weight Management

Adding provider reviewing data for HT: The

Basics education requirement

Patient Participation 70% requirement at least over

90 days

Returned Merchandise Authorization Process

Home Telehealth Reporting of IT issues

HPDP & standalone prevention DMPs; Weight

Management co-morbid & category of care

VA Provider vs VA PCP

Closing CCHT consults to be in compliance with

Directive 1232: Consult Processes & Procedures;

CHOICE Program

Home Telehealth Operations Manual- December 2017 Page vii

Effective Date Page Description

A-1

Clarifying co-signing vs additional signer

Recommendations for reducing duplication of efforts for assessment documentation requirements for HT and specialty programs like TeleMOVE, Homeless Veterans & SCI

Monitoring note and partial response

Periodic Evaluation Note and provider additional signer

Patient Participation 70% requirement at least over

90 days; clarification for 30 minutes of monitoring

Add vetted HT Mental Health User Guide to list of attachments

Add vetted Pain Management Toolkit to list of attachments

9 September 2017 4

13&31

38-39

Minor spelling correction

Adjusted content to reflect HT video terminology

Care Coordinators will conduct on going chart reviews as part of their routine case management and process of care for evaluation of Veterans current needs, overall status, and changes that may have occurred.

Return Merchandise Authorization (RMA) changed to reflect new HT Equipment Contract

New DMP Process changes as communicated via

National Alert Email

Content addition on reviewing daily alerts

Addition of content related to HT Consult Referrals

Updated content for the Initial Assessment &

Home Telehealth Operations Manual- December 2017 Page viii

Effective Date Page Description

49-50

63-64

Treatment Plan Note

Enrollment Agreement is now required to support documentation of Veteran’s rights & responsibilities for HT Program

Updated content for Continuum of Care Form Note

Updated content for Technology Education &

Intervention Notes

Updated content for Periodic Evaluation Note-changed from between 3-6 months to every 6 months

Change in section title from Telephone Encounter

& Office Encounter to HT Note. New content added

Added content related to Re-enrollment and new note templates with clinical reminders

Deletion of Patient Self-management courses

Changes in encounter section to reflect release of new national note titles and templates

Changes in risk management content to include addition of COOP risk stratification levels explanation

Added Clinical Reminders and Dialog document to

Resource Table #1

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1. Purpose, Development Process and Audience

1.1 Purpose

The purpose of the Home Telehealth (HT) Operations Manual is to provide standard operational guidance and resources to implement, operate, monitor and sustain quality, safe and effective Home Telehealth care in the Veterans Health Administration (VHA). This manual will describe the prerequisites and critical success factors for providing these services within the framework of VHA strategic plans for Telehealth. The content and tools therein serve as a resource for quality improvements as well as to expand the delivery of non-urgent care via HT and ensure the efficiency, quality and sustainability of these services.

The HT Operations Manual will assist Veterans Affairs (VA) staff to integrate the practices and procedures used in VHA Home Telehealth programs for the benefit of patients, caregivers, families and practitioners. This integration of processes and procedures apply to both establishing a new HT program and operational standards for an existing HT program. This manual references and links to all VHA Office of Connected Care programs including Clinic based Telehealth

The HT Operations Manual is meant to complement existing VHA clinical and administrative directives and guidelines. It provides sufficient detail for the intended audience to gain an understanding of the complex components of developing and managing HT programs. The Operations Manual also contains links to additional training, tools, and resources that will compliment other national, VISN and local requirements ensuring competency and the ability to successfully plan, deploy and manage HT programs.

1.2 Development Process

Telehealth leaders from the 18 VISNs comprised the development committee for this Operations Manual with oversight and leadership from the Telehealth Implementation Team within the VHA Office of Connected Care program office. Content was developed with the underlying goal of providing the greatest amount of relevant information to ensure safe and high quality services to Veterans. Final reviews were completed by key staff within VHA Office of Connected Care prior to approval and publication.

1.3 Audience

Although much of the content of this Operations Manual may be pertinent to HT operations outside of VHA, this document is a resource developed solely for internal VHA Home Telehealth programs. The intended audience is VISN Telehealth leadership, Facility Telehealth Coordinators (FTC), Lead Care Coordinators, Care Coordinators and administrative/technical staff, Telehealth practitioners and VHA staff that provide management and/or support to HT Programs.

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2. Home Telehealth: Introduction and History

2.1 Introduction to Home Telehealth

The nation's largest health care system, the Department of Veterans Affairs’ (VA’s) Veterans Health Administration (VHA), uses a wide variety of communication and information technologies to ensure excellence in the health care delivered to our nation's Veterans. New information technologies continue to revolutionize health care and VA has been recognized by the Institute of Medicine as a leader in using these technologies to improve the quality of health care delivery. VA’s application of three areas of technology --health informatics, telehealth, and disease management -- enables VA to coordinate the care of Veterans by extending and enhancing current care and case management activities.

The focus of this Operations Manual is HT which primarily occurs between the Veteran in his or her place of residence and a VA clinical setting. Home Telehealth also occurs in other settings and, with the addition of mobile technologies such as Interactive Voice Response (IVR) systems and “Browser” or web-enabled technologies, HT can take place almost anywhere a Veteran chooses.

The term “Home Telehealth” applies to the use of telecommunications technologies to provide clinical care and promote patient self-management as an adjunct to traditional face-to-face health care. Health Information is exchanged from the Veteran’s home or other location to the VA care setting, thus alleviating the constraints of time and distance.

2.2 Definition of Home Telehealth

In VA, Home Telehealth is defined as a program into which Veterans are enrolled that applies care and case management principles to coordinate care using health informatics, disease management, and technologies such as in-home and mobile monitoring, messaging and/or video technologies. The goal of HT is to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits for Veterans in post-acute care settings, high-risk Veterans with chronic disease or at risk for institutional long-term care, and Veterans that would benefit with additional health promotion and prevention activities.

The essence of HT as implemented in VHA involves the ongoing assessment, monitoring, patient education and case management of Veterans in their place of residence and provides the appropriate information to Patient-Aligned Care Teams (PACT) and the healthcare system to enable timely care. Use of HT has the potential to reduce clinical complications and the use of healthcare resources that health complications may consume.

The use of technology is only one aspect of HT and a core component of the HT model which includes active care and case management. Case Management paired with technology increases patient satisfaction, improves outcomes and enhances management

Home Telehealth Operations Manual- December 2017 Page 3 of chronic disease through collaboration between the Veteran, the HT clinician (Care Coordinator), and the Veteran’s health care team using an interdisciplinary approach.

It is important to note that Care Coordinators (licensed clinical professionals that can make clinical assessments within their scopes of practice,) combine the use of HT technologies with the ongoing assessment, monitoring and case management of Veterans which allows providers and the healthcare system to have appropriate information to enable timely care.

HT is not intended to replace or duplicate other care management or case management activities. Rather, the use of disease management and health informatics technologies in HT enhances and extends current VA care management and case management activities into non-VA settings and Veterans’ homes for those not otherwise provided case management services. It is important these technologies are applied in a safe, effective, and cost-effective manner. The interdisciplinary and standardized approach taken by VA’s Home Telehealth program means it can be applied across a variety of services and Veteran circumstances where combining services will enhance care to veterans but not duplicate care.

2.3 The Home Telehealth Model

Systematically implementing HT throughout the continuum of care has been a major undertaking for VHA, one that is associated with evidence of clinical and cost effectiveness such as:

Increased access to health care Improved access to primary and specialty care Alternatives to long-term institutional care Decreased Veteran travel Improved clinical outcomes Improved Veteran and Provider satisfaction Making the Veteran’s home the preferred place of care when appropriate

The changing incidence and prevalence of chronic diseases has influenced VHA’s choice in placing its continued strategic emphasis in expanding the existing HT model. A cornerstone of the HT model is the adoption of the principles of Wagner's Chronic Care Model1.

The Wagner Chronic Care Model 2.3.1

The Wagner Chronic Care Model identifies the essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems. There are evidence-based change concepts under each

1 1E.H. Wagner, “Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness?” Effective Clinical Practice 1, no. 1 (1998): 2–4.)

Home Telehealth Operations Manual- December 2017 Page 4 element and in combination they foster productive interactions between informed patients who take an active part in their care and clinicians who have the resources and expertise to assist them.

The Chronic Care Model can be applied to a variety of chronic illnesses, health care settings and target populations. The bottom line is healthier patients, more satisfied providers and cost savings.

In 2003, five additional themes were incorporated into the Chronic Care Model:

Patient Safety (in Health System);

Cultural competency (in Delivery System Design);

Care coordination (in Health System and Clinical Information Systems) Community policies (in Community Resources and Policies); and Case management (in Delivery System Design).

When the HT Model was developed in 2003, the Wagner Chronic Care Model was used as a foundation for identifying Veterans who would most benefit from services. HT staff play a fundamental role in coordinating care, educating patients, building self-management skills and applying care and case management strategies to effectively monitor and intervene for the Veteran's well-being. These areas are integrated into the HT process of care and in education and training required to provide services. These roles and responsibilities have focused on helping Veterans with chronic diseases become more actively involved in their health care decisions and Care Coordinators advocating as change agents for them.

Tenets of the Home Telehealth Model 2.3.2

The Model for HT was developed based on the following principles:

Making the Veteran’s home and local community the preferred place of care when appropriate

Focusing on Veterans with the highest patterns of utilization Providing case management for non-institutional care (NIC) Veteran patients and their caregivers Promoting improved Veteran patient self-management and knowledge of chronic disease states Providing patient education and health coaching to promote healthy behaviors Providing patient navigation support and advocacy throughout the healthcare system to meet health needs (i.e., for chronic disease management)

The HT program utilizes a seamless interdisciplinary approach with an expectation that its Care Coordinators will coordinate care across all settings, episodes of illness and at the appropriate level of care within their scopes of practice. Home Telehealth is designed to help maximize function and independence while also recognizing an individual’s right to self-determination. The fundamental components of HT are as follows:

Screening Assessment

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Care planning Intervention Evaluation

The intent of the HT program is to provide non-urgent/non-emergent care and case management that also includes tracking and trending vital signs, other biometric data and symptoms. On enrollment in the HT program, all patients are given instructions on how to reach a health care professional (e.g., nurse line) after normal work hours or in an emergency at any time during the day. Based on their judgement and when indicated by symptoms being experienced, they are to continue to seek emergency medical assistance using their community resources (such as the Emergency Room or 911, etc.) as they did prior to enrollment in HT. Home Telehealth is not a program that provides care and case management 24 hours per day, 7 days per week.

In general, HT programs operate on a Monday through Friday work week, during routine business hours. Data transmitted to and from patients using HT technologies over a weekend or holiday is reviewed by Care Coordinators on the next standard workday. In addition, the model for HT does not require or expect that data will be reviewed immediately as it is received during normal work hours; Care Coordinators will review data at various times during the day and this may result in data not being reviewed on the day it was actually electronically received.

Patient Populations and Categories of Care 2.3.3

The HT program focuses on enrolling Veterans with chronic diseases such as, but not limited to, diabetes, hypertension, heart failure, post-traumatic stress disorder, depression, spinal cord injury, traumatic brain injury, chronic respiratory disease and other vulnerable populations.

In 2007, Office of Connected Care developed four categories of care in which Veterans enrolled in HT are placed. All patients must be placed in the appropriate Category of Care based on a formal assessment of individual patient health status. The four categories of care and their explanations are below:

Non-institutional Care (NIC) o Must meet NIC criteria based on the administration of the Continuum of Care

Form (CCF) o Has deficits in three or more activities of daily living (ADLs) or one or more behavioral/cognitive deficits or has less than six months to live. If the Veteran does not meet the aforementioned NIC requirements then they can achieve NIC status by having two or more ADL deficits in combination with three or more instrumental activities of daily living (IADLs) deficits or is age 75 or older, lives alone or has 12 or more clinic stops in the past 12 months.

Chronic Care Management (CCM) o Does not meet NIC criteria but must meet both below criteria for CCM based on administration of the CCF.

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Diagnosis of one or more chronic illnesses amenable to HT Requires on-going intensive case management, monitoring and interventions.

Acute Care Management (ACC) o Patient has short-term clinical needs such as, but not limited to: post-operative care, transition management or post-hospital care (enrollment<= 6 months).

Health Promotion/Disease Prevention (HPDP) o Primary need is for health promotion, disease prevention, and self-management education in maintaining healthy behaviors.

o Is unable to answer at least 70% of the time through the technology for at least 90 days.

2.4 History of VA Home Telehealth

VHA’s Office of Connected Care, within the VHA Office of Patient Care Services, was established in July 2003 to support the development of new models of care in VA using leading edge health information technologies to address the pressing health needs of Veterans. VHA Office of Connected Care’s mission and vision is to improve quality, convenience, and access to care for Veteran patients with the use of health informatics, telehealth, and disease management technologies that enhance and extend care and case management.

VHA Office of Connected Care is responsible for telehealth implementation throughout VA in addressing clinical, technical and business issues whenever required to ensure telehealth programs are safe, useful, cost-effective and sustainable to meet the needs of Veteran patients. VHA Office of Connected Care supports the use of information and telehealth technologies to integrate the management of patients across the continuum of care and ensure patients receive the appropriate level of care when and where they need it.

Collaborations necessary to support this work include the following:

Working with other Services in the Office of Patient Care Services and Office of Connected Care to incorporate telehealth and disease management technologies into routine practice.

Working alongside or embedded with Patient Aligned Care Teams (PACTs) and other VA offices/departments, clinicians, educators and patient groups to assist patients in easy access to relevant data about their own health status to enable them to actively participate in self-managing their care. An example is participating with other constituents in VHA in the continued development of MyHealtheVet.

Collaboration with Office of Information Technology (OI&T) to support safe and secure technology.

Collaboration with Patient Care Services and Office of Connected Care to provide innovation and secure technology.

Working with the Denver Acquisition and Logistics Center (DALC) to ensure timely purchase, patient assignment, delivery and refurbishment of technology.

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Linking with other VA offices/departments, clinicians, educators and external caregiver groups to understand the needs of caregivers in the context of telehealth, engaging in activities to support informal caregivers and volunteers and how they need to be considered in the planning and delivery of VHA Office of Connected Care.

Making the home the preferred place of care maintains the caregiver in a pivotal position in the care delivery process. Office of Connected Care, in partnership with others, supports the desire of Veteran patients to achieve the following experience from their interactions with VHA: "no decision about me is made without me."

2.5 Growth of Home Telehealth in VA

Since 2003, VHA Telehealth programs have continued to grow. Over 156,000 Veterans were served via the Home Telehealth program care for fiscal year 2015 and at the end of fiscal year 2015 there were more than 96,000 Veterans currently enrolled within approximately 139 HT programs nationally.

The following figures provide the growth of HT within VA since 2003:

Figure 1: Home Telehealth Active Patient Census (Rounded), EOFY2003-2014

*Source: Care Coordination Home Telehealth (CCHT) Data Cube

2.6 Telehealth Organization and Infrastructure

The importance of organization and infrastructure at both VISN and VAMC (Station/Site) levels, in the development and operation of telehealth programming, cannot be over emphasized. Because telehealth involves such a large number and variety of organizational entities within these different levels of the organization, high degrees of coordination and oversight are necessary. An effective communication plan is essential.

Telehealth must be seen as a continuum including clinic-based, home and mobile patient settings, as well as synchronous (Clinical Video Telehealth [CVT]) and asynchronous (Store and Forward Telehealth-SFT) modalities of clinical service delivery.

2,000 4,400 8,900

21,600 31,300 35,400

40,300 48,300

66,000 77,800

89,400 94,000

20,000

40,000

60,000

80,000

100,000

FY 03 FY 04 FY 05 FY 06 FY 07 FY 08 FY 09 FY10 FY11 FY 12 FY 13 FY 14

Home Telehealth End of Year Census

Census of Veterans enrolled at the end of the Fiscal Year

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VISN and Station-Level Infrastructure and Oversight of Home 2.6.1

Telehealth

The VISN level infrastructure begins with a Telehealth Program Manager who has the responsibility and authority to guide, govern and strategically plan, deploy and operate telehealth programs. In some cases, a VISN-level HT Program Manager is appointed to provide this oversight as HT is one part of the telehealth continuum and must be integrated into an overall telehealth organizational matrix. Station level infrastructure may include the FTC overseeing all Office of Connected Care staff within the local setting, including Clinical Video Telehealth (CVT), Home Telehealth (HT) and Store-and-Forward Telehealth (SFT). Alternatively, station level infrastructure may include a HT Lead that oversees the HT program and works collaboratively with the FTC.

National-Level Infrastructure and Oversight 2.6.2

VHA Office of Connected Care provides guidance and support for HT Programs through its national HT Lead and Clinical Nurse Analyst, National Development and Implementation Teams, as well as its Data Analyst and Contracting Representative. In addition, the Quality Team provides support and guidance in the oversight of program responsibilities in providing HT Services through the Conditions of Participation (COP).

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3. Planning and Expanding Home Telehealth Programs

Developing a business plan is essential to implementing new programs or expanding existing HT services and this plan involves numerous steps. A methodological approach is recommended to ensure that critical elements are not overlooked, which could seriously impact overall program success. Successful HT programs integrate technology and case management with clinical program need. The primary components of planning for integrated HT programs are:

A thorough needs assessment, which includes basic infrastructure such as staffing, equipment, space and unmet clinical needs.

A strong business case which includes an analysis of the return on investment and plan for sustainability, which are essential foundational elements for HT program development.

A plan for integrating HT services across the continuum of care.

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4. Business Case Development

A business case analysis addresses, at a high level, the business need that the program seeks to address. It includes the reasons for the program, the expected business benefits, the options considered (with reasons for rejecting or carrying forward each option), and the budget which presents the expected costs of the program. It should also include a GAP analysis, which is a well-established technique for determining what direction an organization should go to move from their current state to their future “ideal” state and the expected risks.

Factors to consider when developing the business case for Home Telehealth:

Costs associated with equipment, labor and space Capital investment, expenses and overhead Start-up and ongoing sustainability Bed Days of Care (BDOC) reduction costs Funding allocations received based on workload that is generated by the program, such as the Veterans Equitable Resource Allocation (VERA) Allocations. The VERA is based on enrollments in NIC and CCM categories of care.

Things to consider when developing the budget proposal:

Perform a needs assessment for HT Services at VISN and/or facility level Identify necessary resources (i.e. telehealth equipment, staffing, furniture, etc.)

Gather supporting data reflective of the needs. For example: waiting times, travel costs, underserved populations, etc.

Estimate cost of resources and set the budget request Develop a proposal that describes the needs, goals, strategies, investment, evaluation and expected outcomes Document the telehealth program investment payback period and successful sustainability of the HT program

The following resources may be helpful to provide guidance regarding feasibility and sustainability of a program:

National Implementation Team VISN Telehealth Program Managers VHA Office of Connected Care Intranet website Satellite Broadcasts for telehealth (VA Knowledge Network and re-broadcast on

Content Distribution Network). Provides current updates and changes in the field and allows for interaction between the field and subject matter experts.

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4.1 Needs Assessment

Strategic planning provides a structure to guide in developing or expanding a HT program and identifies the goals and objectives. In order to develop the strategic plan, one needs to complete a needs assessment. The needs assessment is an important part of the business case and is constructed from the following:

Numbers of patients that have health needs that can be treated via HT Costs of providing care via HT as compared to traditional methods

Given the on-going demand for primary and specialty care services in VHA and the mandate to improve access to services, especially at geographically remote sites, it is likely that the need for HT will continue. A major component of the needs assessment will be the process for identification and enrollment of high-risk, high-cost patient populations most likely to benefit from HT.

The needs assessment identifies the goals and objectives of the program as well as resources and activities needed to achieve the plan. It is also used to provide information such as the targeted population, business perspectives and metrics for performance evaluation. A needs assessment is also a systematic method of identifying the unmet needs of the population and making changes that will benefit from an intervention.

The Telehealth Program Manager needs to determine the patient population as well as the specific fields of relevance for analyses. Useful data includes:

Patient data (e.g., utilization outcomes, quality outcomes, clinical outcomes) Documented problems in meeting the needs of a group of patients (such as distance and travel barriers, no-shows, particular medical problems, weather problems, etc.)

Available resources Workload and capacity Special needs populations Provider data (e.g., utilization data, satisfaction data, clinical data) How will HT fill the gap from one service to another Avoiding a duplication of services

The criteria in the needs assessment appraisal must include the following:

Access to the targeted population: What specialty population(s) will be served with

HT?

Expected outcomes from both the clinical and business perspectives (i.e., accomplishments using HT)

Performance measures: What performance measures will HT assist?

Space and resources available: Is there appropriate space to expand HT?

Staffing needs: What clinical and other staff will be necessary to expand HT?

Capacity and workload: How many patients could be enrolled in HT based on the resources available?

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Technical considerations: What types of HT technologies will best serve the identified population? What are the associated costs of that equipment or service?

Information received from the needs assessment will help support a productive clinical strategic plan to expand HT. The following are key elements that should be included when developing the strategic plan:

The plan should focus on the “Who, What, Where, When and How” of both clinical and business aspects of the HT program.

Roles and responsibilities of the team should be well-defined for a successful implementation.

Action items and deadlines should be clearly stated.

It is important to develop specific strategies and targets to guide HT program development.

The next step in developing the plan is execution and deployment. Information obtained from the needs assessment should guide the plan.

4.2 Determining Home Telehealth Enrollment Goals and Panel

Size

As part of the process for determining the types of patients that will be enrolled, a decision for panel sizes should be made. Panel sizes for full time, dedicated Care Coordinators should be dependent on the Care Coordinator’s scope of responsibilities and scope of practice as well as on the complexity of the care and intensity of service needs of the patients in the panel (case mix).

Historically, panel sizes in the HT program have averaged approximately 100 - 110 patients per Care Coordinator. To further study these, in 2014 Telehealth Services chartered a national Panel Size Workgroup. Membership included a VISN Program Lead, Lead Care Coordinators, Care Coordinators and Master Preceptors. This group implemented a multi-site, multi-VISN time study to determine current panel sizes, what non-clinical tasks were being provided by Care Coordinators and the availability of program support staff. The group also looked at a number of factors (via the multi-VISN time study) that impacted Care Coordinator workload including: staff coverage, use of over-time, comp time or non-compensated time; numbers of vendors and peripherals being used; administrative duties, Leads and Master Preceptor duties. From the results of the time study, the group developed a “Panel Size Calculator.” Use of this tool, which is highly recommended by the Office of Connected Care, will help leadership and HT program staff determine what is safe and effective for their individual panel size based on these and other unique factors. The use of the Panel Size Calculator tool is not mandatory, however if programs choose not to use it, they must have some other rational in place to justify current/target panel sizes for all HT staff.

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4.3 Space Planning for Home Telehealth

The square footage needed for a HT program office will vary depending on the number of staff and the types of services being provided. Basic planning for space should include an office that provides privacy for both audio and video interactions. These include face-to-face encounters and those that occur over the telephone.

If multiple HT staff members are conducting enrollment visits within the same space, privacy considerations need to be addressed to ensure HIPAA (Health Insurance Portability and Accountability Act) compliance. Use of headsets by Care Coordinators as well as white noise technologies are recommended. If video equipment is being used, privacy of conversations and images must also be addressed within the planned space.

All HT programs should be in consultation with site safety staff to ensure office furniture is placed in such a manner to ensure maximum staff safety and accommodate patients with disabilities. There should be consideration of the installation of panic buttons for staff use in case there is a patient crisis.

Telework may be a viable option to resolve space issues because HT does not require daily face-to-face contact. In this consideration, it is recommended there be staff on-site available during working hours to manage walk in visits by patients ensuring the “Right Care at the Right Place at the Right Time”. Telework has been successfully implemented as an option for HT in several VISNs. For more information about VHA Telework see Employee Education Service.

4.4 Deploying and Managing Home Telehealth Programs

There are several factors that should be considered when utilizing HT services, such as whether to expand existing HT programs or establish a new one, or create a combination which will meet the needs of the patient population(s) to be served. Once the implementation or expansion plan has been developed and agreed by all stakeholders, the VISN Telehealth Program Manager or HT program manager can collaborate with stakeholders to determine how to take the necessary steps for successful implementation.

A key consideration for how best to implement HT is how to ensure integration with other services so that the care coordination provided by the HT program can be most effective and efficient for all members of the healthcare team, most importantly, the patient. HT is a very flexible program and its integration within the healthcare system can take place with many variations and via multiple mechanisms. Even with all of its flexibility, this integration for HT will fall into two categories:

Option 1 Program: A widespread, broad service, organizationally separate from any one primary or specialty care service/clinic, providing care and case management to patients with multiple chronic conditions who are receiving care anywhere across the VA healthcare continuum with outreach to non-VA health care settings. For example, the “Rural Home Telehealth Program” located within a VA Medical Center in Florida that reports directly to the Chief of Staff.

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Option 2 Program: A specialized service, organizationally aligned (‘embedded’) within an existing service or clinic, focusing care and case management to a limited subset of patients or special populations cared for by that service/clinic, with outreach to other VA and non-VA health care settings for those same patients. For example, a Mental Health HT Program embedded in the Mental Health Outpatient Clinic.

In either case, it is important that the HT program collaborate with the healthcare teams it will be working with closely prior to implementation to gain agreement for how care will be coordinated, how communication will occur and what, if any, clinical protocols are approved for standardized plans of care and/or clinical interventions. The next several sections describe some of the more frequent options employed for integrating HT programs.

Integrating Home Telehealth with Other Services 4.4.1

HT requires a collaborative and interdisciplinary team process across the continuum of care; this collaboration takes place regardless of how the HT program is aligned organizationally.

HT has been successfully affiliated with Patient-Aligned Care Teams (PACTs), Health Promotion programs (i.e., MOVE!), Home-Based Primary Care (HBPC) and Mental Health.

Effective communication by the HT program staff with the health care team must happen regularly and whenever there is a significant change in the health status of the Veteran.

The goal of VHA’s Home Telehealth model is to integrate longitudinal, remote case management within the in-person care provided by each patient’s interdisciplinary team to optimize transitions between inpatient and outpatient care, facilitate specialty care, optimize patient education and incorporate services such as PACT, Home Based Primary Care (HBPC), Mental Health Services and many others. Collaborating with the interdisciplinary team helps to facilitate seamless care management, incorporate population management, support flexibility across healthcare settings and encourages the Veteran to be a primary partner in the team through self-management skill building.

Home Telehealth team members should perform the following tasks:

Become visible to Interdisciplinary team members. Create opportunities for frequent formal and informal interactions.

Collaborate with PACT in the development of patient specific goals and plans of care.

Share their expertise in care coordination and case management through team huddles, implementation meetings, grand rounds and other meetings.

Focus documentation on the patient. Focus communication activities on the provider and the RN Care Managers (RNCM) in the interdisciplinary team.

Formally share outcome data and performance improvement approaches with the team.

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Collaborate with the team to develop/utilize disease specific treatment/intervention protocols to increase quality and efficiency in providing care.

Use feedback as an essential tool for continued success.

When making the decision to develop or expand an existing program, it is imperative to review the needs assessment and decide which organizational alignment would best meet the needs of the Veteran. It is important to remember that integration can and should occur regardless of the selected alignment. Much collaboration has resulted in population-specific Disease Management Protocols (DMPs). These DMPs resulted in the need for HT implementation supplements such as for TeleMOVE!, Mild Traumatic Brain Injury (mTBI) and Spinal Cord Injury (SCI) DMPs.

4.4.1.1 Integration with Patient Aligned Care Teams

VHA implemented the PACT model as an approach to providing comprehensive primary care for adults. PACT is a health care model that facilitates partnerships between individual patients and their personal providers and the patient’s family and or caregiver.

VHA’s principles of PACT are as follows:

Veteran or patient-centric care On-going relationship with provider Physician directed medical practice Whole person orientation Coordinated care across the health system Quality and safety Enhanced access to care

The goal of VHA’s PACT model is to integrate coordination of care which optimizes transitions between inpatient and outpatient care, facilitates specialty care interfaces, incorporates supportive services such as HT and HBPC, includes seamless care management, incorporates population management, supports flexibility across healthcare settings and encourages the Veteran to be a primary partner in the team through self-management skill building.

Home Telehealth Care Coordinators have the skill set to leverage the use of case management, health informatics, telehealth technologies and disease management strategies to coordinate care of Veterans with high risk, high cost and/or high utilization patterns. Home Telehealth focuses on improving patient self-management skills to assist with improving overall patient outcomes. Because of these, HT has been an excellent partner for PACT.

4.4.1.2 Collaboration with MOVE!

Office of Connected Care and the VHA National Center for Health Prevention and Promotion worked together and deployed a Weight Management (TeleMOVE!) DMP in 2010. A national kick-off helped disseminate information and educate staff about this collaboration.

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An implementation guide was developed and is located at the end of this section under Resources. This single DMP is a health promotion/disease prevention (HPDP) Category of Care DMP and has created very healthy and energetic networking with Nutrition and Food Service partners. In 2017 a Weight Management DMP may be combined with other VA DMPs to make a co-morbid or tri-morbid DMP. The stand-alone Weight Management DMP is still considered an HPDP DMP. However, when combined with other VA DMPs the Veteran may be classified as HPDP, CCM or NIC as appropriate through screening with the Continuum of Care Form.

4.4.1.3 Integration with Home Based Primary Care

Some HT programs are embedded within the HBPC program where HT is used to lengthen the time between home visits. Home Telehealth is a great tool to assist with the daily care management of the HBPC Veteran with complex needs that require both program initiatives.

Home Telehealth is also used to help meet the in-home needs, as appropriate, of those Veterans that live outside the distance restrictions established by the HBPC program, thus offering services to Veterans that cannot be managed by the HBPC program.

4.4.1.4 Integration with Mental Health

Home Telehealth is also often integrated within the Mental Health Service line. There are HT programs that have designated Mental Health Care Coordinators as well as having some programs that manage mental health patients within their chronic medical populations and work collaboratively with Mental Health and medical providers and programs. Positive outcomes have been demonstrated in the Mental Health population as HT provides case management for the Veteran’s mental health condition plus their other chronic medical conditions.

Although programs have been enrolling patients with a variety of mental illnesses, VHA developed and released nationally a Substance Use Disorder (SUD) Disease Management Protocol in 2010. The HT Program Care Coordinator helps the Veteran transition from an intensive in-patient or out-patient Substance Abuse Program to successfully experience sobriety beyond their intensive program.

Since this time, Mental Health DMPs such as Depression and Post Traumatic Stress Disorder (PTSD) have been developed and nationally released. Other conditions (e.g., Psychotic Disorder and Bipolar Disorder) have been developed to meet the needs of all Veterans with chronic mental health issues.

Home Telehealth Collaboration Agreements 4.4.2

Facility-developed written service agreements such as HT collaboration agreements or Care Coordination agreements have been used in VHA for many years to define the expectations of care coordination and hand-offs between services. Development of such agreements between PACT teams (and/or specialty care teams) and HT programs are highly encouraged, especially for new HT programs to clearly define the expectations of care coordination. The purpose of such an agreement is to formalize the trust based

Home Telehealth Operations Manual- December 2017 Page 17 relationship between PACT or specialty teams and HT and to ensure that timely, high quality, comprehensive, coordinated and patient-centric care is provided to each Veteran in a safe, effective and efficient manner. The agreement should be reviewed and updated at regular intervals (e.g., such as every two years) and as needed when there are any significant changes. The agreement should clarify the clinical, business and technical details of the care and communication methods between HT and PACT or specialty care teams.

A local agreement between PACT or specialty care teams and HT defines how they will work together to accomplish care management without duplication of services for the patient. Topics for inclusion in the agreement include:

Referral methods Frequency and types of routine communication (e.g., using Computerized Patient

Record System [CPRS] notes with the "identify additional signer" function and/or secure messaging)

How changes in care plans will be coordinated and communicated Explanation of what types of diagnoses and conditions the HT program is best equipped to manage, including the available DMPs Protocols- Which program/staff will act as "first contact" for patient issues and how follow-up is communicated to the team The process for ensuring smooth patient hand-off at the time the patient is discharged from HT and other areas of mutual concern

Such agreements may also identify aggregate clinical indicators of mutual interest that will be utilized in ongoing performance improvement activities by HT. Examples of these activities might include inpatient admissions and emergency room visits in the past year, aggregate Hemoglobin A1C data both pre-and post- enrollment for patients with Diabetes, and aggregate blood pressure data both pre-and post- enrollment for patients with Hypertension.

Clinical Protocols 4.4.3

One example of the collaboration tools that are sometimes utilized in HT programs are Nurse (Advanced Practice Nurse [APN] or RN)-driven protocols. Such protocols are written as standardized plans of care or order sets that provide detailed descriptions of steps to be taken by the APN/RN to deliver elements of evidence-based care to selected groups of patients (i.e., diabetic patients or patients with chronic heart failure or Chronic Obstructive Pulmonary Disease [COPD]).