D.13 Home Telehealth Operations Manual.pdf

D.13 Home Telehealth Operations Manual 36C24621R0068

VHA Office of Health Informatics: Connected Care/Telehealth Services

Home Telehealth Operations Manual

July 2019 vaww.telehealth.va.gov www.telehealth.va.gov http://www.telehealth.va.gov/

Home Telehealth Operations Manual - July 2019 Page i

D.13 Home Telehealth Operations Manual 36C24621R0068

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 TELEHEALTH ORGANIZATION AND INFRASTRUCTURE

3. PLANNING AND EXPANDING HOME TELEHEALTH PROGRAMS

4. BUSINESS CASE DEVELOPMENT

4.1 NEEDS ASSESSMENT

4.2 HOME TELEHEALTH ENROLLMENT GOALS AND PANEL SIZE

4.3 SPACE PLANNING FOR HOME TELEHEALTH

4.4 DEPLOYING AND MANAGING HOME TELEHEALTH PROGRAMS

4.5 CARE COORDINATORS

4.6 LEAD CARE COORDINATORS

4.7 FACILITY TELEHEALTH COORDINATOR

4.8 HOME TELEHEALTH SUPPORT STAFF

4.9 HOME TELEHEALTH MASTER PRECEPTOR

4.10 HOME TELEHEALTH PRECEPTOR

4.11 HOME TELEHEALTH CLINICAL CHAMPION

4.12 VISN HOME TELEHEALTH PROGRAM MANAGER

5. STAFF EDUCATION, TRAINING AND COMPETENCY

6. ORIENTATION

6.1 NATIONAL TELEHEALTH TRAINING TEAM

7. HOME TELEHEALTH CLINICAL PATHWAY AND CARE COORDINATION PROCESS

7.1 SCREENING AND IDENTIFYING APPROPRIATE VETERANS

7.2 ENROLLMENT OF APPROPRIATE VETERANS INTO THE HOME TELEHEALTH PROGRAM INCLUDING ASSESSMENT

AND DEVELOPING A PLAN OF CARE

7.3 ONGOING CARE COORDINATION - CASE MANAGEMENT AND MONITORING

7.4 DISCHARGE/TRANSITION TO OTHER SERVICES

7.5 PATIENT PARTICIPATION

8. HOME TELEHEALTH TECHNOLOGY PLATFORMS-VA APPROVED

8.1 TELEHEALTH TECHNOLOGY ORDERING, INVENTORY AND SUPPORT

8.2 DENVER LOGISTICS CENTER

8.3 MATCHING TECHNOLOGIES TO CLINIC NEED

Home Telehealth Operations Manual - July 2019 Page ii

D.13 Home Telehealth Operations Manual 36C24621R0068

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

8.5 TECHNOLOGY USER GROUP

9. DISEASE MANAGEMENT PROTOCOLS (DMPS)

9.1 DISEASE MANAGEMENT PROTOCOL PROCESSES

10. DOCUMENTATION STANDARDS

10.1 DOCUMENTATION OF CASE MANAGEMENT ACTIVITIES

10.2 THE HOME TELEHEALTH CONSULT REFERRAL

10.3 ASSESSMENT TREATMENT PLAN AND TECHNOLOGY EDUCATION NOTES

10.4 ONGOING DOCUMENTATION

11. WORKLOAD CAPTURE AND DATA MANAGEMENT

11.1 CODING AND WORKLOAD CREDIT

11.2 COMPLETING THE ENCOUNTER INFORMATION

11.3 VETERANS EQUITABLE RESOURCE ALLOCATION (VERA) FOR HOME TELEHEALTH

11.4 CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE DEPARTMENT OF VETERANS AFFAIRS (CHAMPVA) – NON-

COVERAGE FOR REMOTE MONITORING

12. QUALITY MANAGEMENT

12.1 CONDITIONS OF PARTICIPATION

12.2 PROCESS AND PERFORMANCE IMPROVEMENT

12.3 DOCUMENTATION/PROCESS OF CARE DOCUMENTATION AUDIT

13. RISK MANAGEMENT

14. INFORMATION OUTREACH

15. POLICY

15.1 PRIVACY

15.2 MANAGING VA-ISSUED TECHNOLOGY WHEN VETERANS GEOGRAPHICALLY RELOCATE

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

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

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

Home Telehealth Operations Manual - July 2019 Page iii

D.13 Home Telehealth Operations Manual 36C24621R0068

List of Tables Table 1: Resources and Links ................................................................................................................................................... A-1 Table 2: Table of Acronyms..................................................................................................................... ..................................B-1

List of Figures Figure 1: Home Telehealth Clinic Pathway Diagram Figure 2: Home Telehealth Quality Improvement and Patient Safety

Home Telehealth Operations Manual - July 2019 Page iv

D.13 Home Telehealth Operations Manual 36C24621R0068

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

Office of Health Informatics: Connected Care/Telehealth

Office of Patient Care Services

VISN Leadership

Facility Leadership

Home Telehealth Master Preceptors

Home Telehealth Operations Manual - July 2019 Page v

D.13 Home Telehealth Operations Manual 36C24621R0068

Document Version History Responsible Office

The development and maintenance of this document is the responsibility of the Veterans Health Administration (VHA), Office of Health Informatics: Connected Care/Telehealth. Proposed changes to this document should be submitted to Catherine.Buck@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

8 Quarterly Update 6 Patient Participation 70% requirement at least over 90 days

12 Employee Education System link not hyperlinked

15 Co-morbidities for DMPs and category of care for

Weight Management

23 Adding provider reviewing data for Home

Telehealth: The Basics education requirement

April 2017

26 Patient Participation 70% requirement at least over

90 days

29 Returned Merchandise Authorization Process

33 Home Telehealth Reporting of IT issues

34 HEALTH PROMOTION/DISEASE

PREVENTION & standalone prevention DMPs;

Weight Management co-morbid & category of care

VA Provider vs VA PCP mailto:Catherine.Buck@va.gov

Home Telehealth Operations Manual - July 2019 Page vi

D.13 Home Telehealth Operations Manual 36C24621R0068

Effective Date Page Description

Closing CCHT consults to be in compliance with Directive 1232: Consult Processes & Procedures;

37 CHOICE Program

Clarifying co-signing vs additional signer

Recommendations for reducing duplication of efforts for assessment documentation requirements for Home Telehealth 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 Home Telehealth Mental Health User

A-1 Guide to list of attachments

Add vetted Pain Management Toolkit to list of attachments

9 December 2017 4 Minor spelling correction

13&31 Adjusted content to reflect Home Telehealth video terminology

28 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, Veterans Equitable Resource Allocation status, and changes that may have occurred.

Return Merchandise Authorization (RMA) changed

38-39 to reflect new Home Telehealth Equipment

Contract

New DMP Process changes as communicated via

National Alert Email

41 Content addition on reviewing daily alerts

Home Telehealth Operations Manual - July 2019 Page vii

D.13 Home Telehealth Operations Manual 36C24621R0068

Effective Date Page Description

Addition of content related to Home Telehealth

Consult Referrals

Updated content for the Initial Assessment &

Treatment Plan Note

Enrollment Agreement is now required to support

44 documentation of Veteran’s rights & responsibilities for Home Telehealth Program

Updated content for Continuum of Care Form Note

46 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

49-50 & Office Encounter to Home Telehealth Note. New content added

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

55 Deletion of Patient Self-management courses

63-64

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 Clinic Reminders and Dialog document to

Resource Table #1

Home Telehealth Operations Manual - July 2019 Page viii

D.13 Home Telehealth Operations Manual 36C24621R0068

Effective Date Page Description

10 June 2019 All

Pages

Updated grammar and language to be consistent within document and to better align with current

VA nomenclature

Provided new background information in

Introduction to Home Telehealth

Updated goals in Definition of Home Telehealth

Added fifth category of care, updated existing categories of care

Added resources to help determine feasibility and sustainability of programs

Updated Collaboration with MOVE! to clarify use of categories of care and co/tri-morbid DMPs

Added clarification about Program Support staff requirements for visits to Veterans’ homes

Added note about forthcoming decentralization of

Preceptor Programs

Updated Home Telehealth Process of Care image and description

Added sections for Enrollment of Veterans into

Home Telehealth

Updated Discharge section and added Patient

Participation section

Updated list of Technologies approved for use

Added guidance for use of Home Telehealth Tech

Education, updated RMA procedures

Clarified TeleMOVE exception to standard DMP requirements

Home Telehealth Operations Manual - July 2019 Page ix

D.13 Home Telehealth Operations Manual 36C24621R0068

Effective Date Page Description

38 Provided updated list of Standardized DMPs

41 Added new Categories of Care to Documentation section

43 Reorganized Consult Guidance section to flow better

48 Revised guidance for Discharge notes

52 Added section for Civilian Health and Medical

Program

53 Updated Conditions of Participation section

60 Added Policy section with guidance on Privacy and

Managing VA-Issued Technology When Geographically Relocate

11 July 2019 17 Added a reference to VHA Directive 1108.13

22 Updated decentralization to refer to both VISN and local levels

23 Updated training terminology

27 Clarified that meeting Veteran needs includes caregiver needs

37 Clarified who is responsible for reviewing vendor-developed DMPs

39 Clarified use of Co-morbid and Tri-morbid DMPs

45 Updated frequency of caregiver burden assessments

Clarified that CHAMPVA patients are currently not eligible for Home Telehealth enrollment

Clarified timeframes for reviewing Veteran data

Home Telehealth Operations Manual - July 2019 Page 1

D.13 Home Telehealth Operations Manual 36C24621R0068

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 Home Telehealth and ensure the efficiency, quality and sustainability of these services.

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

The Home Telehealth Operations Manual is meant to complement existing VHA clinic 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 Home Telehealth 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 Home Telehealth 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 Training Team within the Office of Health Informatics: Connected Care/Telehealth 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 the Office of Health Informatics: Connected Care/Telehealth prior to approval and publication.

1.3 Audience

Although much of the content of this Operations Manual may be pertinent to Home Telehealth operations outside of VHA, this document is a resource developed solely for internal VHA Home Telehealth programs. The intended audience is VISN Telehealth

Home Telehealth Operations Manual - July 2019 Page 2

D.13 Home Telehealth Operations Manual 36C24621R0068 leadership, Facility Telehealth Coordinators, Lead Care Coordinators, Care Coordinators and administrative/technical staff, Telehealth practitioners and VHA staff that provide management and/or support to Home Telehealth Programs.

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. The mission of Telehealth Services is to utilize health informatics, disease management, care/case management, and Telehealth technologies to facilitate access to care and improve the health of Veterans with the intent to provide the right care in the right place at the right time. 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 and has become mission critical to the future direction of VA care to Veterans.

The term “Home Telehealth” applies to the use of telecommunication technologies to provide clinic 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. The Home Telehealth Operations Manual focuses on care that primarily occurs between the Veteran in his or her place of residence and a VA Non-Institutional Care setting. Home Telehealth also occurs in other settings and, with the addition of mobile technologies such as Interactive Voice Response systems and “Browser” or web-enabled technologies, Home Telehealth can take place almost anywhere a Veteran chooses.

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 remote patient monitoring, messaging and/or video technologies. The best candidates for these programs and activities are Veterans who are in post-acute care settings, high-risk Veterans with chronic disease or Veterans at risk for institutional long-term care. The goal of Home Telehealth 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;

Home Telehealth Operations Manual - July 2019 Page 3

D.13 Home Telehealth Operations Manual 36C24621R0068

• High-risk Veterans with chronic disease;

• Veterans at risk for institutional long-term care; and

• Veterans that would benefit from additional health promotion and disease prevention activities.

Home Telehealth provides non-urgent/non-emergent care and case management that also includes tracking and trending vital signs and other biometric data and symptoms.

The essence of Home Telehealth 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 and the healthcare system to enable timely care. Use of Home Telehealth 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 Home Telehealth and a core component of the Home Telehealth model which includes active care and case management. Case management paired with technology increases patient satisfaction, improves outcomes and enhances management of chronic disease through collaboration between the Veteran, the Home Telehealth 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 Home Telehealth 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. Home Telehealth 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 Home Telehealth 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 Home Telehealth throughout the continuum of care has been a major undertaking for VHA, and has resulted in evidence of positive clinical outcomes 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

Home Telehealth Operations Manual - July 2019 Page 4

D.13 Home Telehealth Operations Manual 36C24621R0068

• Improved clinical outcomes

• Improved Veteran and provider satisfaction

• Making Veterans’ homes 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 Home Telehealth model.

A cornerstone of the Home Telehealth model is the adoption of the principles of Wagner's Chronic Care Model1.

The Wagner Chronic Care Model

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

In 2003, five additional themes were incorporated into the Wagner 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 Home Telehealth Model was developed in 2003, the Wagner Chronic Care Model was used as a foundation for identifying Veterans who would most benefit from services.

Home Telehealth 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 Home Telehealth 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

The Model for Home Telehealth was developed based on the following principles:

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 - July 2019 Page 5

D.13 Home Telehealth Operations Manual 36C24621R0068

• 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 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 (e.g., for chronic disease management)

The Home Telehealth 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 Home Telehealth are as follows:

• Screening

• Assessment

• Care planning

• Intervention

• Evaluation

Upon enrollment in the Home Telehealth program, all patients are given instructions on how to reach a health care professional (e.g., nurse line) after normal work hours or for an emergency at any time during the day. Based on their judgement when symptoms are being experienced, Veterans are to continue to seek emergency medical assistance using their community resources (e.g., Emergency Room, 911) as they did prior to enrollment in Home Telehealth. Home Telehealth is not a program that provides care and case management 24 hours per day, 7 days per week.

In general, Home Telehealth programs operate on a Monday through Friday work week, during routine business hours. Data transmitted to and from patients using Home Telehealth technologies over a weekend or holiday is reviewed by Care Coordinators on the next standard workday. In addition, the model for Home Telehealth 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 electronically received.

Patient Populations and Categories of Care

The Home Telehealth 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.

Home Telehealth Operations Manual - July 2019 Page 6

D.13 Home Telehealth Operations Manual 36C24621R0068

In 2007, Office of Health Informatics: Connected Care/Telehealth developed four categories of care in which Veterans enrolled in Home Telehealth are placed. All patients must be placed in the appropriate Category of Care based on a formal assessment of individual patient health status. On March 12, 2018, a fifth category of care was released, Non- Institutional Care Low Responder. Until that time, Veterans not responding regularly were placed in the Health Promotion and Disease Prevention Category of Care due to the daily response requirement for Veteran Equitable Resource Allocation (VERA) reimbursement.

During the panel size calculator study, data showed that Veterans who met the Non- Institutional Category of Care but did not meet the daily response requirement required the same amount of case management workload as Non-Institutional Care Veterans who were responding daily. Therefore, to appropriately capture that workload without impacting VERA reimbursement, the Non-Institutional Care Low Responder (NICLR) Category of Care was developed. The five categories of care and their explanations are below:

• Non-institutional Care: Must meet Non-Institutional Care criteria based on the administration of the Continuum of Care Form. To meet Non-Institutional Care requirements a Veteran must have one of the following:

▪ Deficits in three or more Activities of Daily Living (ADL); or

▪ One or more behavioral/cognitive deficits; or

▪ Expected life limit of less than six months.

o If the Veteran does not meet the Non-Institutional Care requirements above, then they can also be categorized as Non-Institutional Care by:

▪ Having two or more ADL deficits; and

▪ Meeting two of the following requirements:

• Having three or more Instrumental Activities of Daily Living (IADL) deficits; or

• Being age 75 or older; or

• Living alone in the community; or

• Having 12 or more clinic stops in the past 12 months.

o If assigned a health promotion DMP such as Weight Management, it must be a co-morbid DMP. If any clinical needs fall outside a Care Coordinator’s scope of practice (i.e., Registered Dieticians or Social Workers), collaboration with an RN Care Coordinator must occur to ensure all aspects of that Veteran’s co-morbid needs are appropriately managed.

• Non-Institutional Care Low Responder (NICLR) o Must meet the same criteria for Non-Institutional Care described above.

o Has been enrolled in Home Telehealth for at least three months (to properly assess and address regular participation).

o Does not meet the patient participation guidelines of 70% response over three consecutive months.

o Veterans assigned NICLR are included in any quality indicators or performance measures that focus on Non-Institutional Care.

Home Telehealth Operations Manual - July 2019 Page 7

D.13 Home Telehealth Operations Manual 36C24621R0068 o Veterans assigned NICLR are not included in Veteran Equitable Resource Allocation reimbursement at this time.

• Chronic Care Management o Does not meet Non-Institutional Care criteria but must meet both below criteria for Chronic Care Management based on administration of the Continuum of Care Forum:

o Diagnosis of one or more chronic illnesses amenable to Home Telehealth; and o Requires on-going intensive case management, monitoring and intervention.

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

• Health Promotion/Disease Prevention 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 and cannot be qualified as NICLR since they do not meet the Non-Institutional Care requirements on the Continuum of Care Form.

2.4 History of VA Home Telehealth

Connected Care/Telehealth Services, within the VHA Office of Health Informatics and Analytics 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. Connected Care/Telehealth Services’ 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.

Connected Care/Telehealth Services 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. Connected Care/Telehealth Services 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 Connected Care/Telehealth Services to incorporate Telehealth and disease management technologies into routine practice.

• Working alongside or embedded within Patient Aligned Care Teams and other VA programs, clinicians, educators and patient groups to assist patients in easy access

Home Telehealth Operations Manual - July 2019 Page 8

D.13 Home Telehealth Operations Manual 36C24621R0068 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 Connected Care/Telehealth Services to provide innovation and secure technology.

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

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

Making the home the preferred place of care maintains the caregiver in a pivotal position in the care delivery process. Connected Care/Telehealth Services, 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 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 a continuum including clinic-based, home and mobile patient settings, as well as synchronous and asynchronous modalities of clinical service delivery.

VISN and Station-Level Infrastructure and Oversight of Home

Telehealth

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

National-Level Infrastructure and Oversight

Home Telehealth Operations Manual - July 2019 Page 9

D.13 Home Telehealth Operations Manual 36C24621R0068

Connected Care/Telehealth Services provides guidance and support for Home Telehealth Programs through its national Home Telehealth Lead and Clinic Nurse Analyst, National Development and Telehealth Training 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 Home Telehealth Services through the Conditions of Participation which can be found under the Condition of Participation category on the Telehealth SharePoint.

3. Planning and Expanding Home Telehealth Programs

Developing a business plan is essential to implementing new programs or expanding existing Home Telehealth 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 Home Telehealth programs integrate technology and case management with clinical program needs. The primary components of planning for integrated Home Telehealth programs are:

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

• A strong business case which includes an analysis of the return on investment and plan for sustainability, which are essential foundational elements for Home Telehealth program development. This is discussed in detail in Chapter 4.

• A plan for integrating Home Telehealth services across the Continuum of Care.

4. Business Case Development

A business case analysis addresses, at a high level, the business needs 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 reduction costs

• Funding allocations received based on workload that is generated by the program, such as the VERA. The VERA is based on enrollments in Non-Institutional Care and Chronic Care Management categories of care.

https://vaww.infoshare.va.gov/sites/telehealth/docs/sop-qd-r.docx https://vaww.infoshare.va.gov/sites/telehealth/docs/Forms/cop.aspx https://vaww.infoshare.va.gov/sites/telehealth/docs/Forms/cop.aspx http://vaww.infoshare.va.gov/sites/telehealth/docs/Gap_Exam.pdf http://vaww.infoshare.va.gov/sites/telehealth/docs/Gap_Exam.pdf

Home Telehealth Operations Manual - July 2019 Page 10

D.13 Home Telehealth Operations Manual 36C24621R0068

Things to consider when developing the budget proposal:

• Perform a needs assessment for Home Telehealth Services at VISN and/or facility level

• Identify necessary resources (e.g. 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 Home Telehealth program

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

• National Telehealth Training Team

• VISN Telehealth Program Managers

• VISN Leads Council

• VHA Telehealth Intranet site

4.1 Needs Assessment

Strategic planning provides a structure to guide in developing or expanding a Home Telehealth 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 Home Telehealth

• Costs of providing care via Home Telehealth 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 Home Telehealth 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 Home Telehealth.

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) http://vaww.telehealth.va.gov/pgm/ht/index.asp http://vaww.infoshare.va.gov/sites/telehealth/Lists/leads/default.aspx http://vaww.telehealth.va.gov/

Home Telehealth Operations Manual - July 2019 Page 11

D.13 Home Telehealth Operations Manual 36C24621R0068

• Documented problems in meeting the needs of a group of patients (such as distance and travel barriers, no-shows, 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 Home Telehealth 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 Home Telehealth?

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

• Performance measures: What performance measures will Home Telehealth assist?

• Space and resources available: Is there appropriate space to expand Home

Telehealth?

• Staffing needs: What clinic and other staff will be necessary to expand Home

Telehealth?

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

• Technical considerations: What types of Home Telehealth 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 Home Telehealth.

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 Home Telehealth 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 Home Telehealth 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 Home Telehealth Enrollment Goals and Panel Size

Home Telehealth Operations Manual - July 2019 Page 12

D.13 Home Telehealth Operations Manual 36C24621R0068

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, scope of practice, and the complexity of care and intensity of service needs for the patients in the panel (case mix).

Historically, panel sizes in the Home Telehealth program have a Veterans Equitable Resource Allocation (VERA) of approximately 100-110 patients per Care Coordinator, but since 2014, panel sizes average 80-100. In 2014, Telehealth Services chartered a national Panel Size Workgroup to do a thorough analysis of appropriate panel size. 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-clinic 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 Coordinators’ 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 Connected Care/Telehealth Services, will help leadership and Home Telehealth 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 rationale in place to justify current/target panel sizes for all Home Telehealth staff.

4.3 Space Planning for Home Telehealth

The square footage needed for a Home Telehealth 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 Home Telehealth staff members are conducting enrollment visits within the same space, privacy considerations need to be addressed to ensure 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 Home Telehealth 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 Home Telehealth 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

Home Telehealth Operations Manual - July 2019 Page 13

D.13 Home Telehealth Operations Manual 36C24621R0068

“Right Care at the Right Place at the Right Time”. Telework has been successfully implemented as an option for Home Telehealth in several VISNs. For more information regarding VHA Telework, including Talent Management System (TMS) training for supervisors and supervisees, see Employee Education Service.

4.4 Deploying and Managing Home Telehealth Programs

There are several factors that should be considered when utilizing Home Telehealth services; such as whether to expand existing Home Telehealth programs, establish a new one, or create a combination thereof which will meet the needs of the patient population(s) to be served. Once the implementation or expansion plan has been developed and agreed to by all stakeholders, the VISN Telehealth Program Manager or Home Telehealth 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 Home Telehealth is how to ensure integration with other services so that the care coordination provided by the Home Telehealth program can be most effective and efficient for all members of the healthcare team; most importantly, the patient. Home Telehealth is a very flexible program and its integration within the healthcare system can take place with many variations and via multiple mechanisms. Even with its flexibility, this integration for Home Telehealth 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.

• 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 Home Telehealth Program embedded in the Mental Health Outpatient Clinic.

In either case, it is important that the Home Telehealth 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, clinic protocols are approved for standardized plans of care and/or clinic interventions. The next several sections describe some of the more frequent options employed for integrating Home Telehealth programs.

Integrating Home Telehealth with Other Services

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

Home Telehealth Operations Manual - July 2019 Page 14

D.13 Home Telehealth Operations Manual 36C24621R0068

Home Telehealth has been successfully affiliated with Patient-Aligned Care Teams, Health Promotion programs (e.g., MOVE!), Home-Based Primary Care, and Mental Health. Effective communication by the Home Telehealth 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 patient monitoring and case management with the face-to-face care provided by each patient’s interdisciplinary team to optimize transitions between inpatient and outpatient care, facilitate specialty care, and optimize patient education and incorporate services such as Patient Aligned Care Teams, Home Based Primary Care, 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 Patient Aligned Care Teams 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.

• Maintain documentation on the patient. Focus communication activities on the provider and the RN Care Managers in the interdisciplinary team. Formally share outcome data and performance improvement approaches with the team.

• 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 Veterans. 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 Home Telehealth implementation supplements such as for TeleMOVE!, Mild Traumatic Brain Injury, and Spinal Cord Injury DMPs.

4.4.1.1 Integration with Patient Aligned Care Teams

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

Home Telehealth Operations Manual - July 2019 Page 15

D.13 Home Telehealth Operations Manual 36C24621R0068

VHA’…