D.20 - Remote Patient Monitoring- Home Telehealth Manual.pdf

VA Telehealth

Remote Patient Monitoring- Home Telehealth Manual (Updated July 2023)

1. Introduction to Remote Patient Monitoring – Home Telehealth

Remote patient monitoring (RPM), according to the American Telemedicine Association, is the collection, transmission, evaluation, and communication of individual health data from a patient to their health care provider or extended care team from outside a hospital or clinical office (e.g., from the patient’s home) using personal health technologies such as wireless devices, wearable sensors, implanted health monitors, smartphones, and apps.

In the U.S. Department of Veterans Affairs (VA), a related term, Remote Patient Monitoring – Home Telehealth (RPM – HT), applies to the use of telecommunications technologies to provide clinical care and promote patient self-management as an adjunct to traditional in-person health care. With RPM – HT, health information is exchanged from the Veteran’s home or another location to the VA care setting, easing the constraints of time and distance.

Systematically implementing RPM – HT throughout the continuum of care has been a major undertaking for the Veterans Health Administration and has produced evidence of positive clinical outcomes and improvements in 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 for medical care.

• Improved clinical outcomes.

• Improved Veteran and provider satisfaction.

• Making Veterans’ homes the preferred place of care, when appropriate.

VA national clinical programs included under the umbrella of RPM – HT are the RPM – HT program (also known as Home Telehealth [HT]) and the Low Acuity/Low Intensity Home Telehealth (L2) Program. In addition to these programs, there are helpful tools such as Annie and other VA mobile apps.

The Office of Connected Care Telehealth Manual contains policies, procedures, and guidance related to telehealth. It guides readers through the steps of fully implementing, managing, and evaluating a telehealth program. This Remote Patient Monitoring – Home Telehealth Manual focuses on care that occurs primarily between the Veteran in their current location and their Care Coordinator.

Note: In this manual, the term Remote Patient Monitoring – Home Telehealth includes both the RPM – HT and the L2 programs unless otherwise specified.

https://vaots.blackboard.com/bbcswebdav/users/kathy.lawrence4@va.gov

1.1. Remote Patient Monitoring – Home Telehealth Program

In VA, the RPM – HT program is defined as a program 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, video technologies, or a combination of these. Veterans must be enrolled in RPM – HT to participate in the program.

The best candidates for RPM – HT are Veterans who are in post-acute care settings, high-risk Veterans with chronic disease, and Veterans at risk for institutional long-term care. The goal of RPM – HT is to improve clinical outcomes and access to care while reducing complications, hospitalizations, and clinic or emergency room visits.

RPM – HT provides nonurgent, nonemergency care and case management that includes tracking and trending vital signs and other biometric data and symptoms.

The essence of RPM – HT, as implemented in VA, is ongoing assessment, monitoring, patient education, health coaching, and case management of Veterans in their place of residence and the provision of appropriate information to the Veterans’ patient-aligned care teams (PACTs) or specialty care teams, as well as the health care system, to enable timely care. Use of remote patient monitoring has the potential to reduce clinical complications and the use of health care resources that health complications may consume. Case management paired with technology increases patient satisfaction, improves outcomes, and enhances management of chronic disease through collaboration between the Veteran, the RPM – HT clinician (i.e., the Care Coordinator), and the Veteran’s health care team, using an interdisciplinary approach.

In 2019, VHA endorsed the Care Coordination & Integrated Case Management (CC&ICM) Model and issued VHA Directive 1110.04(1), “Integrated Case Management Standards of Practice,” which outlines integrated case management standards of practice for all professions performing case management. (NOTE:This is an internal VA site that is not available to the public.) To provide further information on the CC&ICM framework, VHA created the Care Coordination & Integrated Case Management (CC&ICM) Portal to address fragmentation, variation, and gaps in care by introducing a systemwide, integrated care coordination framework. (NOTE:This is an internal VA site that is not available to the public.) Each VA Medical Center will determine how the program will be structured at its location. Because of the RPM – HT program’s long history in providing case management services, local RPM – HT programs are encouraged to reach out and participate in dialogues that occur at their facilities so that Veterans can benefit from Care Coordinators’ expertise in this area.

RPM – HT is not intended to replace or duplicate other care management or case management activities. Rather, the use of health coaching, disease management, and health informatics technologies in remote patient monitoring enhances and extends current VA care and case management activities into non-VA settings, including Veterans’ homes, for those not otherwise provided with such services. It is important that these technologies be applied in a safe, efficient, and cost-effective manner. The interdisciplinary and standardized approach https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8489 https://vaww.va.gov/vhapublications/ViewPublication.asp?pub_ID=8489 https://dvagov.sharepoint.com/sites/VHACMSWS/CMI_Taskforce/ICM_Toolkit/GovernanceCouncil/Communications https://dvagov.sharepoint.com/sites/VHACMSWS/CMI_Taskforce/ICM_Toolkit/GovernanceCouncil/Communications taken by VA’s RPM – HT program means that it can be applied across a variety of services and Veteran circumstances where combining services will enhance care to Veterans but not duplicate care.

RPM – HT programs operate on a Monday through Friday workweek, during routine business hours. Data transmitted from Veterans over a weekend or a holiday is reviewed by the Care Coordinators on the next business day. In addition, RPM – HT does not require or expect that data will be reviewed immediately upon receipt, even within those normal work hours. Care Coordinators will review data at least once daily; however, depending on when the data arrives and the Care Coordinator’s review schedule, data may not be reviewed on the day it was electronically received.

Care Coordinators may choose to reach out to their panel of Veterans directly, due to alerts, or as they deem necessary or desirable. Contact may be by telephone, video, or a face-to-face visit. If a Care Coordinator uses either telephone or video visits, they must comply with the training, encounter, coding, and visit requirements for these methods of contact. For current information on VA Video Connect, visit the VA Video Connect intranet page (NOTE:This is an internal VA site that is not available to the public) and the VA Video Connect (VVC) Community on Connected Care Academy.

The usual Veteran requirement for participation in the RPM – HT program is daily response to questions in the disease management protocol (DMP) and input of vital-sign and other biometric data.

1.2. Low Acuity/Low Intensity Home Telehealth Program (L2

Program)

The L2 Program is a recognized national program under the Remote Patient Monitoring – Home Telehealth umbrella that extends services of the existing VHA RPM – HT program to Veterans who have stable health conditions (low acuity) that do not require frequent interventions (low intensity). This program was fully implemented as an extension of RPM – HT; it also integrated mobile apps. The goal of the L2 Program is to use the Veteran’s own devices, such as computers, tablets, or cellphones unless the need to issue technology is clearly indicated. In certain instances it may be appropriate for Veterans to use a hub device to participate in the L2 program such as when a Veteran is transitioning from HT to L2. L2 is for Veterans who would benefit from patient education, whole health coaching, patient self-management, and appropriate input from health care professionals for management of symptoms and behaviors.

The L2 Program also aims to provide these Veterans with knowledge about their chronic conditions (or conditions at risk of developing into chronic conditions that could lead to avoidable deteriorations), as well as improving their health and reducing outpatient visits.

The L2 Program focuses on Veterans’ self-care, with Care Coordinators providing education, coaching, and resources on disease management, health promotion, and disease prevention;

https://vaww.telehealth.va.gov/pgm/vvc/index.asp#fundamentals https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2591_1 https://vaots.blackboard.com/webapps/login/?action=guest_login&new_loc=%2Fwebapps%2Fblackboard%2Fexecute%2Flauncher%3Ftype%3DCourse%26id%3D_2591_1 however, L2 Care Coordinators will provide care management interventions, in collaboration with the PACT, when deemed clinically appropriate and necessary.

In L2, Veterans are encouraged to identify self-care goals and report progress on these goals to the Care Coordinator. Where traditional RPM – HT focuses on comprehensive case management, the L2 Program features the Care Coordinator as a partner or coach in patient self-management using the Whole Health Model. L2 DMP responses, including biometric data, are reviewed on a weekly basis at a minimum and calls will be made as clinically indicated.. The usual Veteran requirement for participation is completion of one to two sessions per week. The exception is for Veterans enrolled for L2 Weight Management, where the aim is daily session completion, which has been shown to improve overall outcomes.

1.3. Annie, Mobile Apps, Wearables, and Peripherals

Remote patient monitoring technologies, such as Annie and other apps, wearables, and peripherals, can collect and, often, send health data. Apps have been developed both by VA and by the private sector.

Annie is a secure VA text messaging service that empowers Veterans to take an active role in their health care by sending various automated self-care reminders. Messages from Annie can include medication reminders, tips for reducing stress, instructions for health care appointments, and more. Information that is sent to Annie is available for the cliical team, however is not regularly monitored. Text messaging responses and graphs of the measurements over time can be viewed online by both Veterans and Clinicians. To learn more, you can go to Annie for Veterans or Annie for Clinicians in the VA App Store.

The best resource for learning about available web and mobile apps is the VA App Store. These applications and other tools can be used and promoted by all VA staff. The primary goal of the Office of Connected Care is to offer a variety of supportive tools to meet Veteran needs at all levels of their health care. Annie is for Veterans self-care and RPM – HT is for Veterans who need monitoring by VA Healthcare Professionals. The RPM – HT program provides Veterans with care and case managment. A relationship is developed between a Veterans and VA Health Care Professionals. Additionall,y in the RPM – HT program, Care Coordinators monitor the responses generated through the technologies.

1.4. My HealtheVet

My HealtheVet is a patient portal that offers a suite of tools designed to help Veterans and caregivers manage the Veterans’ care, contact their providers, and access health information, as well as helping with various care needs, such as appointments and medication refills. The portal is accessed through a computer, tablet, or cellphone. My HealtheVet has many benefits, including tools that encourage Veterans to gain a better understanding of their health, monitor and improve their health status, and improve communication with their health care team. In https://www.va.gov/wholehealth/ https://mobile.va.gov/app/annie-app-veterans https://mobile.va.gov/app/annie-app-clinicians https://mobile.va.gov/appstore/ https://mobile.va.gov/appstore/ https://www.myhealth.va.gov/mhv-portal-web/home addition, Veterans can review upcoming appointments, schedule or cancel appointments, and view their medical record wherever they have internet access. With a premium My HealtheVet account, Veterans can also send secure email messages to their care team. The My HealtheVet portal also contains a library of health materials developed with Veterans in mind.

2. The Remote Patient Monitoring - Home Telehealth Framework

Systematically implementing Remote Patient Monitoring-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

• Improved clinical outcomes

• Improved Veteran and provider satisfaction

• Making Veterans homes the preferred place of care when appropriate

VHA has expanded the Remote Patient Monitoring – Home Telehealth framework based on data on the incidence and prevalence of various chronic diseases. Models that have influenced this framework include the Wagner Chronic Care Model and the Whole Health Model.

2.1. The Wagner Chronic Care Model

A cornerstone of the Remote Patient Monitoring – Home Telehealth framework is the adoption of the principles of the Wagner Chronic Care Model. This model was selected in 2003 as a framework for the RPM – HT program because it embodies the essential elements of a health care system that encourages 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, the elements foster productive interactions between informed Veterans, 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, which makes it an ideal foundation for a remote patient monitoring program. The bottom-line goals are to heal Veterans, 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).

• Case management (in delivery-system design).

In 2015, the Wagner Chronic Care Model was again used as a framework for the L2 Program.

The RPM – HT and L2 programs and their strategies fit well with the Wagner Chronic Care Model. RPM – HT staff play a fundamental role in coordinating care, educating Veterans, building self-management skills, and applying care and case management strategies to effectively monitor, and intervene to assist, the Veteran. These roles and responsibilities have focused on helping Veterans become more actively involved in their own health care decisions.

Knowledgeable Veterans, combined with advocacy by the Care Coordinators, create a more Veteran-centric environment.

2.2. Remote Patient Monitoring - Home Telehealth Framework:

Principles and Process

The framework behind Remote Patient Monitoring – Home Telehealth was developed based on the following guiding principles:

• Make the Veteran’s home and local community the preferred place of care, when appropriate.

• Focus on Veterans with the highest levels of health care service utilization.

• Provide case management for Non-Institutional Care (NIC) Veteran patients and their caregivers.

• Promote improved patient self-management and knowledge of chronic disease states.

• Provide patient education and health coaching to promote healthy behaviors.

• Provide patient navigation support and advocacy throughout the health care system to meet Veterans’ health care needs (e.g., for chronic disease management).

In 2014, VA created its Whole Health Model, which was inspired by remarks by Donald Berwick, the co-founder of the Institute for Healthcare Improvement, which called on leaders of the nation’s hospitals and medical delivery organizations to engage “new rules for radical redesign of health care.” From this inspiration, a whole health and Veteran-centric care model that focuses on what matters to Veterans, not what is the matter with them, was born. This means the health care team gets to know each Veteran as a person before working with them. This helps staff develop a personalized health care plan that is based on the Veteran’s values, needs, and goals. The major approach taken with this model is patient health coaching.

Figure 1.VA Whole Health Model

This model has been integrated into RPM – HT and is the primary purpose of the L2 Program.

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

• Screening

• Assessment

• Care planning

• Intervention

• Evaluation

3. Patient Populations and Categories of Care

From its inception, RPM – HT has focused on enrolling complex, high-risk Veterans. Outcomes showed improvements in Veteran self-care, reductions in hospitalizations, reductions in bed days of care, and improved access to care. In VHA, Geriatrics and Extended Care (GEC) programs focus on this population and the many Veterans that need home- and community-based extended care services. These Veterans are classified in the Non-Institutional Care (NIC) category of care. These extended care programs strive to keep Veterans out of hospitals, assisted living facilities, and nursing homes by providing them and their caregivers with an array of services. In 2003, RPM – HT was formally included as one of the nine NIC programs within the home- and community-based extended care services that GEC offers. The goal of the RPM – HT program has been to serve the NIC population. The expectation is that these Veterans will be monitored daily. This expectation, in turn, drove the requirement that Veterans respond daily in order to be classified as NIC. To determine NIC classification, the RPM – HT program adapted a screening tool taken from a larger geriatric and extended care questionnaire used at that time to determine extended care needs. This tool, called the Continuum of Care Form (CCF), is discussed later in this manual. Veterans enrolled in RPM – HT who qualify as NIC are eligible for Veterans Equitable Resource Allocation (VERA) allocation, as discussed in more detail in Section 15, Workload Capture and Data Management, in this manual. (NOTE:This is an internal VA site that is not available to the public.)

In addition to the NIC category of care, there are five other categories used to classify Veterans based on clinical need. The six categories are:

• Non-Institutional Care (NIC)

• Chronic Care Management (CCM)

• Acute Care Management (ACM)

• Health Promotion/Disease Prevention (HP/DP)

• Low Acuity/Low Intensity (L2)

• Non-Institutional Care – Low Responder (NICLR)

Chronic Care Management is for Veterans who do not meet NIC criteria but have one or more chronic illnesses that might benefit from RPM-HT care.

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Acute Care Management is for short-term clinical need such as but not limited to postoperative care, transitional management, or post hospital care with enrollments being 6 months or less.

This level of care has seldom been used, the exception being its use during the COVID Pandemic when Veterans were enrolled for ACM. (Note: ACM is not included in VERA.)

Health Promotion/Disease Prevention is for Veterans who primarily need health promotion, disease prevention, self-management, are stable and are assigned DMPs specifically for health promotion such as TeleMove, Other Veterans may have this classification based on response rates see guidance document

Low Acuity/Low Intensity category is used for Veterans enrolled in the L2 program. A CCF is not completed.

The sixth category of care, NICLR, was released on March 12, 2018. Until that time, Veterans not responding regularly were placed in the Health Promotion/Disease Prevention category of care due to the daily response requirement. However, this classification did not allow these Veterans to be counted in the NIC enrollment performance measure (Tele 10). In addition, it was learned that the RPM – HT Panel Size Calculator (described below) identified that nonresponding and partially responding patients required the same amount of case management. The new NICLR level of care captures the workload of NIC patients who don’t respond daily; however, these patients do not receive VERA allocation because they do not meet the daily response requirement. (NOTE:This is an internal VA site that is not available to the public.)

4. Getting Started: VISN-and Station-Level Infrastructure and Oversight

The VISN-level infrastructure begins with a Telehealth Program Manager or VISN Lead who has the responsibility and authority to guide, govern, strategically plan, deploy, and operate all telehealth programs, including Synchronous Telehealth (previously, Clinical Video Telehealth [CVT] /VA Video Connect), Asynchronous Telehealth (previously, Store-and-Forward Telehealth), and Remote Patient Monitoring – Home Telehealth, which includes L2. In some cases, an RPM – HT Program Manager is appointed to provide this oversight because RPM – HT is one part of the telehealth continuum and must be integrated into an overall telehealth organizational matrix.

The station-level infrastructure includes the Facility Telehealth Coordinator (FTC), who oversees all Connected Care and Telehealth Services at a facility. The station-level infrastructure lead for RPM – HT is the Lead Care Coordinator, who oversees the program and works collaboratively with the VISN Lead and the local FTC. Many programs also have a program manager, who works collaboratively with both the FTC and the RPM – HT Lead.

https://vaots.blackboard.com/bbcswebdav/xid-605034_1 http://vaww.arc.med.va.gov/

For information on national-level infrastructure and oversight, see the Telehealth Manual.

4.1. Planning and Expanding Remote Patient Monitoring -

Home Telehealth Programs

For detailed information on planning and expanding programs, see Section 6, Getting Started, in the Telehealth Manual.

4.2. Remote Patient Monitoring - Home Telehealth Programs

Enrollment Goals and Panel Size

Establishing appropriate panel sizes should be part of the process when determining which Veteran populations will be considered for program enrollment. Panel sizes for full-time, dedicated Care Coordinators should depend on the Care Coordinator’s scope of responsibilities and scope of practice, as well as the complexity-of-care and intensity-of-service needs of the Veterans in the panel (referred to as the “case mix”).

A tool called the RPM – HT Panel Size Calculator was developed to help determine appropriate panel sizes. The use of this tool is not mandatory but is strongly recommended and will help VISN and local leadership determine what is safe and effective in terms of their individual panel sizes. If programs choose not to use the calculator, they must have some other rationale in place to justify current or target panel sizes for all RPM – HT staff.

Panels for dedicated L2 Care Coordinators (those with only L2 Veterans in their panel) are expected to have a higher number of Veteran patients due to the lower acuity of this population and the limited time spent on ordering and helping with the technology.

4.3. Space Planning for Remote Patient Monitoring

For details on facility space requirements for telehealth programs, refer to Section 6.4, Space Resources, in the Telehealth Manual.

4.4. Deploying and Managing Remote Patient Monitoring-Home

Telehealth Programs

Several factors should be considered when using Remote Patient Monitoring – Home Telehealth services; these include whether to expand existing RPM – HT programs, establish a new program (either RPM – HT or L2), or create a combination thereof that will meet the needs of the Veteran 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, VISN https://vaots.blackboard.com/bbcswebdav/xid-510063_1 https://vaots.blackboard.com/bbcswebdav/xid-510063_1 https://vaots.blackboard.com/bbcswebdav/xid-605034_1 https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Telehealth%20Foundations/th_manual/th_manual/TH-manual.html#64-space-resources https://vaots.blackboard.com/bbcswebdav/library/LibraryContent/Telehealth%20Foundations/th_manual/th_manual/TH-manual.html#64-space-resources

RPM – HT Program Manager, and VISN Lead can collaborate with stakeholders to determine how to take the necessary steps for successful implementation.

A key consideration in determining how best to implement remote patient monitoring is how to integrate it with other services so that the care coordination provided by the RPM – HT program can be most effective and efficient for all members of the health care team, especially the Veteran. RPM – HT is a very flexible program, and its integration within the health care system can have many variations and take place through multiple mechanisms. Nevertheless, despite the program’s flexibility, integration of RPM – HT programs will fall into either of two categories:

Option 1 Program: A widespread, broad service, organizationally separate from any one primary or specialty care service or clinic, providing care and case management to Veterans with multiple chronic conditions who are receiving care anywhere across the VA health care continuum with outreach to non-VA health care settings.

Option 2 Program: A specialized service, organizationally aligned with (or “embedded” within) an existing service or clinic, focusing care and self-management on a limited subset of Veterans or special populations cared for by that service or clinic, with outreach to other VA and non-VA health care settings for those same Veterans.

In either case, it is important that, before implementation, the RPM – HT programs closely collaborate with the health care teams they will be working with in order to gain agreement on how care will be coordinated, how communication will occur, and what, if any, clinic protocols are approved for standardized plans of care or clinic interventions. The next several sections describe some of the more frequently employed options for integrating RPM – HT programs within the health care system.

4.5. Integrating Remote Patient Monitoring - Home Telehealth

With Other Services

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

Remote Patient Monitoring – Home Telehealth has been successfully affiliated with PACTs, health promotion programs (e.g., MOVE!), home-based primary care (HBPC), specialty care, and mental health care. Effective RPM – HT program staff communication 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 RPM – HT programs is to integrate longitudinal, remote patient monitoring and case management with the face-to-face care provided by each Veteran’s interdisciplinary team to optimize transitions between inpatient and outpatient care, facilitate specialty care, optimize patient education, and incorporate all services. Collaborating with the interdisciplinary or specialty team helps facilitate seamless care management, incorporate population management, and support flexibility across health care settings, as well as encouraging the Veteran to be a primary partner in the team through building self-management skills.

Remote Patient Monitoring – Home Telehealth team members should perform the following tasks:

• Become visible to interdisciplinary or specialty team members. Create opportunities for frequent formal and informal interactions.

• Collaborate with PACTs and specialty teams in the development of Veteran-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 Veteran. Focus communication on the provider and the registered nurse (RN) care managers in the interdisciplinary or specialty team. Formally share outcome data and performance improvement approaches with the team.

• Collaborate with the team to develop or use disease-specific treatment or intervention protocols to increase quality and efficiency in providing care.

• Use feedback as an essential tool for promoting 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 Veteran patients. It is important to remember that integration can and should occur regardless of the selected alignment.

4.5.1. Integration With Patient-Aligned Care Teams

VHA implemented the PACT model as an approach to providing comprehensive primary care for adults. The PACT health care model facilitates partnerships between individual Veterans, their family or caregiver, and their personal providers.

VHA’s principles of PACTs are as follows:

• Veteran or patient-centric care.

• Ongoing relationship with the provider.

• Physician-directed medical practice.

• Whole-person orientation.

• Coordinated care across the health care 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 RPM – HT and HBPC, includes seamless care management, incorporates population management, supports flexibility across health care settings, and encourages the Veteran to be a primary partner in the team by building self-management skills.

Remote Patient Monitoring – 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 patterns reflecting high risk, high cost, high utilization, or some combination of the three. RPM – HT focuses on improving patient self-management skills to help improve overall patient outcomes. Because of these factors, RPM – HT has been an excellent partner for PACTs.

4.5.2. Collaboration With MOVE!

Connected Care and Telehealth Services and the VHA National Center for Health Promotion and Disease Prevention have worked together since 2010. This partnership created the Weight Management DMP, which is modeled on and complements the VA MOVE! Workbook. When this DMP is used as a single disease management protocol, the Veteran is classified under the HP/DP category of care. If the DMP is combined with other VA or vendor disease management protocols, the Veteran may be classified as HP/DP, CCM, or NIC, as appropriate, based on screening with the Continuum of Care Form.

The Care Coordinator requirement for reviewing DMP responses is weekly for Vetrans enrolled in the L2 Weight Management program and daily for Veterans enrolled in the HT Weight Management program.

Weight Management is available through Home Telehealth, L2, Annie and other apps, with use determined by the clinical needs and wishes of the patient. The VHA Weight Management DMP is used in RPM-HT and L2. In RPM-HT the DMP may be combined with other VA or vendor DMPs to make a comorbid or trimorbid DMP, as long as weight management is listed as the primary DMP in the vendor web site so that all DMP content is provided. The secondary DMP selection would then be abbreviated content so that the session length is appropriate. Care Coordinators must consider this when assessing whether this is the appropriate option for the Veteran based on their clinical need. In addition, there should be thorough documentation that all aspects of care are being managed appropriately by Care Coordinators working within their scope of practice. For those reasons, Care Coordinators who are registered dietitians or social workers should be collaborating with RN Care Coordinators.

Note also that the ability to combine the Weight Management DMP with another DMP to create a comorbid DMP may be limited by vendor programming.

4.5.3. Integration With Home-Based Primary Care

https://vaots.blackboard.com/bbcswebdav/xid-1639967_1 https://vaots.blackboard.com/bbcswebdav/xid-1639967_1 https://www.move.va.gov/vetworkbook.asp

Some RPM – HT programs are embedded within the HBPC program, where remote patient monitoring is used to lengthen the time between home visits. Remote patient monitoring is also used to help meet the in-home needs, as appropriate, of those Veterans who live outside the distance restrictions established by the HBPC program. This enables VHA to offer services to Veterans not eligible for HBPC.

4.5.4. Integration With Mental Health

Since its inception, the RPM – HT program has partnered with the Office of Mental Health and Suicide Prevention, providing overall guidance and support for enrolling, and caring for Veterans with chronic mental illness and those with comorbid conditions and symptoms. In 2021, there was a renewed commitment to supporting and expanding the use of RPM – HT with Veterans experiencing mental health challenges, with the goal of having all mental health programs enrolling Veterans at each VHA clinical site. Office of Mental Health and Suicide Prevention leadership has appointed a clinical champion as well as subject matter experts to aid in this effort and to assist in ongoing revisions of the mental health DMPs. The daily monitoring and proactive care interventions of the RPM – HT program have successfully reduced admissions and bed days of care and is effective suicide prevention.

A major part of suicide prevention is providing case management as Veterans transition from inpatient care to their place of residence. The aim of case management in these circumstances is to foster collaborative clinical relationships and ensure adherence to medication and post-hospital treatment planning. Successful programs have formed strong alliances between the RPM – HT program and local mental health service lines.

VHA DMPs have been written for depression, post-traumatic stress disorder, bipolar disorder, substance use disorder, Stable and Able (for newly housed Veterans or those having difficulty maintaining housing), and dementia. These are reviewed or revised annually. The L2 Program has a VHA Depression DMP, which is helpful for newly diagnosed Veterans or those identified by the PACT as being in need of mental health care but not requiring services from the mental health clinic. Care Coordinators use DMPs (both VHA and vendor), as well as other tools, such as apps, to help Veterans get the care they need. These DMPs all include monitoring of mental health symptoms, such as mood and depression, and contain information about the Veterans Crisis Line (call 988 and press 1, or dial 1-800-273-8255 and press 1, text to 838255, or chat online at VeteransCrisisLine.net/Chat) so that Veterans have that information readily available if needed.

4.6. Remote Patient Monitoring - Home Telehealth

Collaboration Agreements

Facility-developed written service agreements, such as RPM – HT collaboration agreements or care coordination agreements, have been used in VHA for many years to define expectations concerning care coordination and handoffs between services. Development of such agreements between PACTs (or specialty care teams) and RPM – HT programs is highly encouraged, especially for new programs, to clearly define the expectations for care coordination. The purpose of such an agreement is to formalize the trust-based relationship between PACTs or specialty teams and RPM – HT programs and to ensure that timely, high-quality, comprehensive, coordinated, and Veteran-centric care is provided to each Veteran in a safe, effective, and efficient manner. The agreement should be reviewed and updated at regular intervals (such as every two years) and as needed when there are any significant changes. The agreement should clarify clinical, business, and technical details of care and the communication methods to be used between RPM – HT programs and PACTs or specialty care teams.

A local agreement between PACTs or specialty care teams and RPM – HT defines how they will work together to accomplish care management without duplication of services for the Veteran.

Topics for inclusion in the agreement include:

• Referral

• Frequency and types of routine communication (e.g., using the Electronic Health Record

[EHR] notes with the “identify additional signer” function).

• How changes in care plans will be coordinated and

• An explanation of the types of diagnoses and conditions the RPM – HT program is best equipped to manage, including the available

• Protocols — that is, which program or staff member will act as “first contact” for patient issues and how follow-up will be communicated to the

• The process for ensuring a smooth patient handoff at the time the patient is discharged from an RPM – HT program, as well as other areas of mutual

Such agreements may also identify aggregate clinical indicators that are of mutual RPM – HT and care-team interest, for use in ongoing Remote Patient Monitoring – Home Telehealth performance improvement activities. Examples of such indicators might include inpatient admissions and emergency room visits within 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.

5. Clinical Protocols

One example of the collaboration tools that are sometimes used in RPM – HT programs is advanced practice nurse (APN)- or RN-driven protocols. Such nursing protocols are written as standardized plans of care or order sets that provide detailed descriptions of steps to be taken by the APN or RN to deliver elements of evidence-based care to selected groups of Veterans (e.g., Veterans with diabetes, chronic heart failure, or chronic obstructive pulmonary disease [COPD]). Use of such protocols may further define the role of the Care Coordinator and allow coordinators to practice “at the top of their license,” thus providing for more consistent and effective approaches to helping Veterans achieve desired outcomes. In some cases, the same protocols might be used by both RPM – HT RN Care Coordinators and PACT RN Care Managers so that the same evidence-based approaches are used by both groups of RNs and with the same types of patients. Use of such protocols requires that the RN be skilled in care and case management, as well as in RPM – HT processes and communications (both verbal and in the EHR documentation notes). It requires well-developed communication strategies with the Veteran’s providers and a trust-based relationship with those providers and with other members of the team. The development, approval, and use of such protocols must follow local policy requirements.

Apps, such as Annie, that are used to provide health coaching and self-management assistance for Veterans may be used as an adjunct to RPM – HT or as a means to help Veterans transition away from the daily monitoring provided by the RPM – HT program. But note: While Veterans may send data to an app, there is no routine review of that data and therefore no likelihood of timely intervention, so it is important that Veterans know when to contact their health care team should a concern arise.

Please follow the Office of Nursing Service guidance such as VHA Directive 1108.13, "Provision and Use of Nursing Medication Management Protocols in Outpatient Team-Based Practice Settings".

6. Roles and Responsibilities

Human factors involved in the care of the Veteran must be considered when creating RPM – HT programs. A major challenge in the implementation and sustainability of RPM – HT programs is collaborating with large numbers of individuals with varying procedures and protocols, different work styles and biases, and new technologies. It is the human factors, such as the personal connection, relationship, and trust built between the Veteran and their Care Coordinator, that matter most in the Veteran’s experience with RPM – HT programs. Beyond the technology, it is the people involved in these programs who contribute most to a successful RPM – HT experience.

One of the critical predictors of a successful and sustainable RPM – HT program is adequate, appropriate, and competent staff. Remote Patient Monitoring – Home Telehealth involves a range of processes that enable innovative new technologies to be used in the delivery of care and case management. The key positions below are provided to help identify the appropriate team members by illustrating how human resources and accreditation requirements should be approached when implementing an RPM – HT program. The following sections provide further detail on each position.

Note: For information on the roles and responsibilities of the Quality and Training Division, see the Telehealth Manual.

Key positions in Remote Patient Monitoring – Home Telehealth include:

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• VISN Telehealth Lead/VISN RPM – HT Program Manager

• Facility Telehealth Coordinator

• Lead Care Coordinator

• Care Coordinator

• Support staff

• Home Telehealth Master Preceptor

• Home Telehealth Preceptor

• Remote Patient Monitoring – Home Telehealth Clinical Champion

6.1. VISN Telehealth Lead and VISN RPM - HT Program Manager

The VISN Telehealth Lead and the VISN RPM – HT Program Manager are administrative roles that have clear oversight over the program within their VISN. These roles strongly support the implementation or expansion of RPM – HT program use. These roles are the primary conduit for two-way communication between the Office of Patient Care Services, Connected Care and Telehealth Services, and their telehealth practice communities.

6.2 Facility Telehealth Coordinator

The VA Medical Center-level FTC is a key player in the success of an RPM – HT program. The FTC is usually, but not always, responsible for the operation of all telehealth programs within their facility. This position may be responsible for the overall planning, coordination, implementation, and evaluation of the clinical application of all telehealth programs (i.e., RPM

– HT, Synchronous Telehealth, and Asynchronous Telehealth) based on facility needs, including emergency management. If appropriate, the FTC must have a good understanding of the RPM – HT program and must work collaboratively with both the VISN-level Telehealth Program Manager and the VISN RPM – HT Lead to optimize the facility program.

6.3. Lead Care Coordinators

Lead Care Coordinators have the same competencies and training as do Care Coordinators. In addition, they perform administrative or supervisory duties, as listed below. Lead Care Coordinators may be registered nurses, nurse practitioners, licensed clinical social workers, or other licensed professional staff members (such as dietitians, physical or occupational therapists, and pharmacists).

The responsibilities of a Lead Care Coordinator may include:

• Serving as local, VISN, and national contacts for specific types of communications related to RPM – HT.

• Taking a direct or indirect supervisory role in reviewing and evaluating the work performance of other RPM – HT employees, making assignments (such as coverage for patients in the event of staff absences), ensuring staff competency, and facilitating or performing peer reviews.

• Providing guidance by establishing and maintaining teamwork among staff.

• Ensuring awareness of national-, VISN-, and facility-level policies and procedures related to the continuity of care during emergency or disaster events.

• Developing a “performance improvement” culture, which includes collecting, analyzing, and reporting on performance improvement measures; providing leadership to staff on continuous performance improvement initiatives; and developing appropriate and effective performance improvement plans.

• Participating in local, VISN, or national committees and task forces.

• Serving as point of contact for the RPM – HT program for Conditions of Participation

(COP), which includes maintaining compliance, addressing deficiencies, and ensuring that the program meets the Conditions of Participation.

• Maintaining the RPM – HT program presence in the local facility or clinic through promotion and awareness-raising activities and development of key collaborations and outreach in local settings.

• Ensuring that new staff are oriented to all business, clinical, and technical program processes.

• Providing oversight for documentation of training completion dates for all program staff.

• Identifying preceptor-caliber staff and supporting the preceptor role.

• Along with the FTC, collaborating with local emergency management staff to ensure that RPM – HT is part of local operations and identifying vulnerable populations. This includes taking regular opportunities to role-play emergencies and conduct practice drills.

• Ensuring that staff are educating, and performing disaster planning with, Veterans.

6.4. Care Coordinators

Care Coordinators are case managers and health coaches who are highly skilled and have specific training and competency in the use of disease management, health care informatics, and remote patient monitoring technologies.

Case management is the cornerstone of Remote Patient Monitoring – Home Telehealth.

Thorough, regular chart reviews and daily monitoring of data are only part of the overall management of care. Especially in the L2 Program, there is a primary focus on enhancing patient self-management, education on the disease-specific elements of care, and oversight of health-related behaviors that are associated with positive patient outcomes.

Both the RPM – HT care coordination and case management process and the L2 care coordination process begin at identification of appropriate Veterans for enrollment and ends at patient discharge and transition from the program.

Care Coordinators are licensed health care professionals, typically RNs, nurse practitioners, or licensed clinical social workers. They emphasize collaboration and engage in processes that assess, advocate, plan, implement, coordinate, monitor, and evaluate health care options and services so that they meet the needs of the individual Veteran.

Other professional staff members, such as registered dietitians, physical or occupational therapists, pharmacists, and physicians, may serve as ancillary Care Coordinators within their scope of practice and should work in collaboration with an RN Care Coordinator based on Veteran need. These role requirements are the same for all RPM – HT programs. In programs that serve Veterans in the Health Promotion/Disease Prevention category of care such as Weight Management, the Care Coordinator may be a registered dietitian or social worker (usually managing mental health) who must collaborate with RNs for care that may be outside their scope of practice.

Licensed practical nurses or other clinical staff members do not have the necessary skills to function as a Care Coordinator. The role requires significant assessment skills and duties that are outside their scope of practice. There are, however, many duties that licensed practical nurses can support in remote patient monitoring. For detailed information on the duties of licensed practical nurses, see RPM – HT FAQ for use of LPNs.

Care Coordinators may work exclusively with RPM – HT Veterans, L2 Veterans, or a combination of the two. With Veterans enrolled in the L2 Program, the focus is on health coaching and self-management skills rather than on intense case management.

Care Coordinator responsibilities may include:

• Providing initial and ongoing comprehensive assessment, including a review of systems that establish a comprehensive plan of care. The L2 Care Coordinator performs a more focused assessment based on the condition for which the Veteran is enrolled. The Care Coordinator identifies, analyzes, and prioritizes problems and interventions and sets appropriate measurable goals (i.e., Specific, Measurable, Attainable, Realistic and Timely [SMART] goals).