Cerebral Palsy of New York State Telemedicine Project

Meghan Calichman Matthew Kaufman, MD

Cerebral Palsy Associations of New York State

2019 Annual Conference

Agenda

2

Review of the State of Telemedicine

Impact of ER Utilization on Individuals with I/DD

Telemedicine and Provider Agency Staff

Status of Transformation Grant

Future Directions

Telemedicine Hype

• Worker absenteeism cost businesses $226 billion annually1

• Telemedicine can save businesses $6 billion annually2

• 90% of large employers are offering telemedicine in 20173

1. Greenwell C, “Worker Illness and Injury Costs US Employers $225.8 Billion Annually,” CDC Foundation https://www.businessgrouphealth.org/pressroom/pressRelease.cfm?ID=281, TowersWatson, “Current 2. Telemedicine Technology Could Mean Big Saving 3. Beckers Hospital Review, August 2016

3

Telemedicine Hype

4

Telemedicine Hype and Gadgets

• Telemedicine Avoided Hospital Visit 29% of Time in SNFs (AJMC, 2018) 5

Telemedicine Data

• RAND study- 88% of telemedicine represented new use 1

• Veterans Health Administration- telemedicine produced $6500 annual savings per person 2

• 29% of SNF patients avoided hospital admissions with telemedicine 3

• 85% reduction in ER use for people with I/DD4

6

1. https://www.rand.org/news/press/2017/03/06.html2.2017, AAMC.3. August 2018, AJMC4. StationMD Data

Telemedicine Policy

• Congressional Budget Office Concerned about higher utilization*

• State Medicaid Programs increasingly cover telemedicine and now reducing originating site restrictions

• Parity Laws becoming more prevalent

7

• *CBO Blog. Telemedicine. Congressional Budget Office. July 29,2015. www.cbo.gov/publication/50680

People with I/DD and ER Utilization

• People with I/DD use the ER significantly more than other groups

• Five times more likely to use for UTIs and pneumonia

• People with I/DD get hospitalized more frequently than other people

8

People with I/DD in the Hospital

• Up to 5x more likely to have complications

• More likely to get re-hospitalized on discharge

9

10

Causes of Frequent ER Use for People with I/DD

High Risk/Multiple

Co-Morbidities

Lack of Access to Medical Care

Otherwise

Regulatory Requirements

Primary Doctor Lacks

Immediate Availability

How can individuals with I/DD access personalized care in a non-disruptive and stable environment?

Challenges for Providers

Regulatory compliance

Complex medical care needs

Staffing• Overtime pay• Shortages, scheduling• Turnover

11

Patient TraumaExposure to

infection

Unspecialized CareDisruption of

RoutineSuboptimal Care

Unnecessary TestsUnnecessary

Hospitalizations

12

The Problem with the ER – Expensive yet Suboptimal Care

=+

+ Excessive Costs=

Why is cost particularly important for this population?

• Expenditures have increased at compound annual growth rate of 5% over last 10 years

• Inefficiencies, inconsistencies, redundancies= bad care• Among last populations to transfer to managed care due to complexity

of their medical conditions• Poor coordination between HCBS services and medical side

13

14

Changing approach: Person Centered

Self-Determination/Independence

Individualized/Integration

Emphasis on Quality of Life

StationMD Solution Addressed Key Expectations

15

Our Goals

Expand Access to the Optimal Care

Decrease Healthcare Costs

Improve the lives of people with I/DD and

their caregivers

Help vulnerable populations lead healthy, independent, and productive lives.

16

StationMD’s Experience Leads to Specialized Telemedicine Care

Founded by four experienced ER doctors

A healthcare solution delivering sophisticated medical care for high risk/multiple co-morbidities

All doctors are emergency physicians, trained to handle complex medical issues

Our SolutionProblem Solution

• Lack of Access • Tehealth technology Removes the Geographic Impediments

• Suboptimal care for specialized needs • SMD Doctors have specialized I/DD training

• Access to Medical records/database• Personalized care provided in safety of

person’s own environment

• Primary Care Evaluation Unavailable Off-Hours

• StationMD System is on and Available 24 hours/day

• Regulatory pressures • StationMD Doctors evaluate immediately

• Provide Full Documentation 17

StationMD Telemedicine Augments but does not Replace Primary Care

StationMD Primary Care

• Addresses high glucose readings with immediate medication adjustment

• Manages daily meds for chronic conditions (i.e., insulin regimen, cholesterol medications)

• Medicationrefills/clarification/reconciliation

• Prescribe long-term medications

• Evaluates after an incident to meet regulatory requirements

• Performs regular “check-ins” as needed

• Manages long-term goals of treatment

• Handles urgent medical issues • Monitors medical screening issues (i.e., colonoscopy)

18

19

Back-end System that Assures Quality

StationMD offers immediate access at anytime to high-quality ER doctors, specially trained in the care of people with I/DD.

Copyrighted treatment guidelines

Doctor training

Quality reviews

Educational series

A turnkey, packaged model that can be rolled out with success anywhere in the country

20

Creating Standards of Care

Standardize Guidelines Created by Clinical Team for Optimal Quality of Care

UTI Dyspnea

Hyperkalemia Chest Pain

Increase in BUN/Creatine PT/INR

Abnormal CXR Hyperglycemia/Hypoglycemia

Vomiting Foley Care

Hypotension Cellulitis/Abscess

Infection/Sepsis Abdominal Pain

URI Anemia

Elevated blood pressure Constipation

Falls GI Bleed

Agitation PEG tube care

Fever Influenza

Seizure C-diff

21

Reporting/Data Analysis

Comprehensive reporting package

Monthly data by site

• Number of visits/calls by• Hour of Day• Day of Week• Physician• Outcome i.e. observe, transfer, etc.• Diagnosis

Comparison on before and after implementation data with regards to transfers to Emergency Departments and other regulatory reporting.

The StationMDProcess Step-by-

Step

23

Change in Condition Activate24 year-old female with CP, asthma• Develops cough• Fever of 101°• Oxygen saturation 90%

• Facility Staff initiates SMD encounter• StationMD doctor reviews patient’s

records

24

Physician Assessment• Telemedicine consultation initiated• A physical exam is performed

25

Treat Patient Share Treatment Plan/Follow-up• Asthma exacerbation and Respiratory infection• StationMD provider prescribes nebulizers,

steroids and antibiotics

• Follow-up exam by StationMD doctor• Breath sounds show improvement. Patient

comfortable. Oxygen 95%• Documentation in EHR, Primary Care Physician Notified

Unnecessary trip to ER avoided

If patient had not improved-StationMD would contact ER to expedite visit & review history

26

Other Typical Cases (not always emergent!)

Medication Refill Order clarification Behavior change Constipation

Evolution of Transformation

Grant in NYS

Initial Phase- DSRIP Grant

• 2 ICFs• 26 Individuals• 89% Treated in place• 85% Decrease in ED use compared to historical data

28

Second Phase- DASNY Grant

• DASNY- Dormitory Authority of the State of NY Nonprofit Infrastructure Capital Investment Program Grant

• 598 Individuals• 104 sites• 2018 Data-94% Treated in place• 2019 Data (through September)-86% Treated in place

29

Third Phase- DOH Transformation Grant

• Statewide Health Care Facility Transformation Program Grant• 7315 people • 1028 sites• We are excited to get started!

30

Results to Date for all I/DD Clients

• 86-89% Treated in place• 2018-all IDD clients for StationMD-89.1% observe in place• 2019-all I/DD clients for StationMD-86.9% observe in place

31

320

5

10

15

20

25

30

35

40

45

50

Jan19 Feb19 Mar19 Apr19 May19 Jun19 Jul19 Aug19 Sep19 Oct19

Visits by Month of Service by Outcome

ER Transfer

Avoided ER Transfer

33

Most calls result in avoided ER transfers across diagnoses

34

Proven Outcomes

85%

Data for Individuals with I/DDMarch 2016-September 2019

StationMD Visits by Outcome

Time Period % Observed in Place

03/2016-12/2016 86.4%

01/2017-12/2017 86.0%

01/2018-12/2018 89.1%

01/2019-09/2019 86.9%

87.1% of StationMD Clients with I/DD Are Treated in Place

Historical Data from Clients Demonstrates an 85% reduction in

ED Transfers

35

StationMD’s Solution is Growing

Skilled nursing facilities (nursing homes; rehab

centers)

~3000 patients covered

daily

Over 6,800 calls in 2018

Payer Partner

Camp & school

programs

Rural Urgent Care/ Clinic

127 group homes/ adding 1000+

in 2019

36

Significant Savings for Provider Agencies & Payers

*Assumes 3-day LOS for admissions

Estimated I/DD Agency SavingsNumber of Consumers

Est. ED Visits in 12-month period

Est. Reduction in ED Visits

200 440 374

Estimated Payer SavingsEstimated 123 of 374 ED Transfers were Avoided

Hospital Admissions

StationMD Telemedicine Estimated Cost Savings

Site Loss of Bed Revenue*

~Cost of Site Bed/Night

Savings

369 Nights $500 $184,500

Site Transportation Costs

~Cost of Transport Savings

176 $500 $88,000

Total Hrs. 3 Staff Members to Cover Avg. ED Visit

StaffSalary/Hr.

Savings

5,610 $15 $84,150

Total Projected Annual Savings for Agency

$356,650

Averted ED Transfers

Average Cost/ED Visit

Savings

251 $1,000 $251,000

Averted HospitalAdmissions

Average Cost/TopDX w. Avg. LOS of 3 Nights

Savings

123 $15,000 $1,845,000

Total Savings (Facility & Payer) $2,452,650

Total Projected Annual Savings for Payer $2,096,000

37

Reimbursement: How can we create a sustainable model?

Per member/per month model of

reimbursement with unlimited calls

Shared Savings Model that includes Payer and Telehealth

Provider

Shared Savings Model that Includes

Provider Groups

Medicaid Waiver System

Thank you

matthew.kaufman@stationmd.com917-750-3139

meghan.calichman@stationmd.com2018-874-4440