Fazzi Associates, Inc.

It all started with one question: Why? Why were some agencies that used telehealth for chronic diseased patients so successful from a quality and financial standpoint, and why were others only marginally successful?

For two industries committed to using telehealth services to better serve home care patients – the telehealth industry and the home care industry – this was a critical question. The answer would not only lead to better services for millions of home care patients suffering from chronic diseases; it would also make telehealth services more financially viable for an industry that needed to incorporate cost savings and quality enhancing strategies into service delivery.

It was this reality that lead to the Philips National Chronic Disease/Telehealth Project. The project sponsored by Philips Healthcare Solutions and co-sponsored by National Association for Home Care and Hospice and Fazzi Associates was a national effort to answer the “why” question. It was also designed to provide the field with insights into how to best apply telehealth services to home care patients with chronic diseases.

In 2007, Philips Telehealth Solutions, the National Association for Home Care and Hospice, and Fazzi Associates initiated a ground breaking study: The Philips National Study on the Future of Technology and Telehealth Services in Home Care. This was the first statistically representative study ever undertaken of the Medicare certified home care industry.

The goal of the study was to learn the level of adaption and success that the home care industry had with four major technologies: fiscal, accounting and backroom systems, point of service systems, electronic medical records, and telehealth. Most of the study centered on the fourth system, telehealth.

Because the study was designed to be statistically representative of the industry, researchers were able to analyze and compare results by size of agency, location, auspices, etc. This allowed for extensive analysis and fun (from a researcher’s perspective) comparisons of the various sectors and types of home care services. It was during this analysis that the question of “why” came up.

Analysis of findings showed that a high percentage of agencies with telehealth programs (66.3%) used their systems for patients with chronic diseases. The analysis also showed that some agencies were very successful and others less successful. What the study did not show (since it was not the focus of the study) was why…and better yet, how did successful agencies get better outcomes.

Given the critical role that telehealth systems are playing and will increasingly play in the future of home care, these were two questions that the Philips Chronic Disease Project set out to answer.

Two very simple reasons: money and quality. First, it is important to understand something that every director knows: Patients with chronic disease are some of the most difficult patients to serve. Their needs are great. The problems that they face in trying to stay independent are often overwhelming. And the impact that they have on an agency’s OBQI and/or Home Health Compare quality scores can be significant. This latter point has double implications when you consider the upcoming P4P efforts of CMS.

And, because most Medicare beneficiaries have two or more chronic diseases, these patients tend to be:

Of equal concern to agency directors are the financial challenges posed by patients with chronic diseases. In a 2007 study by the Milken Institute , researchers found the following:

In fact, in a study by Home Care Financial Review using data from 2005, researchers found that Medicare patient with the four most prevalent chronic diseases – COPD, CHF, hypertension and diabetes cost the government nearly 2.4 billion dollars.

There were two very compelling reasons why Philips opted to initiate a study that focused on best telehealth practices for patients with chronic diseases. First, the original Philips National Study on the Future of Technology and Telehealth in Home Care discovered that nearly two-thirds (66.3%) of agencies with telehealth systems targeted patients with chronic diseases. Rather than focus on all chronic diseases, they tended to focus on those chronic diseases most prevalent with home care patients.

The second and far more compelling reason was the success being reported by agencies using telehealth service on patients with chronic diseases. When agencies targeted specific chronic diseases using telehealth services, many reported very strong results. In fact, in a study of Fazzi Associates clients participating in a national best practice service, researchers discovered that agencies that used telehealth services for chronic disease patients generated stronger financial outcomes as well as better quality outcomes.

But, in the midst of reporting success, some questions arose - particularly questions related to why some agencies were so successful and others not.

In delving deeper, researchers discovered that the successes were not consistent. For example, while:

Why? Why were some agencies successful while others were not? The simple answer was “practices.” What the Philips study discovered was that agencies who were most successful used specific practices to get better results! Unfortunately, what this representative sample study did not explore was how successful agencies did it; how they generated better quality outcomes and stronger financial results. It was a question that needed to be answered.

Philips Telehealth Solutions, the National Association for Home Care and Hospice, and Fazzi Associates recognized that there needed to be an effort directed at finding best practices for dealing with the major chronic diseases most often found in Medicare home health patients. They also recognized that in order to get best practices, two distinct groups needed to be involved – nationally recognized chronic disease medical experts and home care professionals who knew first hand the reality of using telehealth in home settings. Together, these two groups represented the knowledge base needed to develop reality based best practice strategies.

The process used for the project was an intensive, dynamic, highly interactive process called Expert Design. Expert Design sessions bring together the best minds on a particular subject and run them through a systematic process resulting in the joint development of best practices.

The project began in January 2008. Over a six month period, four nationally recognized chronic disease medical experts (one for each of the four major chronic diseases) were recruited along with a fifth nationally recognized expert, Dr. Phillip Corsello. Dr. Corsello, the Medical Director of National Jewish Health Disease Management Programs, served as the Medical Lead for the project.

Also recruited were over 40 national home care professionals with extensive experience managing telehealth programs. In most cases, there was only one expert from each state. Participating agencies met all or most of the following criteria:

The participants represented 35 states and every region of the country. They brought a range of experiences, from heavily rural areas to heavily urban areas. They represented hospital-based agencies, hospital-affiliated agencies, and freestanding agencies. They were for-profit and not-for-profit, and their sizes ranged from under one million dollars to the nation’s largest agency with an overall budget in excess of one billion dollars.

Together, the Medical Experts and home care telehealth/chronic disease practitioners reviewed the medical realities of those with chronic diseases. They also reviewed telehealth protocol from national groups. They also reviewed the proven experience and protocol developed by participating agencies who had demonstrated success in using telehealth with one or more of these patient populations. Based on these insights, the National Expert Panel identified key components of an ideal protocol and collectively developed systematic guidelines in each component for each of the four chronic diseases.

While specific clinical parameters will need to be tested and refined by many of the agencies involved in the process, by Philips clients and by others, three general findings became readily apparent:

Successful Agencies Targeted Their Telehealth Programs: The most successful agencies were very clear on what they did. Rather than arbitrarily assigning their telehealth systems to patients, they were very focused. The agency had admission criteria that identified potentially eligible patients, and staff immediately began exploring whether or not these patients were appropriate candidates for their telehealth program. They were also clear that high priority would be given to patients with one or more of the four major chronic diseases served by home care: CHF, COPD, hypertension and diabetes.
Successful Agencies Had Clear Clinical Protocols for Each Chronic Disease: Successful agencies did not use generic protocol even through there were clear similarities. They also didn't start a program and simply monitor a few vital signs. They had a clear plan and they knew what they were doing. Most agencies had very clear protocols. They had safety parameters that were individually developed for each patient. There were targets for improvement that needed to be achieved. There were clear clinical measures that were rigidly monitored to ensure patient safety and improvement. And they knew how to effectively integrate visits with remote patient monitoring.
Successful Agencies Had Five Components That Were Part of Their Protocol: Prior to the actual Expert Design Forum, interviews were conducted with the various practitioners. What emerged was the fact that many of these agencies had common components to their chronic disease management protocol. For each of the chronic diseases, they had distinct criteria. The components included:
- Inclusion/Exclusion Criteria: Agencies felt that there needed to be very clear criteria for who would be eligible for being monitored and supported through their telehealth program. The criteria went well beyond simply having one of the chronic diseases as their primary diagnosis. Patients needed to meet all criteria before being eligible for inclusion for telehealth service.
- Focus of Monitoring: Each of the disease states clearly had specific areas needed to be monitor. For example, hypertension patients would obviously have their blood pressure, pulse and weight monitored. Within these areas, agencies would have specific ranges and, in fact, one of the classic warning lights occurred when patients went outside of their range.
- Patient Education Focus: Educational materials targeted to the specific disease were viewed as an integral part of the disease management protocol. Whenever possible, agencies used educational material from national sources and other experts as means of keeping patients aware of factors related to their condition. Most agencies had additional information that supported their telehealth components.
- Expected Outcomes: Stabilization was the obvious outcome for all patients, but the definition of stabilization differed depending on the primary disease. CHF patients, for example, needed no rehospitalization, no emergent care, improvement in ADLs, stabilization within specific patient ranges, and improved self-management for specific activities. Diabetes patients on the other hand may have some of the same criteria as CHF but would also had criteria that included blood glucose within targets.
- Service Guidelines: The challenge is to balance the use of telehealth services with home care’s standard visit practices. Increasing daily monitoring while decreasing unnecessary visits is a key component. Service guidelines were obviously one of the most challenging criteria. They included medication, frequency of monitoring, frequency of visits, rationale behind visits, etc.

What emerged over the two day intensive Expert Design Forum were clear protocols for each of the four chronic diseases. Within each of the protocols were specific criteria for each of the five components. These will be tested and further refined over the next twelve months.

Given the demographic realities of a growing senior population and the economic realities that necessitate more cost effective ways of dealing with these seniors, there is no question that telehealth services (particularly telehealth services for patients with chronic diseases) will play a growing role in the future of home care.

Over the next year, the participants, clients from Philips Telehealth Solutions, and others will be testing the protocol and refining them to create even better protocols for serving patients with chronic diseases.

The Philips Chronic Disease Project represents a proactive effort by industry leaders to find better and more effective ways to cost-effectively and qualitatively support our growing number of home care patients. In many ways, it is an effort to ensure that those agencies using telehealth services have the very best insights into how to best monitor and best serve patients with chronic diseases. Thanks to the national chronic disease medical experts and the home care chronic disease telehealth experts, we have a taken a positive step forward to creating best practices for serving people in years to come.

Dr. Gerard Criner

Dr. Criner, Professor of Medicine, Temple University, Section of Pulmonary and Critical Care Medicine, is director of the Medical Intensive Care Unit and Ventilator Rehabilitation Unit. His clinical interests are in advanced lung disease (COPD, emphysema, pulmonary fibrosis, pulmonary hypertension, respiratory failure) and critical care medicine.

Dr. Christopher Hebert

Christopher Hebert, M.D. is a general internist and staff physician with the Cleveland Clinic Department of Nephrology and Hypertension, with a dual appointment in the Department of Quantitative Health Sciences. His interests include community hypertension, risk prediction, outcomes measurement, and increasing the value of health care services. He is a graduate of the VA National Quality Scholars Fellowship Program, and presently serves as Director of the Center for Quality Patient Care in the Glickman Urologic and Kidney Institute.

Dr. Frank Smart

Frank W. Smart, MD, is The Dorothy and Lloyd Huck Chairman of the Department of Cardiovascular Medicine at Atlantic Health and The Gagnon Heart Hospital of Morristown Memorial and Overlook Hospital, New Jersey. Dr. Smart’s research interests are primarily devoted to translational and clinical heart failure and the consequences of heart failure. A sought-after speaker, he has delivered invited lectures and presentations concerning the treatment of decompensated heart failure, the management of heart failure and vasoreactivity in heart failure outpatients, mechanical support for heart failure patients, and cardiac transplantation.

Dr. Jay Skyler

Jay S. Skyler, MD, MACP is Professor of Medicine, Pediatrics, & Psychology, in the Division of Endocrinology Diabetes & Metabolism, Department of Medicine, University of Miami Leonard M. Miller School of Medicine. He is Associate Director for Academic Programs in UM’s Diabetes Research Institute. He is Chairman of the NIH (NIDDK)-sponsored Type 1 Diabetes TrialNet, a nationwide network conducting clinical trials to interdict type 1 diabetes. Dr. Skyler is a graduate of Penn State University and Jefferson Medical College, and did postgraduate training in Internal Medicine and in Endocrinology and Metabolism at Duke University. He was on the faculty at Duke, and worked two years at the Hypertension-Endocrine Branch (Section on Biochemical Pharmacology) of the National Heart and Lung Institute.

Dr. Phillip Corsello

Dr. Corsello is Medical Director of National Jewish Health Disease Management Programs. He is a board-certified pulmonologist with over 30 years experience in the treatment of Chronic Obstructive Pulmonary Disease (COPD). He is the Associate Medical Director of the National Jewish Health Pulmonary Rehabilitation Program (PRIDE). Dr. Corsello is a graduate of the University of Pittsburgh and completed his fellowship in pulmonary disease at the University of Colorado. He engaged in a small group private practice of pulmonary medicine, much of it critical care medicine, for nearly fifteen years prior to joining a large, capitated multi-specialty medical group in southern California in 1981. In 1985 he returned to Colorado as a faculty member at the National Jewish Health, and has thus had extensive experience in no less than three healthcare delivery systems.

Controlling the Future:
The Philips National Chronic Disease Project

CARING Magazine January 2009
Dr. Robert Fazzi, Managing Partner
Timothy Ashe, Partner
Lynn Harlow, Partner

Controlling the Future: The Philips National Chronic Disease Project

CARING Magazine January 2009 Dr. Robert Fazzi, Managing Partner Timothy Ashe, Partner Lynn Harlow, Partner

Controlling the Future:
The Philips National Chronic Disease Project

CARING Magazine January 2009
Dr. Robert Fazzi, Managing Partner
Timothy Ashe, Partner
Lynn Harlow, Partner