evidence-based toolkit to evaluate telemedicine delivery

Aubrey Dwyer, BSN, RN DNP Project Final Defense April 11th, 2019

Evidence-Based Toolkit to Evaluate Telemedicine Delivery of Palliative Care

Acknowledgements •  Dianne Conrad DNP, RN, FNP-BC •  Susan Harrington, PhD, RN •  Rachel Cardosa, DNP, RN, AGNP-C •  Simin Beg, MD, MBA •  Angela Kinch, BSN, RN •  Theresa Tanis, BSN, RN •  Lisa Vanderwel, LMSW

Objectives for Presentation 1. Review the clinical problem 2. Review evidence-based solution

to the clinical problem 3. Review project results 4. Review enactment of DNP

Essentials

Background •  Many individuals prefer to die at home

•  Majority spending EOL with frequent hospitalizations and ICU stays (Hennemann-Krause et al., 2015; Institute of Medicine [IOM], 2015).

•  Advances in healthcare have led to individuals living longer (Matzo & Sherman, 2015).

•  Oncology providers appropriately focus limited time on test results and treatment options •  Symptom management and goals of care are often overlooked

(Gulcan et al., 2018).

Background continued •  Palliative care is an important part of

the cancer treatment plan from diagnosis until EOL (CAPC, n.d.)

•  Access to palliative care in rural settings is limited. •  Telemedicine to increase access (Henneman-Krause et al., 2015)

•  CMS reimbursement measures for oncology providers (CMS, 2017)

Literature Review: Aims Palliative care for individuals diagnosed with cancer: 1.  Does outpatient palliative care versus standard care lead to

improvement in symptom management? 2.  Does outpatient palliative care versus standard care

increase survival rate? 3.  Does outpatient palliative care result in decreased

healthcare costs? 4.  Is telemedicine a beneficial form of outpatient palliative

care?

Literature Review: Results Integration of palliative care into cancer patient’s treatment plan: • Increased quality of life

–  Increase in patient satisfaction (Davis et al., 2015; Zimmerman et al., 2014)

• Decrease in symptom intensity

–  (Bakitas et al., 2015; Bukki et al., 2013; Davis et al., 2015; Hennemann-Krause et al., 2015; & Kassianos et al., 2018 )

• Decrease in hospital admissions –  Less ICU stays (Hennemann-Krause et al., 2015; Romano et al., 2017)

• Decrease in aggressive treatment at the EOL –  More likely to receive hospice care (Blackhall et al., 2016)

Literature Review: Results Continued Is telemedicine a beneficial form of outpatient

palliative care? •  Increases access to care

–  (Hennemann-Krause et al., 2015).

•  Improved symptom management –  (Hennemann-Krause et al., 2015).

•  Increased survival rates –  (Bakitas et al., 2015).

•  Decreased emergency department visits –  (Hennemann-Krause et al., 2015).

Assessment of Organization: Burke & Litwin

(Burke & Litwin, 1992)

SWOT Analysis

Clinical Practice Question

What is an evidence-based toolkit to evaluate the structure,

process, and outcomes for outpatient telemedicine delivery

of palliative care?

Project Purpose Collaboration with a Midwest hospice and palliative care organization to evaluate the structure, process, and outcomes for outpatient telemedicine delivery of palliative care.

Ethics and Human Rights Protection

•  CITI training •  Project team and statistician will

have access to de-identified data – De-identified data kept on M:/drive

•  IRB

Design • Program Evaluation Quality

Improvement Project

– Improve outcomes for BOTH the patient and the healthcare organization (AHRQ, 2013)

Setting & Participants Setting: Division of hospice and palliative care within a large Midwest healthcare system

– Expanding current services to rural outpatient oncology setting

Participants: •  The organization

– Key stakeholders •  Patients

Structure Process Outcomes

Conceptual Model: The Donabedian Model

(AHRQ, 2015)

Deliverable: Evidence-based toolkit to evaluate telemedicine delivery of palliative care

What is the phenomenon of interest?

Implementation Model: PDSA Cycle

(Lee, Wadhwa, Kruskal, & Larson, 2015)

Project Objectives & Strategies

1.  Identify and determine costs of key elements of structure by November 9th, 2018.

2. Identify the billing codes for telemedicine visits

with key stakeholders by November 9th, 2018. 3. Collaborate with key stakeholders to enhance the

care flow process from November 2018 through February 2019.

4. Establish referral guidelines utilizing previous

DNP baseline data by November 15th, 2018. –  Incorporate CMS oncology performance indicators

Project Objectives & Strategies 5. Informal interviewing to identify staff satisfaction by January 12th, 2019 6. Collect preliminary results of both organizational and de-identified patient outcomes by February 22nd, 2019.

– Organizational: ROI – Patient: Primary diagnosis, patient satisfaction,

advance directives on file, symptom intensity

Project Objectives & Strategies 7. Perform a cost savings analysis by February 22nd, 2019. 8. Create sustainability plan by February 22nd, 2019. 9. Present toolkit to key stakeholders by April 11th, 2019. 10. Defend final evidence-based toolkit to evaluate outpatient telemedicine delivery of palliative care by April 11th, 2019. Upload to ScholarWorks©.

Timeline of DNP Scholarly Project

Timeline of DNP Scholarly Project

Identify and determine key elements of structure: 11/09/18

Identify billing and coding for telemedicine services: 11/09/18

Establish referral guidelines: 11/15/2018

Perform cost savings analysis: 02/22/2019

Create sustainability plan: 02/22/2019

Collect preliminary organizational and patient outcomes: 02/22/2019

Present work to key stakeholders, Defend final DNP scholarly project: 04/11/19

Informal interviewing of staff: 01/12/2019

Analysis of Evaluation Plan

•  Desired outcome – Acceptance of evidence-based toolkit to utilize

within the hospice and palliative care organization

•  Preliminary data collected with assistance of statistician – Both organizational and patient outcomes

Resources

•  Commitment of staff and project team

•  Access to:

–  EHR, PCQN Database, Telemedicine Database

•  Laptop

Budget DoctorofNursingPracticeProjectFinancialOperatingPlanProjectTitleEvaluationofTelemedicineDeliveryofPalliativeCareRevenueProjectManagerTime(in-kinddonation) 14,000.00TeamMemberTime:

DirectorofHospiceandPalliativeCare(SiteMentor) 2,450.00Doctoral-preparedNursePractitioner(SiteMentor) 2,500.00PalliativeCareNurseManager(SiteLead) 2,000.00

ConsultationsTelemedicineSpecialist(EducationSession) 45.00Statistician 100.00

ProjectedcostmitigationEmergencyDepartmentVisit(preventionof1EDvisit) 1,233.00IntensiveCareUnitStay(preventionof1dayinICU) 6,285.00

TOTALINCOME 28,613.00

ExpensesProjectManagerTime(in-kinddonation) 14,000.00TeamMemberTime:

DirectorofHospiceandPalliativeCare(SiteMentor) 2,450.00Doctoral-preparedNursePractitioner(SiteMentor) 2,500.00PalliativeCareNurseManager(SiteLead) 2,000.00

ConsultationsTelemedicineSpecialist(EducationSession) 45.00Statistician 100.00

EquipmentPlantronicsblackwireC725 164.99ThinkLabsOneDigitalStethoscopewithWarranty($741.70/5) 148.34CA750TelemedicineCart($2,746.00/5) 549.20CiscoTelepresenceCEDX80($2,746.00/6) 457.67LenovoLaptop 673.67RuralSettingOfficeSpace($31.60permonth) 31.60DowntownSettingOfficeSpace($200.00permonth) 200.00

TOTALEXPENSES 23,320.47

NetOperatingPlan 5,292.53

Results: Structure

• Equipment • Staffing • Training Required

Results: Process •  Care Flow Process

–  Intake Form

AppointmentScheduled

PatientpresentsatRegionalCancerCenter

ProviderReferral

FormsplacedintoEHR.Providerreviews.

Patientsignstelemedicinecontract.Intakeformgiventopatient.Medicationcontractgiventopatienttosign

yearly.

Palliativecarestaffcontactspatientviaphoneto

schedulereturnvisitifneeded

Staffjabbersproviderto

informpatienthasarrived

Telemedicineconsultationoccurs.

RegionalMAjabbers

providertostatethatthepatient

isready

Providerwearslabcoatand

badgeMAcheckspatientout,printsAVS

ProviderdropsprofessionalchargeinEHR.Documentsvisit(usingsmart

phrase)and“conductedviatelemedicine”start/endtime.

Ifrequired,OpioidStart

Talkingformispresentedtopatient

Results: Process • Referral Guidelines •  Informal Interviewing of Staff • CG-CAHPS + Additional Questions

Results: Outcomes •  Informal Interviewing: Staff Satisfaction

•  “The more I complete the video visits and follow up with the same patients, the more the video barrier is broken down and rapport is built”

•  Patient Satisfaction •  Convenience of not having to drive over an hour for an

appointment

Results: Patient Outcomes •  Advance Directives on File •  Symptom Intensity •  Emergency Department Visits •  Hospitalizations •  Hospice Admission •  Hospice Length of Stay •  Patient Miles Saved

0

100

200

300

400

500

FY19PalliativeCarePatientMilesSavedRoundTrip

PatientMilesSaved

Results: Outcomes •  Revenue capture over two months

Results: Outcomes •  Cost Analysis

CostAnalysisofTelemedicinePalliativeCareTwoMonthPeriod

RevenueNewPatientCode

99204(X1) 92.12EstablishPatientCode

99214(X5) 299.0599215(X1) 132.99

FacilityChargeforTelemedicine40355401(X7) 113.74

TOTALINCOME 637.90

ExpensesHealthcareProfessionalTime

OverheadPhysician($98.00/hrX8hourspermonthX2months) 1,568.00NursePractitioner($51.00/hrX4hourspermonthX2months) 408.00PhysicianAssistant($50.00/hrX4hourspermonthX2months) 400.00MedicalAssistant($12.00/hrX8hourspermonthX2months) 192.00FrontDeskMedicalReceptionist($13.56/hrX8hourspermonthX2months) 216.96TelemedicineSpecialist($30.00/hrX16hourspermonthX2months) 960.00PalliativeCareNurseManager($40.00/hrX3hourspermonthX2months) 240.00PalliativeCareRegisteredNurse($27.00X2hourspermonthX2months) 108.00PatientServiceRepresentative($14.00X3hourspermonthX2months) 84.00

Equipment(StartUpCosts)PlantronicsblackwireC725 164.99ThinkLabsOneDigitalStethoscopewithWarranty($741.70/5) 148.34CiscoTelepresenceCEDX80($2,746.00/5) 549.20CiscoTelepresenceCEDX80($2,746.00/6) 457.67LenovoLaptop 673.67

OngoingOperationalCostsRuralSettingOfficeSpace($31.60permonthX2) 63.20DowntownSettingOfficeSpace($200.00permonthX2) 400.00


NetOperatingPlan -5,996.13

Discussion •  Evidence-based toolkit to evaluate

telemedicine services created to ensure standardized care delivery – Collection of data – Cost-effectiveness – Quadruple Aim of Healthcare

(Bodenheimer & Sinsky, 2014)

Limitations •  Small scale in oncology setting

– Limited data for patient outcomes and revenue generated

– Education to oncology providers •  How data is collected

Sustainability Plan •  Standardize the collection of data •  Continued evaluation using PDSA

Cycle – CMS oncology performance indicators – Changes in PCQN database – Telemedicine Specialist

Sustainability Plan

•  Projected Cost Analysis

CostAnalysisofTelemedicinePalliativeCareTwomonthPeriodèSixMonthPeriod

RevenueNewPatientCode

99204(X1)($92.12X3) 276.36EstablishPatientCode

99214(X5)($299.05X3) 897.1599215(X1)($132.99X3) 398.97

FacilityChargeforTelemedicine40355401(X7)($113.74X3) 341.22

CostmitigationEmergencyDepartmentVisit(preventionof1EDvisit) 1,233.00IntensiveCareUnitStay:AverageLOS10days($6,536.00X10) 65,360.00

TOTALINCOME 68,506.70

ExpensesHealthcareProfessionalTime

OverheadPhysician($98.00/hrX8hourspermonthX6months) 4,704.00NursePractitioner($51.00/hrX4hrspermonthX6months) 1,224.00PhysicianAssistant($50.00/hrX4hourspermonthX6months) 1,200.00MedicalAssistant($12.00/hrX8hourspermonthX6months) 576.00FrontDeskStaff($13.56/hrX8hourspermonthX6months) 650.88TelemedicineSpecialist($30.00/hrX16hourspermonthX6months) 2,880.00PalliativeCareNurseManager($40.00/hrX3hourspermonthX6months) 720.00PalliativeCareRegisteredNurse($27.00X2hourspermonthX6months) 324.00PatientServiceRepresentative($14.00X3hourspermonthX6months) 252.00

Equipment(StartUpCosts)PlantronicsblackwireC725 164.99ThinkLabsOneDigitalStethoscopewithWarranty($741.70/5) 148.34CiscoTelepresenceCEDX80($2,746,00/5) 549.20CiscoTelepresenceCEDX80($2,746.00/6) 457.67LenovoLaptop 673.67

OngoingOperationalCostsRuralSettingOfficeSpace($31.60permonthX6) 189.60DowntownSettingOfficeSpace($200.00permonthX6) 1,200.00


NetOperatingPlan 52,592.35

Dissemination 1. 2019 Academy of Hospice and Palliative

Care Conference in Orlando, FL 2. Final Defense at GVSU 3. MidWest Hospice and Palliative Care

leadership team 4. The Graduate School and the Center for

Scholarly and Creative Excellence Showcase

5. Uploaded into ScholarWorks©

Summary Organization has identified the need to increase access to palliative care for oncology patients in rural setting •  Implementing telemedicine palliative care

Clinical Question: What is an evidence-based toolkit to evaluate the structure, process, and outcomes for outpatient telemedicine delivery of palliative care? Outcome: Evidence-based toolkit to provide a comprehensive, evidence-based evaluation plan

DNP Essentials Reflection Essential I Scientific Underpinnings for Practice

Essential II Organizational and Systems Leadership for Quality Improvement and Systems Thinking

Essential III Clinical Scholarship and Analytical Methods for Evidence-Based Practice

Essential IV Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Health Care

Essential V Health Care Policy for Advocacy in Health Care Essential VI Interprofessional Collaboration for Improving Patient and

Population Health Outcomes Essential VII Clinical Prevention and Population Health Essential VIII Advanced Nursing Practice

Discussion: Questions?