Nursing facilities have evolved from rest homes to medical facilities over the last 20 years.
Patients are sicker, older, have more medical comorbidities, and are frailer. They require more assistance with activities associated with daily living and have much greater rates of cognitive impairment. People over 85 are the most rapidly expanding demographic and the elderly segment of the American population is expected to double in 2030 from 2010. Even with a shift to providing higher-intensity care in people’s homes, the demand for nursing facility-level care is slated to double. Meanwhile, there are significant workforce challenges that prohibit nursing home patients from getting the medical care they need. Fortunately, telehealth can help fill these gaps.
The availability of clinicians has always been a challenge. The medical community too often avoids nursing facilities, with less than 1% of medical school graduates choosing to work in geriatrics. The total number of Board Certified Geriatricians in the U.S. has declined from over 10,000 in 2000 to less than 8,200 today. By 2030, we are projected to have less than 7,300 geriatricians nationwide. Approximately 50% of geriatric training program slots are unfilled annually. Among the many challenges these staffing shortages cause is that they prevent facilities from accepting new patients because they don’t have the staff. This in turn jams hospitals as they have no place to discharge patients, extending hospital stays and increasing costs.
Too often, state and federal surveyors evaluating nursing facilities focus on antiquated regulations around site visit requirements rather than other attributes that better define quality care, such as comprehensive notes with actionable care plans or timely care upon admission or readmission. Current federal requirements introduced in 1991 call for patients to be seen on-site by a physician within one month of admission and monthly for an additional two months, after which the patient must be seen at least every other month.
A disproportionate number of hospitalizations occur within 10 days of admission to a nursing facility, and over 10% of patients admitted to a nursing facility never see their doctor. For those patients not seen, the chances of hospitalization are twice that of patients who have been seen. Further, almost 40% of hospital admissions are avoidable. These potentially avoidable hospitalizations roughly cost Medicare over $1 billion annually, not to mention the personal toll on a frail population and their loved ones.
Current regulations, though well-intentioned, do not consider new technological advancements via telehealth, nor do they meet the clinical needs of patients. Simultaneously, they create an administrative and operational burden on the many underfunded and under-resourced facilities, which often cannot be met. Moreover, the regulations do not reflect the reality of our accelerating gap in the clinician workforce.
The standard of care should be about on-time and face-to-face (virtual or on-site) visits. People should be seen and clinically evaluated within 72 hours of admission and immediately when there is a change in condition, not just once per month unless hospitalized. Today, when a patient has a change in condition, the clinician is called and orders are given to treat or to send the patient to the hospital.
Telemedicine can help fix this problem.
Telemedicine – defined as bidirectional video, a digital stethoscope allowing the clinician to listen to the patient’s heart and lungs, an otoscope and a wound care camera – can provide care on-demand and reduce hospital admissions. Telemedicine equipment is inexpensive to implement and nearly universally available, with high-speed internet accessible even in most rural locations. In a 2018 study, a telemedicine after-hour program in a facility with 365 patients was able to prevent 91 hospital admissions over the one-year period of study, with a net anticipated saving to Medicare of over $1.3 million.
Allowing telemedicine visits within the regulatory framework and updating clinical requirements to be consistent with the science regarding rehospitalization would make possible on-time care, high patient satisfaction, decreased hospitalizations and decreased administrative burdens on our already stretched nursing facilities.
We must modernize federal regulations to allow both urgent and follow-up visits to be provided by telemedicine. Creating an enhanced standard such that all people need to be seen within the first week of admission and allowing telemedicine visits to meet the monthly visit requirement would go a long way toward solving the clinical care gap.
We call on Medicare to update its regulations if we truly want to improve care for America’s most vulnerable population – our seniors.
