Telehealth for aged care
When the federal government announced the introduction of its telehealth scheme last year, it pinpointed the aged care sector as one area that telehealth could potentially have a revolutionary effect. Under the scheme, it introduced new incentives and MBS numbers for specialist video consultations with residential aged care facilities, providing a one-off, lump sum payment to eligible nursing homes that register with Medicare Australia.
It also introduced MBS rebates for specialists undertaking a video consultation and a rebate for the aged care provider itself. One of the main problems with the scheme, however, is that it excludes general practitioners.
For aged care providers, the aged care on-board incentive consists of a one-off, $6000 payment paid upon the lodgement of the first claim for hosting a telehealth consultation. This was to be reduced to $4800 on July 1 2012, and then to $3900 in 2013 and $3300 in 2014. That last payment has now been scrapped, as it has with the GP and specialist on-board incentive.
The telehealth hosting service incentive provides an ongoing, monthly payment based on the total number of telehealth consultations by the aged care provider over the preceding month. In the original scheme, this amounted to $60 per consult up to July 1 2012, $48 in 2013, $39 in 2014 and $33 in 2015.
Specialists are able to claim the normal MBS attendance items, with a derived fee adding to the base item fee when conducted by video conference. However, the exclusion of item numbers for GPs at the patient end has caused some disquiet. There is also no rebate for GPs doing a video consultation with a patient in a nursing home from the GP’s practice.
The AMA in particular has opposed this move, saying it had highlighted problems with ongoing access to medical care for residents of aged care facilities for many years. An AMA spokesperson said the telehealth initiative provides incentives for aged care providers to set up video conferencing facilities, but that it was “extremely inefficient” for these facilities to be used only for referred specialist consultations.
“Medicare rebates for GP video consultations to residents of aged care facilities will improve the efficiency of providing follow-up care by general practitioners, and ensure full use is made of the video consultation infrastructure in aged care funded by government,” the spokesperson said.
“Similarly, there are rural, remote and outer metropolitan patients who have difficulty attending general practices because of mobility problems or because of distance. Medicare rebates for GP video consultations to these patients will improve the efficiency of providing follow-up care by general practitioners, and ensure full use is made of the video consultation infrastructure funded by government.”
One general practitioner who has experienced this disparity is Igor Jakubowicz, a GP in outer suburban Melbourne who acts as the main provider of medical care to residents of the Martin Luther Homes aged care facility in The Basin. Martin Luther Homes is an 88-bed residential aged care facility with 51 units for independent living. Of the residential beds, 16 are low care, 30 are high care and 42 are dementia-specific. The high-level care rooms are specifically designed for those in a frail condition.
While he doesn’t actually get paid for it, Dr Jakubowicz recently took part in a trial of video conferencing at Martin Luther Homes, aimed at finding out if this sort of service was worthwhile or not. “I would use this whenever I can but I’m not paid for it,” he says. “The MBS item number is for patients seeing a specialist — the aged care facility is considered an area of need but it only applies to specialists, so GPs don’t actually see those benefits as they have to physically attend the nursing home anyway.”
While the trial at Martin Luther Homes was considered successful, with patients reporting an improved understanding and knowledge of their conditions, reduced anxiety and an increase in their quality of life, it also found that there was some major barriers to overcome before wider uptake can be expected.
One problem is the shortage of specialists willing to provide the service. For aged care, the obvious specialties are those such as dermatology and urology as well as private geriatricians, but as Dr Jakubowicz says, it’s hard to find specialists who want to give it a go. “There are a small number of them,” he says.
“They would say this is best for follow-up consults – most want to first see the patient in the flesh. But we have a dermatologist on board and what happens is there is a referral and if they are looking at a specific skin lesion you can do a high res photo and you can send it in advance. If you have a good webcam, you can do a close up and it’s high quality.”
Dr Jakubowicz says the success of any telehealth program in aged care will depend on the motivation of both the nursing home and the specialist. “There is a dearth of specialists out there so it is up to the government. The specialists have no incentive really.”
Dr Jakubowicz worked on the trial with a semi-retired dermatologist called Doug Czarnecki, who has offered his services to areas of need such as northern Tasmania, where there are few dermatologists to be found. Unfortunately, while Dr Czarnecki was willing, it seems the aged care providers weren’t.
While many GPs and specialists would prefer not to work out of hours, some like Dr Czarnecki are more than happy to do so. Dr Jakubowicz strongly suggests the government consider an MBS item number for GP consultations in aged care, which he says will vastly improve the uptake of the technology.
This is something that the Australian National Consultative Committee on Electronic Health (ANCCEH) has also recommended. In a discussion paper on the development of a national telehealth strategy released by the ANCCEH in November last year, it described the exclusion of GPs, as well as allied health professionals such as occupational therapists, psychologists and clinic nurse coordinators, as “unhelpful”.
The ANCCEH discussion paper quoted figures from an Access Economics report into telehealth for aged care from November 2010, which detailed a cost benefits analysis of the introduction of telehealth intervention into existing aged care programs. Access Economics modelled three pilot sites: one in Townsville, one south of Wollongong and the other in an area west of Armidale in NSW.
The results of that modelling demonstrated that over the two-year course of the intervention, net financial benefits were expected to be $6.6 million. This figure is a 61 per cent return on investment.
According to the ANCCEH, based on these attractive percentages, telehealth for aged care should remain a government focus, with more targeted and aligned funding for areas such as GP consultations and community nurse or nurse practitioner consultations. It also suggested some specific current and new areas for focus across the aged care continuum including wound management, dementia support, mental health support related to social isolation, and comprehensive geriatric assessments.
For the aged care sector as a whole, the ANCCEH said video consultations for residential aged care was only the first stage, followed by aged care in the home.
According to the paper, both would require:
- A choice between mobile and non-mobile telehealth video installation
- A mechanism to reward GPs for video consultations with both the elderly and the nurse or carers involved (home and residential care)
- The ability of specialists to support residential aged care without GPs in attendance and possibly with GP referrals
- Aged care is essentially a team-based activity due to co-morbidities. As such both point-to-point and point-to-multipoint telehealth services (especially involving allied health) need to be provided along with adequate quality of service
- Service provision via telehealth needs to be widened to include clinical discussions (such as pre-acute admission issues, case conferencing and dementia assessment) and for improved administrative coordination
- Supporting enhanced clinical care in-situ where nurses can obtain telehealth-based support from other clinicians (i.e. for palliative care) and to better co-ordinate treatment
- An understanding that the burden on nurses will increase with increasing telehealth deployment and, as such, nurses required greater support
- A recognition that the facility service fee for aged care establishments using video consultation ($60 per session) is unlikely to be an aid in adoption as the average size of an aged care facility in Australia is 71 beds.
Figures for the uptake of telehealth initiatives in aged care are not available, but perhaps in recognition that aged care – both residential and in the community – stands to benefit the most from telehealth, the government announced a new program in May to provide extra funding for pilots of telehealth programs with an emphasis on aged care, palliative care and cancer care. The catch, however, is that these pilots much be in areas enabled by the National Broadband Network.
Invitations to apply for the program, which involves $22.2 million over three years, were issued in April, with winning tenders to be announced shortly. Jointly sponsored by the Department of Health and Ageing (DoHA) and the Department of Broadband, Communications and the Digital Economy (DBCDE), the program has been designed to promote telehealth in NBN-enabled areas.
“Telehealth can solve the tyranny of distance by using technology to bring health services that are sometimes only provided hundreds of kilometres away from the patient’s home right into their living room,” Health Minister Tanya Plibersek said in the announcement. “We want patients to get the health care that they need, when they need it and where they need it.”
The program also aims to provide coaching and healthy living support in the home to improve overall health outcomes for older Australians or those living with serious illness. In its guidelines to applicants, the government said it expected the amount of funding provided for individual pilots will generally be around $1 million to $3 million. “Higher levels of funding may be available for pilot projects that are able to demonstrate exceptional prospective benefits,” the guidelines state.
Funding can be used for a number of capital and infrastructure purposes, including:
- equipment, for example telehealth monitoring equipment, tablet devices or computers service delivery (unless this is funded through alternative sources)
- cost of access to broadband internet services (e.g. for patients to participate in the trial)
- staffing and on-costs, including appropriate training for healthcare practitioners and patients
- administrative costs (including legal, accounting and insurance).
Funding can also be used for the initial establishment of secure networks, licensing software and patient internet access where it does not already exist in the practice.
“Project funds would cover the costs of managing and operating the telehealth system for the duration of the project,” the guidelines state. “Any ongoing costs beyond the project’s life, would be the responsibility of the applicant.”
In the May budget, the government also announced funding for a new $8.1 million trial of in-home telehealth for 300 veterans living in communities soon to be linked to the NBN.
Commencing later this month, the trial will demonstrate the potential for tele-monitoring and video consultations to improve the management of the complex chronic conditions often suffered by veterans and to reduce preventable hospitalisations.
Posted in Australian eHealth