Issue link: https://beckershealthcare.uberflip.com/i/759111
31 Executive Briefing more tools for identifying gaps in care. With these tools, pro- viders can close gaps in a timely manner through virtual care encounters that can surface the need for medication adjust- ments, periodic labs associated with chronic conditions or overdue specialist visits. 4. Plan and coordinate personalized chronic care: Telehealth makes personalized chronic care planning manageable and affordable. Integrating remote device patient telemetry for pa- tients with chronic conditions into EHR and analytics infrastruc- ture enables real-time monitoring with alerts personalized to each patient's diagnosis and treatment plan. However, the sys- tem is designed to avoid "alert fatigue" among clinicians. 5. Coordinate and monitor discharges to skilled nursing fa- cilities, long-term acute care, rehab and in-home care: For pa- tients who are discharged to SNFs, LTACs, rehab facilities or with in-home care orders, telehealth enables timely two-way video communication between the discharging acute care providers and the attending providers at the intermediate facilities or with those providing in-home care. Virtual video visits at intermediate facilities or with in-home providers com- bined with vital signs and other patient data enables timely medication adjustments, changes in wound care and other treatment that can drive down avoidable readmission rates. 6. Telehealth as a reliable source of disease burden docu- mentation and risk adjustment: Documenting disease bur- den and related risk adjustment are key components of val- ue-based care programs that involve risk sharing. Telehealth services can be configured to capture the data required by various value-based care incentive programs, specifically the data required for the Hierarchical Condition Categories, to document the case for risk adjustment. Documenting disease burden is relevant for healthcare organizations participating in QHP/ACA, Medicaid and Medicare Advantage Plans. 7. Risk adjustment involves accurately capturing all aspects of a patient's conditions so the difficulty of managing and treating a specific population segment can be appropriately measured and valued under value-based care performance programs. Virtual care through telehealth lowers the barri- ers for providers to establish multiple patient contact points enabling providers to readily pick up and capture disease burden data. Using telehealth-enabled virtual visits to doc- ument patient disease burden and establish risk adjustment parameters enables health plans to optimize Medicare and Medicaid payments to health systems. 8. Internet of telehealth things and in-home presence services: Capturing actionable, relevant data from the growing array of consumer and medical grade devices and services — the 'Internet of Telehealth Things' — and coordinating with in- home presence offerings are two challenges where inte- grated telehealth services can give healthcare organizations more options for monitoring and delivering affordable care in the patient home. Data from mobile devices, applications and wearables can provide useful diagnosis and treatment insight when com- bined with an accurate medical history and presented in providers' EHR-based workflow. Home-based activity sen- sors can be used to establish normal and abnormal patient activity patterns and issue relevant alerts to family members and/or home health providers. Voice activated 'smart' assistants like Amazon's Echo and similar applications/devices from Apple and Google are configurable today to provide patients with generic answers to common health questions. Voice activated smart assis- tants in the future will be secure and configurable to specific patient conditions and care plans creating a new opportuni- ty to extend personalized care to the patient home. In addition to the various wearables, organizations like Pag- er.com, Matrix Medical and Heal.com offer on-demand and scheduled in-home licensed provider exam and treatment services that can be an affordable, timely and convenient alternative where a virtual visit with an in-network provider is not optimal for the patient's mobility limitations, location, condition or preferences. Organizations like Iggbo can dis- patch licensed personnel to obtain specimens for labs at patient homes or places of work. Virtual Value-Based Care Outlook The key tactical elements of a successful virtual value-based care service for healthcare organizations will be: • Health systems and health plans move beyond telehealth as a limited, third-party low-acuity service to offering virtual care services for primary and specialty care with full reve- nue cycle integration • Healthcare systems leverage existing EHR and analytics infrastructure investments to support targeted telehealth solutions and services matched to incentive program per- formance targets • Health systems and plans tie utilization of integrated telehealth solutions to specific quality and incentive program metrics • Healthcare systems and plans focus telehealth solutions and virtual care services on transitions-in-care, closing gaps-in-care and delivering affordable chronic care plan- ning and management • Healthcare systems and plans use virtual care encounters to deliver the detailed disease burden and risk adjustment documentation required by CMS Virtual care delivery should be a transformative strategic initia- tive for all healthcare organizations. Successfully empowering virtual care delivery for healthcare consumers, patients and providers requires deep knowledge of telehealth technology and the healthcare industry. Integrat- ing virtual care with next-generation incentive programs and electronic health system workflows will be a key requirement for telehealth success. n Founded in 2009, MDLIVE is a visionary and pioneer in the digital delivery of high-quality, cost-efficient virtual care for medical and behavioral health conditions. The company provides consumers, health plans, health systems and self-insured employers with 24/7/365 access to its network of board-certified doctors and licensed therapists. MDLIVE is pioneering applying virtual care technology to close gaps in care to improve quality performance scores and financial incentive performance. www.MDLIVE.com.