West Des Moines, Iowa-based UnityPoint Health prides itself on being on the leading edge of palliative care. The fourth-largest nondenominational health system in the U.S., which estimates a patient load of 4 million visits per year, was a winner of the 2013 Circle of Life Award for its integrated approach to serving palliative care patients.

The system is further innovating by testing palliative telehealth in a nursing home and patients' homes, with pilots running in Ft. Dodge, Iowa and Peoria, Ill. Lori Bishop, executive director of clinical transformation and palliative care for UnityPoint at Home, said the pilots were designed to gauge the ability of remote palliative care to extend the system's resources beyond its physical locations and also to gauge the timeliness of providing palliative services to patients with serious illnesses.

"Our ultimate goal is the widespread adoption of this if we can demonstrate the value," Bishop said.

The pilots have not been large in the number of patients served – Bishop estimates about 20 are taking part in the nursing home-based pilot in Ft. Dodge and that 50 to 100 will take part in the home-based pilot in Peoria. But Bishop also said the sea change in reimbursement models, plus simple consideration for the needs of seriously ill patients, make testing remote palliative care imperative.

"In a fee-for-service world it may be counterintutive, but in a value-based world and population health world, it makes perfect sense," Bishop said. "You want to be timely and responsive to the individual who is seriously ill, you want to minimize their burden, and palliative care is really growing for us, so we are trying to find ways to extend our providers and reach our population in a timely manner.

"So while there isn't reimbursement per se for some of these visits, negating a billable visit potentially, we're decreasing the patients' burden of transportation, wait time, and having to go to an ER, which a lot of these folks do because of their symptom burdens. When they don't get into the clinics in a timely manner they end up going to the ER. And of course, most of these people would prefer to be able to have their needs met in their homes. That's where we see the value."

Currently, the pilots' staffing consists of two physicians, a nurse practitioner, an RN case manager, and a half-time social worker in Ft. Dodge, and one physician, one social worker, and an RN case manager in Peoria. In the nursing home, the bedside technology is a tablet, owned by the nursing home, brought to each patient's bed as necessary. In the Peoria pilot, the UnityPoint staff will be bringing the end user technology with them as they visit patients at home. Monique Reese, vice president of clinical services and chief clinical officer of UnityPoint at Home, said the organization expects to combine its 15 years of experience in creating telehealth services plus its experience in serving more than 20,000 patients with palliative care to fine-tune the service.

"As we look at the difference between the larger population and the palliative care population, the foundational components are very similar," Reese said. "What may be adapted, it wouldn't matter what the population was – we'd design the service around the needs of the patients and being able to have the flexibility to meet the individual patient's needs." The telehealth approach, she added, can also serve to stretch the ability of the relatively small number of board-certified palliative providers to reach more patients.

In terms of selecting patients for the pilots, Bishop said UnityPoint looks at prospective patients' overall health status. Those patients for whom leaving their home surroundings would be an undue burden are best able to use the service, she said. UnityPoint also targets patients who are high ED utilizers.

The pilots are not intended to supplant in-person visits, Bishop notes. In fact, because the Peoria pilot is being conducted in patient homes, the RN case manager and social worker are bringing the video device to the patient, so the in-person component is built in. In the Ft. Dodge pilot, UnityPoint staff and nursing home staff have built a more collegial relationship around the service.

"In fact, sometimes we have to be careful because we want to make sure we support the relationship for the primary care provider first and foremost. Palliative care is really consultative. So some of what we're doing is looping back with the primary providers to make sure the appropriate provider got triggered for those patents in the nursing home."

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