The promise and practice of telemedicine in long-term care

Some say telemedicine will play a critical role in the U.S. healthcare system’s progression and in improving outcomes in LTC facilities. In fact, telemedicine and telehealth are already finding their way into long-term care, and some facilities are using these tools to reduce readmission rates or costs, perhaps without even knowing it.

The Institute of Medicine of the National Academy of Science classifies telemedicine as the use of electronic information and communication technologies to provide and support healthcare when distance separates the participants. It’s been shown to increase access to healthcare, improve outcomes and reduce healthcare costs, among other benefits.

At this time, there are plenty of incentives for LTC facilities to adopt telemedicine. Readmissions are costly, and Medicare is cracking down on them under the Affordable Care Act, in which the Centers for Medicare & Medicaid Services (CMS) will penalize hospitals for excess readmission rates starting in 2013. Telemedicine can help prevent readmissions by enabling LTC facilities that receive hospital discharge patients to monitor patient conditions remotely.

Yet the adoption of telemedicine in long-term care faces reimbursement issues and other hurdles while standards and legal precedents have yet to evolve. As a result, LTC facilities using telemedicine need to fully understand the risk management issues involved and consider it as an additional liability exposure.

Closely associated with telemedicine is the term “telehealth,” which is used to encompass a broader definition of remote healthcare that does not always involve clinical services. Telehealth monitoring includes the remote exchange of a patient’s vital signs (such as blood pressure and weight) and other biometric data (such as pulse oximetry and blood glucose levels) between patient and medical provider to assist in diagnosis and monitoring.

Whether used in real-time or through “store and forward” digital images, telemedicine and telehealth enable providers to more efficiently reach post-discharge and post-acute patients—especially those with chronic conditions—to improve health outcomes and reduce costs.


Telemedicine’s most promising benefit in the long-term care arena is the reduction of resident hospitalization and readmissions, especially for chronic disease. An estimated 40 percent of nursing facility residents are admitted to the hospital in a typical year, and one-quarter of these may be preventable. Of these admissions, about 14 percent of patients are discharged directly from hospitals to skilled nursing facilities are sent back to the hospital for conditions that could have been avoided.

The reduction in congestive heart failure hospitalizations alone can potentially save the United States $10.1 billion. The reduction in diabetes hospitalizations, $6 billion; the reduction in COPD hospitalizations, $4.9 billion. 

Telemedicine also has the potential to improve staff productivity, says William Miska, CEO of CMS Telehealth Solutions and Consulting Services. “Using telemedicine, you can free up the nurses to do a lot more,” he says.

Another documented benefit: telemedicine improves the quality of care and may improve health outcomes. For instance, sensors can be used to keep tabs on a client’s vital signs after discharge to monitor their condition remotely. Patient compliance is improved, and providers have better insight into a patient’s condition.

“This kind of monitoring will provide better outcomes for patients who may be hemorrhaging or have fractures,” Miska says. “We think this is the area with the most potential for long-term care facilities.”

In addition to these benefits, other opportunities include attracting new patients who may not have previously had access to care, and empowering patients and families to take a more active role in care and self-monitoring.


Despite all of these advantages, there are hurdles for LTC facilities to clear before they can fully adopt telemedicine. Reimbursement may be the biggest stretch. There is a lack of uniformity across states, since states have the individual authority to change legislation regarding reimbursement and must submit an amended plan to CMS for approval. Interstate licensure is often required, which is a rigorous process and requires background checks. In addition, any reimbursement for telemedicine services must meet federal requirements for efficiency, economy and quality of care. (See detailed federal requirements.)

A facility must then have the financial infrastructure to initiate a successful telemedicine program. This includes not only funding the equipment and telecommunication service, which varies widely in cost depending on the delivery method, but also the ongoing costs of preventative maintenance, management of IT aspects, staff orientation and training and emergency technical support.

Other barriers to telemedicine and telehealth specific to rural areas may include having access to spare parts, batteries and electricity, getting adequate transmission speed, the compatibility of telehealth equipment and ongoing education for complex software models.

Increasingly, barriers are being overcome. As communication capabilities evolve and portability of equipment improves, the cost of equipment and teleconnection continues to decline. The expansion of CMS reimbursement will further offset staffing and equipment costs. The next concern for long-term care will be setting the standards and legal precedents for telemedicine.


Although the American Telemedicine Association has released guidelines for telemedicine and telehealth interactions, most standards and legal precedents have yet to evolve. LTC facilities using telemedicine still need to consider it as an additional liability exposure, as most insurance companies will view it as an additional risk—even though in some cases telemedicine or telehealth services may actually reduce risk.

According to a report by risk management firm OmniSure Consulting Group, LLC, each LTC facility or provider needs to review their own telemedicine and telehealth risk management issues related to patient privacy, patient information security, quality of care, patient choice, clinical protocols, an audit trail for images and information and technology issues such as back-up equipment.

More training is also necessary, Miska says.

“So many facilities’ staff are not yet trained in chronic disease management,” he says. When it comes to chronic disease management, providers can run into major problems if patients are readmitted to an LTC facility without proper clearances, which “could jeopardize Medicare reimbursement and future referrals,” Miska says.


Telemedicine holds the promise to significantly impact some of our most pressing healthcare problems—such as an aging population and decreased access to healthcare providers. It helps caregivers manage care more closely and allows patients to take an active role in disease management.

Moreover, burgeoning healthcare costs could be reduced and insurance coverage issues could be improved through telemedicine. With the implementation of the Affordable Care Act, there will be a laser-like focus on readmissions.

If staff is well-versed in chronic disease management, Miska says that LTC facilities could very well find themselves in a favorable position to earn new business through telemedicine.

Bryan Baird is president of K&B Underwriters, LLC, an insurance program administrator providing values-based risk solutions to the senior living industry. He can be reached at (888) 760-3194

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