New Tech For Senior Care: What’s Here? What’s On The Horizon?
 Wonderful new technological devices and programs are available now, and many more possibilities are on the horizon, that apply across the whole spectrum of senior care—from self-monitoring to remote monitoring, remote doctor/patient “visits” to remote doctor/specialist consultations, daily tracking of the health status of patients recovering from serious illnesses to routine tracking of those with chronic diseases, connecting with patients living in dense urban areas to reaching those living in rural areas far from necessary medical care, and improving the quality of life of seniors living independently in private homes to helping those residing in senior communities or assisted living facilities.
 To understand the breadth of possibilities that technology presents for senior care providers and for seniors themselves, it’s helpful to understand some of the current nomenclature. While the American Telemedicine Association continues its effort to develop precise definitions for what are still rather new ways of delivering services—and although people often use the current terms interchangeably—three “big buckets” are generally accepted.
 1. Telemedicine was the earliest definition for the entire field and continues to be the term used by the trade association and by Medicare when describing reimbursing doctors for performing a service. As the field has developed, however, telemedicine now focuses more on the illness aspect of remote medical care—highly professional doctor-to-doctor communications that are often diagnostic or procedural. The actual communication may be face-to-face or only a transmission of data.
 2. Telehealth is now accepted as the broad, overarching term for anything that has to do with providing remote health-care support to individuals living in their own homes or in group homes. It usually has more to do with wellness and the remote accessing of health-care information than with illness diagnosis or procedures. Telehealth may involve anything from doctor/doctor or doctor/patient communications to remote monitoring of a patient in his or her own residence. Data may be transmitted by a device, appliance, or sensor; through a videoconference with a nurse; or by the patient testing vital signs—e.g., blood tests to monitor glucose levels—and/or responding to questions and uploading the results onto the Internet for review by and then feedback from a nurse, a physician, or the software itself.
 3. Telemonitoring (remote monitoring) refers to applications that relate directly to enhancing safety and security in a residential setting. It may involve the patient wearing a simple pendant alert device to call for assistance; an apparatus, such as a pedometer or 24-hour cardiac halter, that records data that the patient then transmits to a nurse or other caregiver via the Web or in a video conference; or sensors embedded in various locations around the home to monitor activities and trigger an alert if an abnormal activity occurs. The technology usually involves someone reviewing the data on a monitor at the caregiver end in real time, at regular intervals, or when an alert sounds—with the timeframe determined by the patient’s illness, situation, and program. That review could be every few hours, within a certain amount of time after transmission of the data, or even once a week or so, depending on what is being monitored. The technology can also determine whether a particular situation indicates that a nurse or physician should be notified immediately.
 Looking ahead, telementalhealth for people suffering from depression or early stages of dementia and telerehab, initially used for post-stroke rehabilitative care, are developing fields—particularly in rural areas and in other locations or situations where accessing providers of care may be difficult for individuals.
Telehealth and senior care
Telehealth is currently affecting senior care in two important ways, according to Deborah A. Randall, a health-services attorney and telehealth consultant based in Chevy Chase, Maryland.
 First, seniors in various parts of the country are participating in programs with their physicians, with home health-care agencies, and with a few health-care systems that are embracing this innovative approach. Health systems, of course, are anxious for seniors to self-regulate their chronic diseases as much as possible, with the hope that, by keeping their symptoms relatively steady, patients won’t suffer an acute flare-up of their illness that requires a visit to the emergency room or hospitalization any more than is truly necessary.
 “All the studies that I’ve seen that included participant reactions indicate a very broad acceptance and a positive feeling about telehealth,” said Randall. “And some of the larger studies, such as those done by the U.S. Department of Veterans Affairs, show a very significant reduction in the rates of emergency room visits and hospitalizations by telehealth program participants, as well.”
 Second, although occurring less widely, some long-term care facilities will bring in a physician for remote diagnostic triaging of patients when certain types of episodes occur rather than immediately transporting those patients to the hospital—which, in many cases, would be the financial responsibility of the nursing facility.
 “The tricky thing about that is that Medicare still does not reimburse many of these activities,” said Randall. “For example, the physician’s remote diagnostic review of a patient living in a long-term care facility may be reimbursable (under current Medicare regulations) only if that patient is in an acute-care setting and receiving Medicare Part A skilled-nursing services.”
 Medicaid reimbursement varies from state to state. Some states reimburse for virtual video visits with a physician but not home telemonitoring; other states will reimburse for home telemonitoring under certain conditions. Some state programs require the patient to be active in a certified home-care program with a skilled-care reason for the monitoring. And some states don’t reimburse at all.
 Third-party insurers, however, seem to be taking a longer view of the benefits of this type of early intervention, according to Randall, and are increasingly interested in how it can help avoid a lot of the expense associated with in-hospital stays. Kaiser Permanente, for example, has been investigating and testing telemedicine/telehealth for some time as an adjunct to its health-care system.
 But where is the patient in all of this? “Many people devoted to senior care are concerned about patients being moved around like chess pieces in the reimbursement game rather than taking a central role,” said Randall. Nonetheless, there appears to be a desire by those in the health industry, as well as the Medicare and Medicaid programs, to figure out ways to lower unnecessary medical costs while improving the safety and efficacy of care. And because reimbursement is the biggest barrier at this point, one resolution might be to make telehealth activities part of a global episode of care.

 Actually, health reform under the Affordable Care Act includes some interesting areas that strongly emphasize telehealth. Independence at Home (scheduled to begin in January 2012) is a demonstration program for a new form of care delivery, focused on geriatric medicine and primary care, in which physicians and/or nurse practitioners would head health-professional collectives that would deliver care predominantly to people in their homes vs. in an institution or a physician’s office.  “A heavy underscoring of the use of telehealth is built into the legislation for this demonstration program,” said Randall. “So I believe the use of remote monitoring—distance education and video visits in lieu of some regularly scheduled in-person nurse visits, except when those appear necessary—is not just promising but probably inevitable.”
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