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As patient preferences have evolved over the last decade, new forms of providing healthcare and home health services have continued to unfold. One popular trend is the rise of telehealth.

For most providers, telehealth can mean a lower cost of providing health service and for patients as it offers convenience and increased access to care.

A major component to a successful telehealth strategy and program is the ability to actively engage patients in their care. Across the healthcare ecosystem, patient and resident engagement is increasingly seen as a top strategic priority due to the opportunity to improve patient outcomes and maximize potential reimbursements. Home health agencies, in particular, are faced with some of the most significant changes in reimbursement and regulatory requirements, highlighting the importance of new, cost-effective strategies to remain competitive and profitable.

Engagement is a set of tools, processes, and actions that allow providers and residents/patients to communicate effectively to make informed decisions to improve outcomes. One common misconception is that patient engagement only happens in the home during home health visits; however, there are many opportunities for agencies and their staff to remain engaged with patients during the entirety of the episode of care and beyond. This is especially critical for skilled nursing providers tracking patients after they are discharged.

Telehealth is one way in which post-acute providers can engage patients in their care between home visits or after discharge. Similarly to how other industries have worked towards perfecting customer engagement, home health agencies in particular must follow their lead and capitalize on the benefits of engaging their consumers, or in this case, patients. If Uber or Safelite can check in before they show up, and follow up to see how your experience was after, why shouldn’t providers?

What does telehealth look like for skilled nursing?

Telehealth can be in reference to a remote biometric monitoring system, or can simply be  provided via phone calls or SMS text messages offering educational and clinical resources between regularly scheduled home health visits or post-discharge from the SNF or home care agency. Many providers use telehealth services to communicate with patients to identify any potential issues such as low supply levels or challenges with obtaining or understanding medications.

There are two ways post-acute providers carry out this type of telehealth. The first being to employ staff members or call centers to perform outreach manually or they can also leverage automated calls or texts to perform the initial outreach and subsequently connect patients to someone who can resolve the issue. While manual outreach can feel more personalized, most providers are realizing the limitations in standardization, reporting, and call volumes. Automation, on the other hand, can be standardized and has the potential to reach out to 100% of patients on census. Depending on the goals of the agency or facility, manual or automated telehealth services should be explored by those looking to augment their patient engagement programs.   

Engaging with patients between via telephone outreach can help providers address patient concerns before an adverse event occurs, such as a readmission.This can mean calls, texts, or other communication methods that prompt patients to answer questions about their status, including medication information, experience, scheduling, and more. Once patients answer, the care worker has the opportunity to proactively address any issues and ensurepatients are on a successful road to recovery.

Being proactive in trying to solve issues could mean help with clinical activities such as ensuring the patient has all of their necessary medications and is adhering to instructions. It can also mean helping with non-clinical activities such as transportation challenges. When staff members are not in the home but are still able to provide clinical and non-clinical services, there is a decreased likelihood that the patient will experience an adverse event such as a readmission or re-hospitalization. This positive outcome is beneficial to the provider, the patient, and referral partners.

In addition to the outcomes benefit, when providers add meaningful and timely patient interactions between home health visits, there is an opportunity to improve the patient and their family’s perceptions of care. Showing concern for a patient’s well being outside of home visits can reinforce positive interactions or even turnaround ones which are negative. Additionally, with telehealth programs, agency or facility staff can close the loop on potential concerns prior to the patient filling out HHCAHPS surveys, resulting in potentially higher scores.

Telehealth can augment revenue

By positively impacting both patient outcomes and satisfaction, agencies can be in a strong position to improve star ratings, increase referral volume. By employing proven telehealth strategies, agencies can drive better patient care at a lower overall cost. And with new payment programs, such as the Home Health Value-Based Purchasing Program (VBP) and the mandatory Patient Driven Grouping Model (PDGM), agencies who provide better care quality at a lower overall cost will likely see additional revenue gains.


Specifically with PDGM, starting in 2020, agencies will receive a higher reimbursement rate for referrals that come from hospitals or skilled nursing facilities compared to community referrals such as a physician’s office. With this in mind, agencies who align their goals with those of network partners, such as the hospital, will likely see a higher volume of referrals, and therefore agency revenue. If an agency can show a positive impact on both readmission rates and patient satisfaction scores there is an increased likelihood that they will become a preferred partner. Additionally, agencies with higher 5-star quality rankings will also be well-positioned under changing regulations.

For skilled nursing facilities, there is also immense benefit to proactively engaging patients with telehealth services. Similarly to what home health agencies are experiencing, SNFs also stand to benefit from showing referral sources that their care is helping to improve patient  outcomes.

Patient engagement is at the forefront of healthcare policy and telehealth is one strategy that is both effective and cost-efficient. Whether you choose to invest in health IT that will meet all of your patient engagement needs or instruct staff members to manually engage with patients, implementing patient engagement programs will have a clear impact on your agency’s bottom line.


John Banks Powell is the Vice President of Post-Acute Strategy at CipherHealth, spearheading CipherHealth’s post-acute and bundled payment initiatives.

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