This article is sponsored by CareXM. This article is based on a discussion with Mark Salley, VP of Innovations and Rehab Solutions ElaraCaring and Ellen Kuebrich, Chief Growth Officer at CareXM. This discussion took place on August 22, 2024 during the HHCN FUTURE Conference. The article below has been edited for length and clarity.
Home Health Care News: Today we have Mark Salley from ElaraCaring, one of the nation’s largest providers of home-based care.
ElaraCaring has a footprint in 18 states, in the Northeast, Midwest, and Southwest, with approximately 26,000 caregivers in more than 200 locations, serving over 60,000 patients and their families every day. Ellen Kuebrich is with CareXM. CareXM helps home health hospice and health system providers lower costs and increase clinician capacity with high-touch, proactive triage technology and services, including 24/7 nurse triage, medical answering service, RPM and telehealth, and patient engagement solutions.
As we know, the health care industry is facing significant staffing shortages and rising patient demands. With that as the backdrop, I’m wondering if you can both discuss how virtual health technology addresses these challenges and why is it so crucial given this landscape?
Mark Salley: CareXM and ElaraCaring have been working together for quite a while now, and it’s going to be nice for us to be able to share the things that we’ve worked on together in the past, what we’re currently working on in pilot setups today, and talk about some strategies for the future.
The problem, as you set it up, is that our challenges are related to staffing. We know that there’s a shortage of clinicians in the community, and along with that, the cost wage increases that go along with that. The second was the complexity of our patient population. As patients are coming to home care, bypassing nursing homes and rehab centers, it becomes a bigger challenge for us. Patients need more care in the home. I would add one-third, which would be financial, and that’s everything that we just heard about in the last session here, regarding our, let’s call them partners, in the insurance world and what challenges that has for us.
How can virtual health care help with these challenges? I know we’re going to talk about a lot of topics. I’ll just bring up one as an example here, to say that in home care, a very unique situation where we’ve got clinicians driving all over. At ElaraCaring, our average amount of time to drive is about 15 to 20 minutes, but that’s just an average. We are in some very rural areas as well. We could be driving twice that far.
To think about how utilizing virtual can help to alleviate the staffing crisis, give us a better opportunity to take more patients. We know right now that 50% of all referrals coming to home care are actually that home care agencies are able to accept. With virtual, hopefully, we can accept more of those referrals. Of course, with virtual, the hope is that we’ll be able to do these services at a reduced cost.
HHCN: Yes, great. Ellen, thoughts from you on this one?
Ellen Kuebrich: Yes, I think that you’ve got really three immovable constraints. We’re not going to see a let-up in the staffing crisis. We don’t have as many people entering the workforce. We’re seeing that birth rates are lowered. We’re also seeing holds on immigration. There’s not going to be a magical fix for the workforce. We would love a magical fix for reimbursement, but if history is a predictor of the future, we may not see that either. Then you’re going to see that we have this immobile wave of people coming in that are going to demand health care in the home. I think the challenge for providers and operators is we feel like we’re in a really tough spot.
I don’t think it’s if we need to innovate, it’s when we need to innovate, and we need to innovate now. Virtual visits provide a lot of capacity for clinicians that they didn’t have before. You’re able to get better access to care for your patients. As Mark said, we are accepting patients in more and more rural areas that don’t have as much access to care. One benefit that we have is it’s not a replacement in any way. For an in-person visit, it’s a supplement. All of a sudden, you’re getting into high-touch, high-tech care, which is improving the patient experience and their outcomes, but you’re able to do it at a reduced cost and a reduced amount of time.
HHCN: Yes, great. That word efficiency has come up in a few panels already today. Glad it’s making an early appearance here. With the increasing need for operational efficiency, how does virtual health technology help reduce clinician burnout specifically and streamline that health care delivery?
Kuebrich: I think Mark has a really good point, and that’s what we see with our other clients that are doing virtual visits with us. The average amount of time for an in-home visit ranges from 50 minutes to an hour, and that includes the drive time of 15, 20 minutes on either side capping that visit. A virtual visit, in contrast, is 15 to 20 minutes, obviously with no drive time. We found with Enhabit, for example, that they had their virtual visit team able to do 50 patient visits per week where their on-the-ground team was doing 20. Two-and-a-half times capacity for those clinicians. They’re able to see more patients.
I also think that there’s a very emotional connection that our clinicians have to our patients that does need to be addressed. This is something Mark and I have talked about, if you feel like that patient needs you in their home, but you’re actually able to connect to your patients more frequently with a virtual visit, and it doesn’t feel like they’re getting less personal time with you. It’s still just a way to increase that touch. I think the capacity relief is one thing for nurse and clinician satisfaction, but I think also the ability to maybe see a patient more often than they would have been able to with just in-person visits alone really fulfills them in their need to give care.
HHCN: Great. Mark, anything you’d add?
Salley: I get the opportunity to meet with a lot of our field staff on a fairly routine basis getting around the country. Before I share with them what I’m there to talk about, I like to give them an opportunity to share with me. I often hear about the stresses that they’re dealing with, and if I could point out the two biggest would be documentation, which we heard earlier today, the vast amount of documentation that they are currently doing, the time that it takes for them to get that into our EMR. We were promised when EMRs came along that documentation was going to be easier. I don’t think that that’s held true.
The other stress that I hear them say often is the complexity of the patient and how they’re alone in the community. They just feel this pressure, this high level of responsibility to improve the lives of the patients that are becoming more and more challenging. Using technology to help our nurses, I can share that this year we implemented a new technology called Swift. I’m sure many of you have heard of it. It’s a digital wound care management tool, and it gives our nurses the ability to take a high-quality digital picture of a wound. That picture does something that the nurses used to have to do themselves, measures the length, the width, and even the depth.
We’ve helped them in that regard, helping them just take that burden off of them. From a virtual perspective, I can see now how our wound care specialist, who’s now able to support all of the nurses throughout the entire service area without actually having to drive to all of those patients, she can now see all of those wounds, see which ones are improving, which ones are not, and then what I’d like to see is a virtual visit along with that.
Maybe it’s the in-home nurse with the patient and our wound care specialist, and having that three-way conversation, maybe our specialist needs to help teach the patient a little bit more about the complexities of wound care. Now, our nurses feel a bit more supported with these very difficult patients in the community.
HHCN: Mark, curious on the rehab programs that ElaraCaring offers. Any examples you can share there on how you’ve integrated virtual visits?
Salley: Yes. I’m blessed at Elara. I have a wonderful partner in my therapy role who helps the company everywhere in the South. I manage just the Midwest and the Northeast. Phyllis and I have wanted to get into virtual visits for some time. As we thought about it, we realized that we needed to build a better electronic platform before we could implement virtual visits for therapy. It’s a little bit different from nursing. About a year and a half ago, we implemented the MedBridge Home Exercise Program system, which I hope many of you have heard.
In the therapy world, MedBridge is the leading HEP company. It’s fantastic. It gives us wonderful home exercises, videos of the exercises that we want our patients to do. It also gives great educational material to go along with teaching the patients about maybe the total knee that they just had, teaching patients how to get off the floor if they fall. I used to have to demonstrate that myself. Now, I’ve got the video to help. This year we just added another technology called Constant Therapy. It’s relatively new in the market in homecare.
Constant Therapy is designed for our speech therapists. Constant Therapy addresses the cognitive and speech language issues that our neurological patients have. This platform is similar to MedBridge in that it helps them to develop a home exercise program. It has some built-in AI in it. It’s fantastic how once the speech therapist sets it up, and our patients can perform these activities on their own, when the patient answers questions accurately and quickly, the system automatically makes the next question more difficult. When we’re not there, the patient is actually progressing on their own. Our clinicians are seeing that progress.
We haven’t implemented virtual visits yet for therapy. We’ve got the platform in place. As of now, we’re in the middle of a pilot project with CareXM. We’re utilizing their platform to do visits, all disciplines, but with our therapy team, thinking about how they can now use the technology that we gave them. Then the next step will be being able to do visits remotely, augmenting what they do. Both systems allow them to change and alter the exercise program according to how the patient’s feeling, making it harder or easier.
Kuebrich: I would say it was a comment made earlier that you should ask your technology vendors to make changes or to help you to innovate. Mark asked for some features that we haven’t had in the clinical nursing virtual visits, but screen sharing and turning a screen around are being added so that he can show exercises. I would say ask your vendors. They’re partners with you. We want to help improve care and make it easier for your clinicians to do their jobs. If there’s innovations like Mark had for therapy, we want to hear about them.
HHCN: Have you found any difference in how patients in rural areas are able or willing to access virtual care?
Kuebrich: I can speak to that. One thing we’ve seen over our history with virtual visits is you can’t make it hard to do for a patient. While I would disagree that our patients are not tech-savvy at all, I think we’ve gotten beyond that. Everybody’s got cell phones these days. It’s not that wild for them to be using a cell phone. If you pulled out your phone right now, I’d be surprised if any of you had less than 100 apps on your phone. What’s not useful is when you give them a specific app, and then they have to remember, what’s the app? What’s it look like? In time for my visit, now I’m late for my visit.
It’s just not a successful way for them to access care. We developed a way where the system just sends a link to their phone via text message or email that they just click on, and they’re in a secure virtual visit. Making it really easy, whether they’re rural, whether they’re urban, we found that it really improves compliance with keeping those visits and makes it nice for the patient.
I don’t know if any of you have had people over your house, and you’re rage cleaning for an hour before, just trying to get everything ready. It’s so stressful having somebody come into your home, and it’s tiring for an elderly patient. I think that we’ve moved beyond the mindset that this is not as good as a physical visit. It in no way replaces it, but in a lot of ways, it’s actually caring for your patients better when you’re not having them prep the home. They’re not having to prepare tea to have with you. They’re just able to hop on, have a quick visit, get that face time with their provider, and then go about their day.
Salley: If I could just add to what Ellen said with regards to the quality of the virtual visit. The NIH did a study last year looking at the effectiveness of virtual visits during COVID. They found that 97% of patients were very satisfied with the virtual care that they received during the pandemic and that there was a higher amount of satisfaction using video with audio versus audio alone. When it comes to the rural areas, I’d say the biggest challenge is the access to that technology if they have high-speed Wi-Fi service. That’s what we see as the issue in some of our rural areas.
HHCN: I just want to make sure, anything else either of you want to say in general how virtual visits stack up against in-person visits in terms of things like reliability and outcomes, things like that?
Kuebrich: Yes, we’ve seen nothing but positive reactions from patients. As Mark said, there’s been studies that show that there’s a really high satisfaction rate. I would also encourage all of you in all sectors of care to really think of how you can use this technology in ways that maybe you haven’t thought of before. Obviously, home health, really easy to do a clinical visit for virtual care, but we actually have a large number of hospice clients that find that this is a really strategic way to use virtual care as well.
When you have a hospice call, and you’re sending a nurse to the home, but it is a transition call or a death call, and you have a family that is in the worst state that they’ve ever been, it’s actually really helpful to say, “I’ve got a nurse on the way, but I’m going to do a virtual call with you right now,” so that they have a nurse face-to-face to give them that compassion and empathy. Even though they’re not providing the care, they are providing that communication. That’s then where we see outcomes in CAHPS surveys with timeliness of care, efficacy of care, even though this wasn’t an official visit, this really improved their care experience along the way.
HHCN: Terrific. Mark, anything you would like to add there on just general acceptance and reliability?
Salley: I’ll say from a technology standpoint, we’re right now analyzing our constant therapy program, and it’s amazing how much activity is happening when we’re not in the home. To say that for every hour that our speech therapist is in the home with the client, the patient is spending another 7.2 hours. That’s pretty impactful. We know that they’re going to be healing much quicker, learning much quicker if they’re doing it on their own.
In therapy, we’ve always had the question of whether or not people were doing their home exercises on their own. Both MedBridge and constant therapy give us this ability with technology to start to measure the acceptance and the engagement of the patients to what we know, and we feel is important for them.
HHCN: As a journalist, I love to hear stories. Are there any success stories you want to share in terms of whether it’s ElaraCaring or other clients, how they’ve started to integrate this technology?
Kuebrich: Yes, Mark and his team have just really started the virtual visits. They’re much more down the road in our remote patient monitoring and patient engagement. We do have another client that really found that the virtual visits allowed them to scale census as well as really pay for themselves with reduction in readmissions and revocations. They have, gosh, seven, eight states doing virtual visits.
I will say that one of the strategies I’d recommend if you’re considering a virtual visit program is it seems to be more useful to have a centralized virtual visit team, even if it’s small, even if it’s one or two people, that’s going and doing virtual visits and then have your in-person in the field team out in the field. This streamlines, they don’t have to change workflows, they’re just able to keep doing what they’re doing all day.
That tends to work a little bit better. What this client found is that they were actually able to improve census in those areas that were doing virtual visits by 15% just because they had the capacity to take on more people without adding any more staff. These are the companies I think that are going to really thrive in the next five years or so are those that are saying, “All right, we know these constraints aren’t changing. What are we changing about our business to make that work going forward?”
HHCN: What about handling rural areas with limited internet? Is that something you’re encountering at all?
Salley: Yes, a few weeks ago, I was in one of our branches in Indiana, and I was sharing with them all the wonderful things that we’re bringing their way. They were excited, but at the same time, they were concerned because about half of their population is in the very rural part of Indiana where their patients don’t have Wi-Fi. They’re wondering if they would even be able to use the technology that we’re giving them if their tablets would be connected and be able to use the various tools that we have.
Is it a challenge? It is. Elon Musk, if you’re listening, Starlink, I know that there’s certain areas where it’s working really well, and in other places, it’s a little slower, and the cost is, of course, right now too high. I know that over time that’s going to get better because I can’t see them running hardwire through the cornfields around the country in order to get us the ability to do home care.
Kuebrich: Some different strategies can come into play, too. Obviously, the cell network is getting better and better, so using a cellular signal can help with the virtual visit. For those that are truly rural, they don’t have great cell signals at all, they don’t have Wi-Fi coverage at all. We’ve also found that just some proactive patient engagement is a really nice way to increase those touch points with those patients. It doesn’t have to come via a text or an email. It can come from a phone call to a landline, and we can start doing automated engagements asking to automate those check-in and tuck-in calls.
We’re talking about clinician capacity. One of our clients said that at the end of the day, their clinicians had an extra hour, at least, to do tuck-in calls to hit their patients that they needed to see before the end of the day, an extra hour of work. They switched to our patient engagement, and now that’s done with the click of a button. They add their five patients that they need to do tuck-in calls with. We have communication preferences already built out.
At the beginning of this program, they asked each patient, do you like phone calls, do you like texts, do you like emails? I don’t pick up my phone when it rings anymore, so I would always prefer a text. We have patients that do. They’re in those rural areas. They just have a landline, and it’s a recorded message in that nurse’s voice asking if they need any medications or supplies before they head into the weekend. They’ve just saved an hour of that nurse’s time, but really proactively engaged with that patient.
HHCN: Mark, what future advancements in virtual health technology are you most excited about, and how do you think they will impact these topics we’ve been talking about, like clinician capacity and patient outcomes?
Salley: It seems like every day in the news, there’s some new technology out there for us to use with our patients. When I think about the additional testing that can be done, I would love to get that physiological data added to our remote patient monitor for the EKG, for the respiratory testing that they can do. That’s on you, Ellen. We’re going to work on that.
Kuebrich: Hey, we’re already integrated.
[laughter]
Kuebrich: You just tell me when you want it. [laughs]
Salley: When we think about all the various things that we’re doing, from communication systems, texting patients in the morning that we’re coming to see them now, to all of the technologies that we’re doing, but they’re all separate. I’d love to see the day where it can all come together. In our last session here, they were talking about putting a bit of pressure on our EMR, on our vendor, to help us incorporate that more.
We are the customers. I would love to see a world where every day our AI texts the patient, asks them questions like, “Did you do your remote patient monitoring? Can you get on there now? Did you do your home exercise program?” We already know they didn’t, but can you do it now? Did they take their medications? We should, with technology, be able to identify what patients actually need to be seen today so that instead of just going out there because it’s a Wednesday, we should be going out there because that’s the priority patient for that day with less staff, with less ability and more patients.
How are we going to manage it? We need to know that the visit that we’re doing today is the most important one for that nurse, and we heard it in the last conversation as well, so that they can operate at the highest level of their license to treat the patients that need them the most. Then the other patients that are on the list, maybe some are appropriate for a video virtual visit that day. Maybe an audio-virtual visit would be enough. Maybe they’re the ones that are seen tomorrow instead of today.
HHCN: Ellen, how about your vision for the future and how this technology is going to keep augmenting?
Kuebrich: I think to Mark’s point, I’ll tell you a story. We’re meeting with an operator that is using us for both triage and for engagement in virtual visits, and he said, I look at the visit notes every morning, the patient was great. They were happy to see me. That’s just a clear indication that we are not looking at visit prioritization. We’re looking at just visits for visits sake. I’m with Mark. We have both sides of our business. We have probably the most data about why patients are calling in in the after-hours and what failures happen during the day that cause them to need to call in.
We’ve got all of this data from our remote patient monitoring and our proactive triage with patient engagement that I would like to see AI be able to mine that data to predict who needs the visit that day, who is declining, but maybe not showing it in our nursing notes for visits, but we can tell from calls in the after-hours. That would be really interesting to me because I think that we’re going to have to continue to pinpoint where we deliver care the most effectively and where we could take a step back and do an engagement, a video visit, and where my nurse needs to be that day to help the most critical patients.
CareXM helps home health, hospice, and health system providers lower costs and increase clinician capacity with high touch, proactive triage technology and services. To learn more, visit: https://www.carexm.com/.
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