How to do telehealth for the elderly: Business models for skilled nursing vs. home care — Lynda Arnold, On Site for Seniors

What are the biggest challenges for making telemedicine work in a Skilled Nursing Facility? For the homebound Assisted Living Facility? How can you make a SNF primary care practice work financially? How can you use telemedicine to improve care for frail elders? Join wound care specialist and On Site for Seniors cofounder, Lynda Arnold, NP, as she discusses the problems of providing telehealth in SNF versus home patients and how their team has implemented their hybrid telehealth model for long-term patient care.

– what are the payment and reimbursement challenges for SNF vs. homebound ALF
– how to create a sustainable hybrid telehealth model for both
– what does a telemedicine set up with multiple sites and facilities look like

About the Speaker

Lynda ArnoldLynda Arnold is the Founder and Board Secretary of On Site for Seniors, providing holistic care services for assisted living facilities, skilled facilities, and home patients. Raised in northern Idaho, Lynda graduated with a Master’s degree in Nursing from Gonzaga University in 2006. She completed her Wound Management training at the University of Washington in 2003 and is board certified in wound care by the WOCNB. Known as a gentle and resourceful provider, Lynda has a passion for caring for frail elders without access to health care. She has over 15 years experience in wound care. Outside interests include gardening, hiking and bicycling.She is also involved in training women for ministry in local churches. More info:

Audience Q&A: 

1: How do you capture cost savings and or efficiency?  [Brian Pratt]

— We in the process of collecting data using a caregiver/nurse survey at present.  We also track rehospitalizations/number ER visits per year. 

2: Are any of your patients or nurses using PC’s? [Ella Vining]

— Yes, but they seem to prefer the tablets and phones to a laptop because of ease of use, image stabilization and autofocus features. Since I do wound care, the “lightweight and mobile” phone has been well received (reversible camera for capturing plantar foot wounds, etc.)

3. What type of provider do you believe is best to treat patients at a SNF via telemedince? A hospitalist? How do you get provider buy-in since reimbursement is limited? [Matthew Clarke]

— For us, the faith-based family practice provider tends to be most willing to serve in this way (like being in a “mission field”). We see a combination of of NPs, PAs and MDs (ours is a geriatrician) that seem to enjoy this role. We don’t have a hospitalist, but the provider role is sometimes similar to that. It does require some “triage.” In ALFs and at home, the “presenter” on the patient’s end is often a home health nurse. They’re invested in caring for their patients and resilient. 

Whoever the provider is needs to be able to patiently guide the patient or user through how to capture important information, and be resilient enough to change direction if something isn’t going as planned. I’m not a particularly “young” provider, but I know how to use the system, redirect or adapt, and when to switch to a store-and-forward with phone call. NPs that have home health experience might do well with this. 

We can bill live telehealth visits in SNFs to Medicare and Medicaid in rural counties (4 of the 5 we serve). Psychiatric and school-based care is reimbursable in rural and sometimes metro areas through Medicare. NP reimbursement is currently lower than MD reimbursement. 

4: Why does the Telehealth Resource Center discourage implementing membership fees?

— I don’t think that the NRTRC discouraged it so much,  but rather a member of that group who tried doing telehealth that way discouraged it. I had heard that it wouldn’t work, but our options were limited. Mainly I think it had to do with the problem of membership collections from individuals. We are moving toward a sustainable model, but we have not “arrived” yet. To a degree, it is working for us because we are well-known in our community.

5: I am not sure if the system is the same for the state where you are located, but how would an provider go about assiting SNF’s and HHC with completing UAI, and other forms required for admissions that dont get completed on the front end (hospital level) prior to discharge. And do you find billing complicated or should I get someone else to do billing?

I’m guessing you’re asking about the physical aspects of getting those assessments completed. If so: We have an online fax (UpDox) that nurses can send info on. We are rarely seeing patients in the hospital setting, except for consults.

We hire someone to do our billing because we don’t like to be involved in the insurance end of it. (Too complicated and we want to take care of people, not forms). 😛 There are provider groups in town that choose to do their own billing. 

6: Lynda, how much are you are you able to charge your clients in your membership plan? [Crystal Jones]

— Ah, the final rate is yet to be determined. We chose a low “introductory rate” to introduce people to the program (less than $100/mo.) that may be too low. We will see how this pans out as the year progresses. We are blessed with multiple funding sources as a nonprofit. You’d need to sort out how many clients would be needed to sustain your program, pay the provider for time, replace aging equipment if needed, etc.  

7: During the process at what point is the telemedicine kit presented to the patient for use, and who would make that decision to administer?[Brante Hester]

 When we first get a referral (usually from a facility, Home health agency or PCP) , we call and discuss our services with the patient or their surrogate. We let them know that participation in telehealth is required to be a patient of our group. We have our office staff find out if the individual has their own computer, iPad or smartphone, and help them get set up at that time if they decide to use our services. If they don’t have any of the above, they can check out a “kit” from us. (Donations accepted! We love to have used iPads or iPhones to use for this!)

8: in the SNF setting, does the Telehealth visit with the physician, can that visit will be good to satisfy the Federal and Statae regulation for the MD to visit the resident at least 1x month?[Darolyn Jorgensen]

— That’s a good question. Since we have been doing specialty care (dementia and wound care) with a few home-based primary care patients, that question has not come up. Will have to research that one. 

9: Another question….do the primary care providers ask you to send them data, pictures, etc. to populate their EMR, etc for care coordination. How have you been able to push your medical notes into the patient chart at the skilled nursing faciity?[Lucas Figers]

— As a courtesy, we do forward our notes to the PCPs. I have occasionally forwarded images to an MD or surgeon. Currently we use an online fax and cloud-based EMR. All info is electronically input and “faxed” back to the facility. The SNF uploads the documents into their system. (Some still use paper here). 🙂

10: Would suggest that you bill your services to payers even though they may say they do not reimburse, to establish a billing legacy that helps them to understandt the extent of hte need.  It may also allow you to retroactively appeal and be paid for dates of services.[Renee Kavon] []

 Good point! Thanks Renee!

11: Have you considered adding other allied health  services?  For example: Respiratory Therapy with high incidence of COPD in the elderly [Bryan W] 

— Not yet. Perhaps in the future. 🙂

10: Do you have a handout of the protocols you use? [Ravi Kamepelli].

— We do have policies and procedures for the SNF setting. We hope to publish that towards the end of November.  Please contact me at for more information. 



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