Transitional Care Management

Transitional care management (TCM) is crucial to improving outcomes for patients with complex healthcare needs. Patients with comorbid conditions often struggle with managing their health during episodes of acute illness, leading to high readmission rates and poor patient outcomes.

TCM addresses these challenges by administering support throughout the entire care continuum as patients move from one healthcare setting to another. Whether transitioning from a hospital to a long-term care facility or returning home after a prolonged hospital stay, TCM ensures patients receive the care they need when they need it – in a setting that best suits their unique needs.

This blog will cover everything you need to know to deploy an effective transitional care management program, including:

Care Coordination and the 30-day Transition Period

The 30-day transition period begins when a patient is discharged from the hospital. During this time, the patient’s care is coordinated by a transitional care manager who must provide interactive communication, both virtually and in-person.

By the end of the 30-day transition period, the patient should receive the care they need to adjust to their new care setting. There are three key components that determine the success of this transition.

  • Patient education and support: Patients and their family members, caregivers, or guardians should be educated on the care plan, the patient’s diagnosis, risk-specific interventions, and self-management tips.
  • Monitoring and evaluation: Diagnostic tests and follow-up on results from previous appointments should regularly be reviewed and monitored to assess if there is a further need for treatment.
  • Coordination of care: Care coordination is the most crucial component in your TCM program. It involves communicating the patient’s needs and preferences amongst interdisciplinary teams to ensure high-quality and high-value healthcare delivery.

Clear and effective communication is key in coordinating care among your inter-professional care team (IPCT) members. A lack of communication between care providers can lead to potential delays in care delivery, avoidable hospitalization, and overall poor patient satisfaction. That’s why it’s so important to close communication gaps by ensuring interdisciplinary teams have full access to the patient’s care plan.

With regular communication between everyone involved in care delivery, comprehensive patient care coordination can be facilitated to ensure your patients are receiving the right care at the right time, as well as receiving the resources to properly manage their conditions.

How to Provide Transitional Care Management

There are various ways to provide transitional care management. Care functions can either be carried out by one transitional care manager per patient or a team of transitional care managers who coordinate care for multiple patients. In a care management team, healthcare professionals with different roles are required to collaborate and plan for effective and timely transition of members to the community through transition activities.

While there is no one-size-fits-all method for running your TCM program, healthcare providers should take the patient’s unique needs and available healthcare resources into consideration.

Common Challenges of TCM

TCM is a proven approach to improving health outcomes and patient satisfaction. However, there are several challenges that healthcare providers should consider in implementing a TCM program.

  • Financial costs: Some healthcare organizations may face financial barriers from the additional costs of hiring medical staff to facilitate transition of care, implementing new telehealth solutions, and providing training to TCM managers and team members.
  • Lack of resource allocation: Staffing shortages, limited community resources from home health agencies and inadequate infrastructure are all factors that need to be considered when allocating resources for TCM.
  • Miscommunication in care coordination: Coordinating between multiple healthcare providers and settings can be difficult. A lack of standardized processes can lead to conflicting recommendations, unclear patient care plans, and inefficient clinical workflows.

Key Benefits of TCM

TCM offers a valuable service to chronic, elderly, and underserved communities by improving health outcomes with high-quality, high-touch care when implemented effectively.

  • Reducing the risk of hospital readmissions for chronic patients: As many as 86% of patients experienced reduced readmissions compared to those who did not engage in TCM services, according to a 2018 study.
  • Increasing access to care for patients in rural areas: By leveraging telehealth, TCM can extend care coordination to chronic patients in rural communities. Telehealth tools enable healthcare providers to consult with patients through virtual visits to increase access in areas where healthcare services are geographically limited.
  • Improving patient satisfaction: With TCM, payors and patients benefit from improved health outcomes and reduced readmission rates. Delivering high-quality healthcare is a competitive advantage that helps with patient retention and referrals.
  • Increasing patient safety: TCM ensures patient safety through collaborative care coordination. With multiple healthcare providers working together to facilitate care transition, the risk of medical errors decreases and provider accountability for patients increases.
  • Reducing the cost of care: As TCM is known to effectively reduce readmissions, providers can utilize the program to avoid value-based penalties that come from hospital readmissions within the 30-day period after discharge.

Billing & CPT Codes for TCM

According to CMS, providers must conduct one face-to-face visit within the timeframe of these two CPT codes used to bill for TCM.

  • CPT code 99495 – TCM with moderate medical complexity requiring a face-to-face visit within 14 days of discharge.
  • CPT code 99496 – TCM with high medical complexity requiring a face-to-face visit within 7 days of discharge.

How Telehealth Supports the Transition

Care transitions are challenging to facilitate in our current healthcare climate due to the rise of chronic conditions and insufficient access to skilled healthcare providers. Telehealth is an invaluable tool in navigating these challenges and ensuring the effective delivery of TCM through improving healthcare access in a convenient and cost-effective way.

Telehealth enables patients who live in rural communities to transition back to their homes easily. Patients have access to healthcare providers at their fingertips without the need to travel long distances. With virtual visits, clinicians can establish strong provider-patient connections while reducing the patient’s burden of traveling. Transitioning patients also receive essential education and support to help them adjust to their new environment with easily accessible online resources.

For patients with chronic conditions, telehealth tools are proven to help patients with chronic care management. In one example, a study examining telehealth’s effects on outcomes for patients with type 1 diabetes recorded an 88% adherence rate for scheduled telehealth appointments, with 100% of patients surveyed expressing their satisfaction with the service.

diabetes glucometer

Ongoing Care Management for Chronic Conditions

After the 30-day transitional period, ongoing care management continues for patients with chronic conditions. In these care management programs, patients are provided services with the goals of improving self-management and reducing healthcare costs. Key components of care management programs include:

One of the most effective ways to manage ongoing care is through virtual care solutions like telehealth. Health Recovery Solutions (HRS) offers a range of telehealth tools that engage patients with care management via tablet offerings, mobile applications, and biometric Bluetooth devices. By actively monitoring patients’ health in a virtual setting, providers can empower them to actively manage their health outside the hospital environment.

Elite Home Health & Hospice is proud to partner with Health Recovery Solutions to bring a comprehensive transitional care approach to your home health services.

4 Tips to Help Your Terminally Ill Loved One Prepare Financially

If you have a loved one who was recently diagnosed with a terminal illness — such as inoperable cancer or Alzheimer’s disease — your life has been turned upside down. Even if your family member struggled with their health prior to the diagnosis, it doesn’t make the situation any easier. In addition to coping with the sadness and anxiety of this difficult time, your loved one will likely need support in preparing for the future financially. This is especially true if the illness came on suddenly or at a younger age.

Elite Home Health & Hospice shares four things that you can do to provide support and assistance to your terminally ill family member.

Handle all tasks and communication with the utmost compassion

Above and beyond anything, show the highest degree of compassion and care in all interactions. As you handle tasks that can be emotional for both you and your family member, be aware of how you are communicating. Avoid showing too little emotion, as this can come off as unfeeling and hurtful. Aim to be a steady source of confidence and love through these challenging end-of-life tasks.

Find ways to help your family member pay for their medical bills

Expenses associated with terminal illnesses are often astronomical. Bills that amount to hundreds of thousands of dollars are often commonplace in these situations. Medications that provide some level of relief from pain and suffering can cost hundreds or even thousands of dollars for every refill. At a time when your loved one is already experiencing such massive distress, the last thing they should have to think about is paying their medical bills.

If your loved one needs extra funds to pay for their prescriptions and medical care, there are options available for most individuals. One popular choice is home refinancing. Refinancing either your home — or your family member’s home — can quickly free up equity for immediate expenses. Research the best refinance rates to ensure that this is the option for you.

Establish end-of-life arrangements

Another incredibly important set of tasks to handle as soon as possible are end-of-life arrangements. This includes everything from creating power of attorney, to planning and funding funeral arrangements. Most people plan to fund funeral arrangements via life insurance, though you may have to change policies after a diagnosis. In such an instance, it’s critical that you fully understand the terms of the new policy and make sure not to cancel the old policy until coverage begins.

When signing so many documents, one option to consider is using an online tool for digital signing. This makes it easier to provide legal signatures for important documents without having to worry about printing and mailing.

It’s also important to plan for or work through selling or closing a business your loved one owns. This can be a relatively simple matter if ownership is in a corporation held in stock. Other business structures can be more complex and may require legal assistance.

Of all of the things you will need to help your family member with, this will almost certainly be the most emotionally challenging. Prepare yourself for these tasks by reaching out to your support network of friends and relatives. Also, if you find yourself struggling most days, consider working with a counselor to cope with your feelings.

Ensure that their will is up-to-date

Revisiting your loved one’s will is a particularly critical task — especially if they have a considerable amount of assets. Without proper designations, some or all of their property could go to the state. Hire an experienced attorney to guarantee that the will is updated in such a way that is legally binding.

Although it can be next to impossible to think about anything other than your terminally ill loved one at this time, addressing the above tasks is an absolute must. Part of honoring your family member is doing everything you can to ensure that their last wishes and requests are granted. As difficult as that is, knowing you helped your loved one when they needed it most can be a great source of comfort in the years ahead.

For trusted home health, palliative care, and hospice servicer, visit Elite Home Health & Hospice today!

Is Telehealth really a good option?

You might wonder if telehealth really is a valid option for seeking healthcare and the opinion of a professional if they are unable to see you in person. Here are some guidelines we use when considering if telehealth makes sense for our patients.

Constitutional: e.g. well-nourished, well-developed, well-appearing, Vitals

Ears, nose, mouth, throat: e.g. normocephalic, atraumatic, external ears normal
by inspection

Eyes: proptosis, extra-ocular eye movement intact, nl sclerae, conjunctivae not

Neck: visible goiter, range of motion of neck

Respiratory: comment on increased respiratory effort

Cardiovascular: patient can palpate PMI

Chest/Breast: e.g. gynecomastia, symmetry

Gastrointestinal: e.g. no caput medusae, no tenderness with self-palpation in
supine position

Genitourinary: visual exam of external genitalia

Musculoskeletal: ROM (active & passive), nails/digits

Lymphatic: Large lymph nodes can be visible

Skin: rashes, ulcers, varicose veins

Psychiatric: anxiety level, affect, memory, tangential conversation

Neurologic: motor deficits, select cranial nerves (e.g. sticking out tongue)

Systems that allow us to gather crucial data, like vitals, facilitate the option for telehealth. Elite Home Health & Hospice pursues telehealth by issuing a system which can support weight tracking, blood pressure recording, pulse oximetry, and heart rate. Telehealth requires patients to participate in their health care assessment, sometimes by being hands on, such as depressing the skin in the shin to show edema.

Using the camera on a phone can facilitate assessment of foot ulcers: Have the patient put the camera on the floor and show you
the bottom of their feet, top of scalp, nape of neck (acanthosis), close-ups of body areas that trouble them, neurologic and musculoskeletal exams: Have the patients move their extremities for passive and active ROM etc, and even GI: self-palpation under supervision may help document rebound, guarding etc, and using a coin/ruler can help create context of the size of a lesion.

Telehealth is a brand new world in healthcare. We are excited to participate in the first steps and bring care to our communities in new ways.



Reduce Hospital Readmissions with Remote Patient Monitoring

Located in Pittsburgh, Home Health and Hospice (AHH) provides a wide variety of care services, including skilled nursing, physical and occupational therapy, speech therapy, hospice, and more. AHH utilizes advanced technology in its clinical care programs to deliver personalized care to support patients in managing chronic diseases and recovering from an illness or surgery. 


Serving communities across western Pennsylvania, including several rural communities, AHH recognized several barriers that many of its patients face when accessing health care services, including lack of transportation, increasing cost of care, and inadequate educational resources available to patients. To address these problems, AHH launched a telehealth and remote patient monitoring (RPM) program in 2019.

However, AHH continued to face the following challenges when deploying RPM services to patients.

  • Wireless Connectivity: Poor connectivity delayed the transmission of patient data and prevented the use of virtual visits meant to provide convenience to rural patients.
  • Lack of Proper Educational Resources: Without educational resources available through RPM, AHH struggled to develop disease self-management skills among its chronic care patients.
  • Reduce ED visits through monitoring and early community intervention.
  • Clinician Buy-in: Lacking educational and clinical support from its previous telehealth and RPM vendor, AHH experienced low buy-in among clinicians, derailing program success.


In January 2021, AHH partnered with Health Recovery Solutions (HRS) to re-launch its telehealth and RPM program. Through its partnership with HRS, AHH aimed to reduce care costs leveraging virtual visits, decrease hospital readmissions and adverse outcomes with real-time biometric monitoring, and support clinicians by providing advanced training and best practices for telehealth and remote patient monitoring.

AHH experienced a seamless transition to Health Recovery Solutions, including

Enhanced wireless connectivity through HRS’ 4G wireless capabilities and SIM card offering, allowing AHH to provide virtual visits. 

Increased access to condition-specific educational resources to improve patient education and strengthen disease self-management among AHH patients. 

A robust onboarding process, offering technical support, marketing resources, logistics and inventory management, clinical and reimbursement consultations, and a telehealth and RPM certification program. 

The ability to personalize telehealth and RPM services through condition-specific care plans and education.

Elite Home Health & Hospice has partnered with Health Recovery Solutions to support a robust telehealth service as part of our home health service line. If you would like more information about how to access these unique services, send us an email at

Answers To Your Top FAQs

Home health care offers a convenient and effective alternative to traditional medical care settings for those in need. By providing personalized care in the familiar surroundings of home, it promotes independence, improves quality of life, and facilitates the healing process.

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5 Ways Telehealth Increases Patient Activation

Elena Muller, MPH

For a patient to achieve good health, patient engagement and activation is crucial. This blog explores the difference between patient engagement and activation and discusses how telehealth can help improve patient activation, and ultimately, health outcomes. 

What is Patient Activation?

Patient activation and patient engagement are not one in the same. Patient activation falls under the umbrella of patient engagement. According to Dr. Hibbard, MPH, “patient activation emphasizes patients’ willingness and ability to take independent actions to manage their health and care” while “patient engagement denote[s] a broader concept that includes activation; the interventions designed to increase activation; and patients’ resulting behavior, such as obtaining preventive care or engaging in regular physical exercise.”

The Power of Patient Activation

Patient engagement and patient activation are essential for good health.  An activated patient is more likely to engage in preventative behaviors such as immunizations and annual appointments, adhere to their medications, understand their health, and have the knowledge to understand and navigate the healthcare system.

Patient education from provider

The Patient Activation Measure and How Telehealth Can Help

Many providers use the Patient Activation Measure (PAM), an 100 point scale that determines how engaged a patient is with their own health. The survey includes 22 items that are weighted to comprise the 100-point scale. Dr. Hibbard and her colleagues who developed the survey, also released a shortened, 13 item survey. Many providers collect survey responses online through the patient portal, or when the patient comes to an in-person visit.

The PAM evaluates a patient’s ability to:

  • Self-manage illness or problems
  • Engage in activities that maintain functioning and reduce health declines
  • Be involved in treatment and diagnostic choices
  • Collaborate with providers
  • Select providers and provider organizations based on performance or quality
  • Navigate the healthcare system

This tool helps providers identify the activation level of their patients, and tailor care accordingly. It helps providers “meet patients where they are.” 

Telehealth: The Best Patient Activation Tool

Telehealth helps improve patient activation by providing patients with tools to actively engage in their own health. It offers providers the tools to collaborate with their patients, and forge partnerships, as opposed to offering care at just one point in time.

When telehealth is leveraged correctly, behavior change is the result. Behavior change results in a more engaged patient, which, in turn, leads to improved outcomes, better health, and reduced cost of care. Telehealth involves patients in their own healthcare. 

“Tell me and I forget, teach me and I may remember, involve me and I learn” 
– Ben Franklin

5 Ways Telehealth Increases Patient Activation


  1. Meets the patient where they are

Every patient is different and requires a unique patient activation strategy. What one patient needs to engage in their care is likely different than their neighbor. Every telehealth care plan can be customized to fit the unique needs of each patient. For example, a patient struggling with medication adherence can leverage medication reminders, while a patient struggling with condition understanding can leverage condition-specific education and symptom surveys.2. Provides more opportunities for patient-provider collaboration

Virtual visits enable patient-provider communication beyond just one point in time. This is important because the creation of a partnership between the patient and provider is facilitated. Telehealth improves access to healthcare—it is not location dependent. 3. Helps the patient understand their health holistically

For a patient to achieve good health, a full picture of their condition is essential. For the provider, understanding their patients’ health holistically allows them to point to what may be contributing to poor outcomes and intervene or customize the care plan accordingly. A patient that understands their health holistically has more control of their health outcomes because they understand the many factors at play—activity, diet, sleep, symptoms, medication, stress, etc. Telehealth and remote patient monitoring allow the patient to track their condition over time, helping them note and understand important trends. 4. Offers opportunities for education

Health literacy, a patient’s ability to use, obtain, and process certain health information is one of the key predictors of whether a patient is activated or not. A patient who is health literate is likely motivated to take control of their health, understands the steps to doing so, and has the ability to obtain the resources they need to effectively manage their condition. Telehealth improves health literacy by providing tools for education, including videos, written materials, and teach-back quizzes. Through telehealth tools, the provider can push out condition-specific information to the patient, that the patient can engage with on their own time. The provider can also offer more opportunities for 5. Improves patient adherence to their care plan

Patient adherence, “the extent to which a person’s behaviour- taking medication, following a diet and/or executing lifestyle changes, corresponds with agreed recommendations from a healthcare provider” (WHO), is often quite low. In the United States, 1in 5 medications go unfilled and half of patients do not take their medication as prescribed. Patient adherence, however, goes beyond medication compliance. It relates to lifestyle changes, diet, showing up for doctor’s visits, etc. Telehealth can help facilitate the behavior change needed to achieve patient adherence by providing tools for medication reminders, activity tracking, nutrition education, appointment reminders, and more. 

These benefits are really just the tip of the telehealth value iceberg. Patients across their patient journey can see the benefits of telehealth in different ways, what’s most important is patient-centric care is at the center of care delivery.

The Activated, Discerning Patient

People want to be in the driver’s seat of their own health. They want to understand how to prevent poor outcomes, and how to self-manage their conditions. By offering digital patient activation solutions, providers have the opportunity to help their patients reach their healthcare goals in a more convenient, patient-centric way.

At Elite Home Health and Hospice, our goal is to provide life changing service. We believe that means identifying your goals of care and supporting those goals with the right program at the right time. We are happy to partner with Health Recovery Solutions (HRS) to support our home health patients heal and recover in the comfort of their own home.

5 Key Benefits of Remote Vitals Monitoring

Through remote vitals monitoring, clinicians can track their patient’s health in real time, take proactive steps to prevent deterioration, and identify potential health issues. This helps reduce hospital visits and readmissions while keeping clinicians connected with patients.

As the telemedicine industry continues to evolve, clinicians have access to an increasing number of clinical-grade monitoring devices to measure key vital signs remotely.

Monitoring Patient Vitals with RPM

Remote patient monitoring, also known as RPM, is a method of healthcare delivery that collects patient data outside of traditional healthcare settings using advances in information technology. As part of an RPM program, a patient’s vital signs, such as blood pressure, heart rate, respiration rate, oxygen saturation level, and temperature, are remotely monitored using digital tools and devices.

Let’s dive deeper into the five key benefits of remote vitals monitoring:

  1. Increased Access to Value-Based Care
  2. Improved Patient Outcomes
  3. Healthcare Cost Savings
  4. Enhanced Patient Engagement
  5. Increased Healthcare Provider Efficiency

1. Increased Access to Value-Based Care

Replacing the traditional fee-for-service reimbursement model, value-based care ties payment for care delivery to the quality of patient care. Implementing value-based care effectively improves patient outcomes and reduces care costs; however, it presents some challenges to the healthcare system.

Lack of resources is one of the most pressing challenges facing organizations looking at implementing value-based care. Remote vitals monitoring can help alleviate some of these challenges by helping providers increase capacity. Through virtual visits and remote vitals monitoring, providers can increase staff efficiency and focus more energy on the highest risk patients. As an average across clients, remote monitoring allows a ratio of 80 to 100 patients for every telehealth nurse.

Value-based care centers around cost-efficiency, achieving better patient outcomes, and increasing patient satisfaction. These are also the pillars of a successful remote monitoring program.

2. Improved Patient Outcomes

Checking vitals such as heart rate, blood pressure, and blood glucose levels usually requires scheduling in-person doctor visits. This can be stressful, especially for those who must take time off from work or coordinate with family members for transportation. But with remote monitoring technology, patients can share their vitals using Bluetooth-enabled biometric devices from the comfort of their homes, making it easier for patients and family caregivers to be more involved in health management, thereby improving health outcomes.

As a real-life example, patients enrolled in the remote monitoring program with Southcoast VNA are monitored daily, with clinicians responding to risk alerts based on their reported vitals and symptoms. To quickly evaluate patients and address any concerns, providers can contact patients directly via a virtual visit or text messaging.

This care model replaces at least one in-person visit a week with a virtual visit, and the additional touchpoint has significantly improved physician-patient trust and communication, while decreasing care costs and staff workload by avoiding unnecessary in-home visits.

In the last 16 months, from October of 2021 until January of 2023, the Southcoast VNA’s RPM program has achieved a low 30-day readmission rate at seven percent for 2,621 high-risk patients.

Southcoast Health Reduces In-Home Care Costs and Hospital Readmissions with Virtual Visits and Remote Patient Monitoring

Southcoast VNA saves an average of 4 in-home nursing visits leveraging virtual visits & remote patient monitoring with a 7% 30-day rehospitalization rate for 2,621 patients over the last 16 months.


3. Healthcare Cost Savings

Remote vitals monitoring can significantly reduce avoidable ER visits, unnecessary hospitalizations, and readmissions, thus reducing healthcare costs. Vital monitoring devices may help patients have a greater understanding of their disease and risk alerts can notify providers of rising patient risk. This allows physicians to have visibility into their patient’s conditions and quickly intervene—without the associated costs of a hospital admission.

Southcoast VNA was able to save an average of four in-home nursing visits annually, and generated over $500,000 in cost savings, using virtual visits and remote monitoring.

4. Enhanced Patient Engagement

In a traditional healthcare setting, once a patient leaves the doctor’s office, care delivery ends until the next visit. Practitioners lose visibility into what is happening with their patients when they are not within their sight. They can only hope that the patients are following their advice.

But with remote monitoring, this barrier is removed, and practitioners have ongoing visibility into their patient’s health condition. This can improve the patient-practitioner relationship and drive better health outcomes. It’s important to implement a program that includes multiple communication channels (text messaging, videoconferencing, phone calls) and resources to support patient engagement. Both patients and clinicians need to be fully engaged with the program to see a positive impact.


The Complete Guide to Patient Engagement

A robust patient engagement strategy comes with many benefits. Two that are most notable are improved health outcomes and reduced cost of care.

View the guide 

5. Increased Healthcare Provider Efficiency

Remote vitals monitoring can help reduce ER visits and avoidable hospital readmissions, allowing practitioners to focus more of their time and energy on patients that need them the most. In the face of an ever-worsening nursing shortage, remote monitoring is key to making healthcare delivery more efficient and streamlined. Care providers can better position their staff to support the most at-risk patients, while also monitoring and educating patients with chronic conditions from afar.

Remote Vitals Monitoring: A Holistic Care Delivery Program

Remote monitoring is a critical part of the modern, value-based care model of healthcare delivery. For patients, remote vitals monitoring provides better access to care, improved health outcomes, and better quality of life. And for healthcare providers, remote monitoring technology allows improved chronic disease management, decreased disease exacerbations, increased productivity for clinicians through improved workflows, and reduced healthcare costs.

Elite Home Health & Hospice is grateful to be a partner with HRS Health Recovery Solutions and offer a comprehensive solution for vitals monitoring. For more information, check out

One of your choices as a patient is to identify the members of your team. Elite Home Health & Hospice is pleased to partner with you and your physician to create a comprehensive care plan around your goals of care.

The Future of Telehealth

HRS Marketing

The COVID-19 pandemic has forced the world to confront a new reality when it comes to healthcare. The unprecedented impact of the pandemic has led governments and healthcare providers globally to re-evaluate their preparedness plans. One of the areas that has seen the most change is telehealth.  

Until recently, telehealth was seen as a niche field with huge potential that remains unexplored. However, COVID-19 has shown that telehealth can play a critical role in times of crisis, and its use is likely to increase in the future. This blog will explore how the telehealth landscape has changed in response to COVID-19, and what lies in store for the future of telehealth in 2022 and beyond. Legislation 

Regulators are starting to see the many benefits of telehealth and virtual care options. This is good news as it will provide more people with access to quality care. Some of the changes that have been made include: 

  • CMS continues to evaluate other telehealth services, such as the ability for Federally Qualified Health Centers and Rural Health Clinics to serve as distant telehealth sites and provide services to patients in their homes.  
  • Several states have updated their laws around access to telehealth services, including California and Georgia. A majority of these changes establish payment parity for telehealth services, ensuring providers are fairly compensated for the time and effort they put into providing telehealth services. 
  • Remote patient monitoring (RPM) and store-and-forward services are being recognized as ways to provide care for patients that may be too sick to visit the office in person. This includes patients recovering from surgery, elderlies, and those living with chronic conditions.  

These changes are significant as they make telehealth services more readily available to those who need it, including those in vulnerable populations. This will help address at-risk patients where social barriers to care prevent individuals from seeking help in person.   


The expansion of telehealth services during the pandemic has led to permanent changes in reimbursement. The continued utilization of telehealth services even after the peak of the pandemic has led to the permanent lifting of restrictions on telehealth use and reimbursement. This will continue to expand the number of reimbursable telehealth services in the future.  

However, there is one trend that will shape how this develops: the shift from fee-for-service to value-based payments. Value-based care is all about paying for the quality and effectiveness of services provided, rather than the services that patients receive. It’s a more efficient way to pay for healthcare, and has the potential to extend access to care to more people.  

But there’s one big catch: payers need to continue to pay for telehealth services. Otherwise, providers will be less likely to use telehealth, and patients will miss out on its benefits. As Dr. Joseph C. Kvedar said in his podcast, Lessons Learned from 2020 Give Us a Lens into Telehealth Adoption

“I keep emphasizing that, but it is a really important thing. There’s no quicker way to put a chill on the whole concept than to, say, have Medicare stop paying for it or pay for only a very small amount.” . 

Rising Demand & Adoption 

There are several factors explaining the rising demand for telehealth services in the U.S.  

1. Chronic diseases are becoming more common. 

According to the CDC, chronic diseases in America are one of the leading causes of death and disability and leading drivers of the nation’s $4.1 trillion annual healthcare costs. 

Patients with chronic diseases often find it difficult to visit the doctor in person. This is due, in part, to the fact that their condition may continue to change and they want to stay at home where they feel more comfortable.  

Care providers can use telehealth to better manage these patients by monitoring them remotely and keeping track of their condition. In addition, this will help reduce no-shows and last-minute cancellations, improve efficiency, and reduce costs. 

2. COVID-19 

The use of telehealth and RPM has expanded beyond chronic care patients, to include those with COVID-19. This shift is largely due to the effectiveness of telehealth and RPM in managing COVID-19 symptoms. Healthcare providers are now utilizing these tools to monitor patients who are not yet symptomatic, as well as those who are recovering from the virus. 

One way providers have been able to increase bed utilization during the pandemic is by working across different departments and organizations to identify, enroll, and monitor COVID-19 patients. Another way providers are increasing utilization is by diverting non-COVID patients from hospital, critical care, skilled nursing, and other departments to receive care and recover at home. This has resulted in an increase in the number of patients receiving telehealth care and an expansion of the patient populations deemed eligible for care. 

Specifically, HRS partners saw a significant increase in the use of telehealth and RPM for oncology, pediatric, dialysis, and sepsis patients, to name a few. The decreased need for in-person visits, improved patient outcomes, and cost savings are some of the benefits that healthcare providers are reaping from implementing telehealth.

3. Consumerization of Healthcare 

As the industry moves towards the consumerization of healthcare, patients are increasingly transitioning into consumers. This is evident in the widespread adoption of technologies such as telehealth, which provide patients with more control and flexibility in their care. In addition, patients are becoming more engaged in their own health, taking an active role in managing their own conditions and seeking out information to make informed decisions about their care.   

This trend is likely to continue as patients become more comfortable with using technology to manage their health. As a result, this heightened competition will spur health systems and insurance payers to adopt new tools and technologies at a faster pace. 

Mental health 

Mental health disorders have been on the rise since the pandemic of COVID-19. According to the World Health Organization (WHO), 93% of countries worldwide reported disruptions in mental health services. This has caused a significant increase in depression and anxiety due to lockdowns, isolations, and the fear of the unknown. 

To circumvent this, healthcare providers had to quickly pivot and offer telehealth as an option to continue therapy sessions. There are a number of advantages to this approach. First, it allows patients to receive care from specialists who may not be available in their local area. Second, it can be more convenient and comfortable for patients than traditional face-to-face therapy. Finally, teletherapy is often less expensive than in-person therapy, making it more accessible to a wider range of people. 

AI,Data, & Analytics 

Artificial intelligence (AI), data, and analytics are trends that have been shifting the way businesses work, and it’s no different for the healthcare sector. The basis of how these tools help is to enhance clinical diagnostics and decision making rather than reduce clinician need. 

AI can help practitioners diagnose patients more quickly and accurately by identifying correlations between symptoms and conditions. This not only increases efficiency, but also provides quantitative and qualitative data that can improve accuracy in early detection and treatment.  

While these tools are typically used for major diseases and on a larger scale, telehealth works like AI but on a smaller scale. It provides healthcare practitioners with the information they need to make decisions around patient care, resulting in prevention of high-risk situations while reducing hospital readmissions. 

Value-based care is a proactive concept that aims to keep healthcare costs down (for both the payers and providers) by focusing on quality and patient outcomes.  

While several barriers still stand in the way of fully implementing value-based care, RPM can address most of these barriers—meaning it can improve your facility’s ability to provide value-based care and lower your operating costs in the long run. 

With the value-based care model on the rise, the adoption of telehealth and RPM can help to further establish the model as an essential part of your facility or as a stepping point to begin your journey to value-based care.  

The Digital Front Door

The digital front door provides patients with quality care by allowing providers and patients to coordinate efforts on behalf of the patient. Bypassing barriers, such as distance or scheduling conflicts, provides ease and convenience for all parties involved.  

Patients and providers benefit from a streamlined and personalized experience. By integrating a variety of data sources, it is an efficient way for healthcare systems to interact with patients and tailor each interaction to their specific needs. This allows for more effective treatment, continuous care, and recovery planning. 

Telehealth in a Post-Pandemic World: Why it’s More Important Than Ever  

Telehealth has the potential to revolutionize how healthcare is delivered while helping reduce costs and improving quality of care and access to care. Find out all you need to know about telehealth in our ultimate guide to telehealth technology.  

From Health Recovery Solutions at

Elite is pleased to offer comprehensive telehealth support for our patients who are the highest risk for rehospitalization. Our clinical teams are trained on these systems and actively partner with HRS to support clinical collaboration and implementation of interventions to aid our patients’ goals to stay healthy in their homes. This service is part of our work to support the community for aging in place. It is part of our home health service line.

If you are interested, send an email to or call us at 509-758-2568

April is Counseling Awareness Month

Counseling is more than managing serious issues. The role of a counselor is to support individuals. There is stigma with accessing counseling services, and this often prevents individuals from seeking the support they need. Counseling Awareness Month is meant to raise awareness that the interventions provided are to support

  • individuals making choices about their life, their health, their home, their family, etc.;
  • individuals in managing, building, and repairing relationships at whatever phase of life they are currently living;
  • individuals in dealing with the complexities of disease, pain, medical issues, treatments, and interventions;
  • individuals recovering from addiction and trauma.

April is alcohol awareness month which is meant to raise awareness on substance abuse and prevention. The connection between substance abuse and mental illness is well established, and the role of mental health professionals is integral to a comprehensive care plan.

At Elite Home Health & Hospice, we engage the professional services of social workers in our home health, palliative care, and hospice service lines. We also support bereavement groups for individuals who have experienced loss under the guidance of our social work and chaplain team.

For more information on Counseling Awareness Month, visit:

For more information on Alcohol Awareness Month, visit:

If you are interested in services provided by Elite, please send us an email at

What is Remote Patient Monitoring?

Tara Fragiacomo

With technology in the passenger’s seat and the COVID-19 pandemic taking the wheel, remote patient monitoring has become a household term among healthcare providers and their patients. Often used during the recovery period, remote patient monitoring, or RPM, allows patients to measure their vital signs, blood pressure, weight, temperature, and more without visiting a doctor or hospital. Data is sent via Bluetooth to healthcare providers who then can determine the recovery progress and if further intervention is needed.

How HRS Can Help

HRS’s mission is simple: reduce hospital readmission rates, decrease costs, change patient behavior. How can this be accomplished? By bringing Telehealth to a patient’s door. Or couch.

Offering both RPM and other Telehealth tools, HRS provides data, education, support, and all necessary equipment to make the transition to technology easier. With Bluetooth enabled technology all data taken by the patient is recorded and sent to a portal where the patient’s provider(s) can analyze the patients’ symptoms and determine if a different treatment is needed. Without going to the office or hospital, providers can adjust patient medications, direct on diet and exercise, and offer advice to prevent symptoms from worsening and the patient having to be readmitted to the hospital.

HRS remote patient monitoring RPM tablet with vital signs

HRS provides the patient with an easy-to-use tablet that includes tools for medication tracking, vital sign monitoring, education, communication, and more.

What can an RPM program offer providers and patients?

There are several benefits of RPM for both healthcare providers and patients. Benefits range from cost savings, avoided ED visits, patient satisfaction, stress reduction, peace of mind and beyond. Here are just some ways RPM programs are beneficial:

  • Easy-to-use equipment is provided by HRS to the healthcare provider and then distributed accordingly to patients. Kits can include a tablet, as well as a Bluetooth pulseox, scale, BP cuff, glucometer, and/or thermometer.
  • Programs benefit patients from those recovering from surgery, to continuing care and hospice patients, to those with chronic conditions like diabetes, heart disease, and COPD.
  • What’s tracked and analyzed: vital signs, blood pressure, weight, and temperature. In cases of more severe chronic conditions, levels monitored can include blood glucose, oxygen levels, heart rate, and more.
  • Because patients don’t have to leave their homes, chances of contracting or spreading illness is decreased significantly.
  • Readmission to the hospital is less likely to occur when symptoms are monitored, and the clinician can intervene accordingly.
Doctor talking with senior patient via virtual visit

How are RPM programs helping those with chronic conditions?

RPM programs are not just for patients with temporary hospital stays. In fact, it’s widely used among those with chronic diseases, in hospice palliative care, and beyond. Patients with diabetes, heart disease, and COPD can largely benefit from RPM programs by getting a more focused level of care. Major factors and benefits of using RPM programs with chronic disease management is reduction in costs, decreases in hospitalizations, and catching spikes or dips before they begin to affect quality of life. Patients can feel more at ease and confident in their daily medical plans when they receive a personalized management plan.

Diabetes & Telehealth: The Florida Initiative in Telehealth and Education (FITE) Diabetes Project

In a Telehealth study that spanned two years, FITE saw a decrease of nearly 10% in hospitalizations among children with type 1 diabetes. Emergency department visits decreased 5.5% per year.

With blood glucose testing readily available in the patients’ homes, the guess work of how real-time data looks is removed. Patients can take their levels immediately upon waking, after a meal, or after exercise. When this data is sent live to their provider, it makes for a more accurate daily monitoring plan by catching spikes, dips, and other vitals important to staying within range and avoiding symptom exacerbation.

Reimagining Cardiac Care

Similarly, those with cardiac conditions such as heart disease can utilize RPM to measure heart rate, respiratory rate, and blood pressure. It can be used for pre- and post-op monitoring as well as patient adherence to new routines, diets or medication. Cardiovascular Disease RPM programs have been known to help detect and prevent arrhythmia, hypertension and heart failure; all resulting in a quick action by physicians to prevent further damage.

Breathing Easier with COPD RPM

A factor considered in using RPM programs for patients with COPD is reducing the cost for the patient. Unscheduled office visits and readmissions to hospitals are a driving cost that RPM programs can help reduce or avoid altogether. Using programs and kits like HRS provides, patients can measure their oxygen levels and ensure it is falling in a safe range. Not only will this reduce costs and increase quality of life, but it can also reduce unexpected health scares and exacerbations.

Reductions in cost and hospital readmissions, and a decline in repeating episodes of illness, are major benefits of using RPM. In today’s pandemic and certainly post-pandemic, patients might grow more wary about going in for a physical office visit. RPM programs give patients the peace of mind of having a healthcare professional check vital signs and ensure a proper recovery or treatment plan is being carried out effectively. For those with compromised immune systems, this can all be done in the comfort of their own home without risking the spread, or contraction, of illness.

This article is part of a collection from Health Recovery Solutions. Elite is proud to partner with HRS to support patients in our community. For more information, check out