Pilot Program Uses Telehealth to Help LTC, Rehab Patients Transition Home

West Virginia University researchers are touting the early results of an ongoing program that uses telehealth to help residents transition back to home after a story in a nursing home or long-term care facility.

“We’ve had some really amazing participant wins,” Steve Davis, an associate professor with WVU’s School of Public Health and principal investigator for the Home and Community-Based Services Telehealth Pilot, said in a recent news release.

“I’ve lived in West Virginia all my life - I know it’s a huge deal to be able to be at home with your family,” he added. “This pilot project wanted to see if when these participants go home, can telehealth help keep them there?” 

Launched in 2018 and continuing through the end of 2021, the pilot builds off of the Take Me Home Transition Program, run by the West Virginia Bureau for Medical Services. That program identifies patients living in long-term care facilities who want to return home and sets them up with support services to make that transition; the pilot adds connected health to that mix.

Through the pilot, currently focused on the Aged and Disabled Waiver Program and the Traumatic Brain Injury Waiver Program, patients are sent home with customized medical equipment needed to continue care at home, along with a tablet (in some cases where internet reception is part, collaboration is handled via landline telephone).

Some 26 patients now involved in the program are connected to care providers via telehealth to help them adjust to living at home and staying healthy enough to avoid a hospitalization. Of that group, only one has returned – albeit voluntarily – to a rehab facility for extra care.

The program targets two growing trends: an increase in seniors wanting to live at home rather than an assisted living facility, and efforts by LTC facilities, including skilled nursing facilities (SNFs), and health systems to reduce overcrowding and move patients back home.

Projects like this focus on ensuring that patients can first get the care they need at home through telehealth, then measure the quality of life at home compared to a facility. Other factors include patient engagement and support, cost of care and reduced negative outcomes, such as hospitalizations.

Davis and his team are prepared to submit a report to state officials in December on the program, with hopes of sustaining it and perhaps scaling out to other populations.

 “Ultimately, the hope is that participants can continue to thrive in their communities — to live at home with family and friends, and to be as independent as possible,” he said.