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4th Annual Eastern Regional Patient Safety and Quality ... - MATRC

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					        Combating The Rising Cost of Care:
Care Coordination and Chronic Disease Management

            MATRC 2 nd Annual Summit
                April 18, 2013



            Bonnie Britton, MSN, ATAF
           VH Telehealth Administrator
  Today’s talk involves ……
 Discussing Vidant Health’s Telehealth &
  Care Transitions Program

 Discussing VH’s Telehealth Outcomes
Vidant Health
VH System TH & Care Transitions Vision
 ◦ Shift focus from hospital to coordinating patient care transitions

 ◦ Define & implement standardized risk stratification tools

 ◦ Standardize post acute care services
   Remote patient monitoring services
      Transitions in care
      Chronic Disease Management
   Care Transitions
   Health Coaches
   Telephonic follow-up




                                                      4
                 Vidant Health Telehealth & Care Transitions
                          Patient Referral Algorithm
                                         Patient Risk Assessment

                                   Completed by Hospital Case Managers




              Hi Risk
                                                   Medium
                                                                             Low Risk
                                                       Risk



        Telehealth &                                             Non         Telephonic
     Transitions in Care                   VMG
                                                                              Services
          Program                         patient               VMG
                                                               patient


   Daily                 Social
 biometric              Issues/           Health              TIC services
    data                                  Coach
                        Frailty
                                                               Consider
                                         Consider             Telephonic
                                        TIC services            Service
    TH                    TIC
Transitions
  in Care               Services
                  VH Hi Risk Criteria
◦ PAM              I & II

◦ Dx               Any chronic disease

◦ Readmissions     < 30 day

◦ ED visits        4+

◦ Medications      6+

◦ Social issues    Homeless      No Transportation
                   No PCP        Un/underinsured




                                                 6
          Hi Risk patients referred to:
◦ Remote Patient Monitoring
  Referred from hospital or clinic
  Enrolled in hospital or home
  Home Visit- Med. Rec. & train/competency validate patient/home safety
   assessment
  Daily biometric data monitoring / Daily phone calls for abnl parameters
  Weekly telephonic assessment, education, coaching
  Staff ratio: 1 -85 – 100 patients
◦ Care Transition Services
    Enrolled in hospital
    Hospital visit
    Home Visit(s)- med. Rec. and patient education
    Phone Calls
  Attend MD Visits
  Staff ratio: 1- 18 – 30 patients




                                                       7
                         Metrics
◦ Clinical Data
   LDL, BP, Pulse, Height, Weight, HgA1c, oxygen
    saturation

◦ Patient Satisfaction

◦ Financial Outcomes- 90 days pre TH, during TH, 30
  days post TH
   Hospitalizations
   Bed Days
      Demographics
               N=926


              Primary Insurance

        22%



                                        Medicare
                                        Medicaid
                                        No Insurance/Self
                                        Commerical


10%
                                  56%


       12%
      Demographics
               N=926



        Patient Gender




                         44%
                               Male
                               Female



56%
       Demographics
                      N=926




                Patient Diagnosis


           3% 2% 3%
                1%                    HTN
      4%
                                      HF
                                      COPD
                                      CHF/HTN
                                      Asthma
                                      Asthma/ HTN
                                      HF/HTN

33%                             54%
Patient Age
   N= 926
Average time utilizing remote
     monitoring services
                              N= 926

       Average Time Patient Utilizing
                            Monitor
      < 30 days   30 days   60 days    90 days    current   > 90 days


                        10%           2%     9%



                                                            18%




         34%



                                                 28%
Patient Satisfaction Surveys
                         N=325




                                 1%
  43%




                                      56%



        STRONGLY AGREE       AGREE    DISAGREE




                                         14
Hospital Admissions
          Total Patients=695




   Decreased by 69% Prior to During
   Decreased by 76% Prior to Post




                                      15
Hospital Bed Days
      Total Patients= 695




  Decreased by 67% Prior to During
  Decreased by 81% Prior to Post




                                     16
Hospital Cost and Reimbursement
          Total Patients =695
                  Medium Risk Criteria
 PAM               III

 Dx                Dementia, Mental Illness, Substance Abuse, new
                    chronic disease

 Readmissions      <30 day with Obs. Within 60 days

 ED visits         2+

 Medications       Anticog./insulin/glycemic, Dig., Phenobarbital,
                    Lithium

 Social Issues     Unstable housing             Relay on others
                    Multiple PCPs                Inability to pay


                                                    18
         Medium risk patient referred to:
 Remote Patient Monitoring- Transitions in Care

 Care Transitions services
  ◦   Enrolled in hospital
  ◦   Hospital visit
  ◦   Home Visit(s)- med. Rec. and patient education
  ◦   Phone Calls
  ◦   Attend MD Visits
  ◦   Staff ratio: 1- 18 – 30 patients


 Health Coaches
  ◦   Enrolled in PCP Clinic
  ◦   Phone Calls
  ◦   Coaching- telephonic and in-clinic
  ◦   Coordination of services


                                                       19
                  Low Risk Criteria
 PAM             III or IV

 Dx              TBD

 Readmissions    0

 ED visits       0-1

 Medications     <6

 Social Issues   Stable housing   PCP   Insurance




                                           20
           Low risk patient referred to:
 Telephonic follow-up/education

 Patient identified in-hospital & clinic




                                            21
  Bonnie Britton, RN, MSN, ATAF
bonnie.britton@vidanthealth.com

				
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