discussing vidant health’s telehealth & care transitions program discussing vh’s telehealth...
TRANSCRIPT
Combating The Rising Cost of Care:Care Coordination and Chronic Disease
Management
MATRC 2nd Annual SummitApril 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
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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
Vidant Health Telehealth & Care TransitionsPatient Referral Algorithm
Patient Risk Assessment
Completed by Hospital Case Managers
Hi Risk
Social Issues/
Frailty
Telehealth & Transitions in Care
Program
Medium
Risk
VMG patient
Daily biometric
data
Low Risk
Telephonic Services
TIC services
Consider Telephonic
Service
TH
Transitions in Care
TIC
Services
Non
VMG patient
Health Coach
Consider TIC services
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VH Hi Risk Criteria◦ PAM I & II
◦ Dx Any chronic disease
◦ Readmissions < 30 day
◦ ED visits 4 +
◦ Medications 6+
◦ Social issues Homeless No TransportationNo PCP Un/underinsured
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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
◦ 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
Metrics
DemographicsN=926
56%
12%
10%
22%
Primary Insurance
MedicareMedicaidNo Insurance/SelfCommerical
DemographicsN=926
44%
56%
Patient Gender
MaleFemale
DemographicsN=926
54%33%
4%3%
2%1% 3%
Patient Diagnosis
HTNHFCOPDCHF/HTNAsthmaAsthma/ HTNHF/HTN
Patient Age
Patient Age Range
13%
19%
24%
23%
18%3%
18-49 50-59 60-69
70-79 80-89 90-99
N= 926
Average time utilizing remote monitoring services
N= 926
2%9%
18%
28%
34%
10%
Average Time Patient Utilizing Monitor
< 30 days 30 days 60 days 90 days current > 90 days
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Patient Satisfaction SurveysN=325
56%
43%1%
STRONGLY AGREE AGREE DISAGREE
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Hospital AdmissionsTotal Patients=695
Reductions Of Hospitalizations0
100
200
300
400
500
600
700
800
900772
257
143
Discharge Patients N=544
90 Days PriorDuring30 Days Post
Decreased by 69% Prior to During
Decreased by 76% Prior to Post
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Hospital Bed DaysTotal Patients= 695
Hospital Bed Days0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
3,458
1,124753
Discharged Patients N=544
90 Days PriorDuring30 Days Post
Decreased by 67% Prior to During
Decreased by 81% Prior to Post
Hospitalization Costs
-
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
6,761,227
1,504,206
875,895
Discharge Patients N=544
90 Days PriorDuring30 Days Post
Reimbursement -
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
6,969,198
2,257,620
1,722,502
Discharge Patients N=544
90 Days PriorDuring30 Days Post
Hospital Cost and ReimbursementTotal Patients =695
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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 othersMultiple PCPs Inability to pay
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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
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Low Risk Criteria PAM III or IV
Dx TBD
Readmissions 0
ED visits 0-1
Medications < 6
Social Issues Stable housing PCP Insurance
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Low risk patient referred to: Telephonic follow-up/education
Patient identified in-hospital & clinic
