rethinking traditional healthcare models: integrating ... · rethinking traditional healthcare...
TRANSCRIPT
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Rethinking TraditionalHealthcare Models:
Integrating TelecareTechnologies as Core
Elements ofCare Delivery
INSERT
Kevin Fickenscher, MD
Boston, Massachusetts
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A Brief Overview of theForces PrecipitatingChange in AmericanHealthcare Technology as a
Transformational andDisintermediating Force Why Telecare? A Framework… Results To Date
The Session…
“You never changethings by fighting
against the existingreality. To changesomething, build a
new model thatmakes the old model
obsolete.”
F. Buckminster Fuller
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“The real voyage ofdiscovery consists not offinding new lands but ofseeing the territory withnew eyes.”
- Marcel Proust
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The Premise… Society is demanding for all goods and services but –
especially for health care – that we…- ↓ Costs- ↑ Quality- ↑ Service
The inherent incentives of the health care industry aredisparate, inconsistent and dysfunctional – causingleaders significant challenges Society is moving inextricably towards an information
democracy rather than professionally dominatedtheocracy
= Focal point for health care change= Appropriate management of information required= Intellectual capital of medicine= Simultaneously empowering (consumers) and disempowering
(physicians)
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The Most CriticalQuestion!
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Why?
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Technology
Incentives
Expectations
Communications
Reasons for the Change…
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AmbCare
Traditional:Acute and Ambulatory Care Focus…
Acute
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10% OF AMERICANS RESPONSIBLE FOR 86% OF SPENDING
Where To Focus?
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Preventive
Acute SNF
HospiceAlt Living
Remote Patient MonitoringTransition
ChronicAmbCare
The Alternative:Comprehensive Coordinated CARE
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ClinicalHealthcare
HealthcareSystem
AppliedComputer
Sciences andTechnology
Source: Gardner RM, Overhage JM, Steen EB, et al. Core content for the subspecialty of clinical informatics. J Am Med Inform Assoc. 2009;16(2):page 154.
= the coordinated,real-time
application and useof technology and
analytics in thecare delivery
process
So, What Is Telecare?
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Telehealth = an over-arching description for the broad array of generic services,education and information using technology rather than face-to-face or hands-oninteractions between an individual and a care provider – such as: remote doctor-patientconsultations (telemedicine), remote monitoring of blood pressure, capture of ECG orvital sign data, and health education services
Telemedicine = refers specifically to the provision of interactive healthcare servicesand education by licensed healthcare professionals through the use oftelecommunications technology to and from a variety of locations
Telecare = the active involvement and engagement of a care delivery team in theprovision of services to individuals with acute and/or chronic illness through theappropriate and effective use of remote tele-management technologies includingproactive, remote care management in various environments including the home,skilled nursing facilities and other non-traditional care units
Splitting Hairs TeleWhat?
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The Tele–Intersection
FocusedAV
Education
IVRAmbientAssisted
Living
InteractiveCall
CenterSupport
IntegratedAnalytics
eVisits
RemotePatient
Monitors
SensorTracking
PatientNavi-gator
Onsite &RemoteAssess
Guideline&
ProtocolsMgmt
AlertsMgmt
CallCenter
Support
Telecare TelehealthRemoteLifestyleMonitors
Triage&
911
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Hospital Readmission Costing $26B Annually 13.6M Patients Over 65 Discharged from Hospital each year 2. 7M (20%) are Readmitted within 30 days of leaving
Poor Discharge Planning / Care Coordination is at Fault Main cause of readmission, especially health attacks and pneumonia $17B preventable if patients received right care
$10K $1K$9K
Avg MedicareCost per Patientper Admission
$20K
Doctor’s OfficeInstitutions
Home
HomeHospitalsLocations
Source: AHRQ
The TeleCare Focus
Telecare…Focusing On Care We Ignore
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PATIENT FRUSTRATIONThe “Transference Effect” of Technology in Other Industries Coming to Healthcare
(Travelocity, Amazon, Open Table)
US CLINICAL WORKFORCE SHORTAGEFewer Doctors, Nurses, Clinicians
To Handle These Patients
PATIENT & PROVIDER FACTORS
A PIPELINE FILLED WITH BABY BOOMERSHighly Complex, High Risk Patients Coming
Will Explode Medicare Costs Without Change
Telecare Drivers…
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Source: http://img.medscape.com/article/836/971/836971-figure.jpg
FINANCIAL INCENTIVESHospital-to-Home Transition ReimbursementRemote Care Coordination Reimbursement
SEARCH FOR EFFICIENCY AND EFFECTIVENESSProviders Seeking Approaches to Reduce Operational
Costs and Improve Efficiency
Telecare can replace…Telecare Drivers…
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Source: http://img.medscape.com/article/836/971/836971-figure.jpg
Telecare Drivers…
FINANCIAL PRESSURERapidly Changing Reimbursement Models
With Financial Penalties for Poor Outcomes
RISK SHIFTING FROM PAYERS TO PROVIDERSMore Accountability for Care Delivery Utilization and
Outcomes
Telecare can replace…
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Telecare…Not An Option, But An Imperative!
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Payment
Focus
Role of theProvider
Incentives
Volume-Based Value-Based
Information
The TheOld World New World
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FOCUS FOR TODAYAreas of Greatest Need and Impact Ambulatory Post-Acute Transition Chronic Illness
FOCUS FOR TOMORROW Non-Hospital Chronic Illness Chronic Illness Prevention Social Interventions Self-Care Management
Changing The Focus To Capture The Greatest Value
Refining The Focus…
CARE
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GAINING TRACTION
Source (Adoption Model): Bohlen, Beal and Rogers, Iowa State University
Critical factors towin over
early adopters
Telecare Is Moving From Early Adoption To Early Majority
Telecare Adoption Trends…
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COMPLEX CHRONIC DISEASE A KEY AREA OF FOCUS
Shifting From Acute To Chronic Care…
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THE CRITICAL NEED: MAPPING THE CARE DELIVERY PROCESS
ACUTECARE
POST-ACUTECARE
TRANSITIONCARE
CHRONICCARE
The Critical Point Of Integration…
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Timely access to actionable information for betterpatient care management
Knowing what is going on with a patient’s course ofcare, in between visits – when he or she is notphysically with the clinician
Detecting pre-acute conditions before the patientclinically decompensates
Not waiting for the patient to show up in the ER beforeknowing that a patient is trending in the wrongdirection
Advantages Of Telecare…
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Robust infrastructure supporting interoperable clinicalinformation exchange
Remote data capture of biometric, location and otherinformation via bluetooth enabled capability
Patient engagement technologies and services thatsupport the individual as well as family members
Real-time clinical call center support services withpatients assigned to specific nurses and clinicalsupport personnel
Management of care delivery via defined protocolswith active outreach “as needed”
Use of predictive analytics to modify and enhancecare delivery over time
Requirements For Effective Telecare…
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What we need is aComprehensiveCoordinatedCARE or… C2CARE
Framework
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Patient ProgramsIntensive Care Management
Super-Utilizers (top 5%)Episode Care Management
Acute Care StayChronic Care Management
10 Chronic ConditionsPalliative/End of Life Management
Provider/Patient EducationPopulation Health
Care Gaps
Coordinated Care TeamsClinical - Nurse
Social/Behavioral - Social Worker,Health Coach/Navigator
Community Health WorkerSupport: Pharmacist, Dietitian
Patient ProcessPatient Selection
ADT Alerts in ER or HospitalReferral Based on Qualification Criteria
Predefined Patient RegistryPhysician Authorized Referrals
Intake ProcessPatient Assessments (Onsite, Remote)
Patient Intake DecisionPatient Program & Services Assignments
Triggered Events & ProtocolPatient Registry (Who has triggers? Which ones?)Triggers (Emergency, patient concerns, transitions)
Notification (Who? How? When?)Associated Action (Remote Triage, 911, eVisit, etc.)
Escalation (Who? How? When?)Patient Monitoring
Ensure Actions - Referrals, transitions, emergenciesMonitor Patient Progress/Care Pathways
Patient Services(Online, Onsite, Remote)Behavioral Health Care
Care Management – Clinical, Social,eVisits (Clinical Consults)
Financial CounselingHome Assessment
Medication ReconciliationMobile Health Formulary
Patient Assessments (Online, Onsite)Patient Education (Online, Onsite)
Patient Empowered Care DecisionsQualified Options Development
Patient NavigatorRemote Patient Monitoring
SNF CoordinationTechnology Setup and Support
Technology PlatformAnalytics Device Support Patient Registry
Care Coordination Workflow Electronic Medical Record (EMR) Portals (patient, providers, etc.)Communications (encrypted texts) HIE (ADT Alerts, CCD, Quality data) Reporting & Distribution
Shared Savings Program Management GovernanceContract Management (ACO, Bundles) Provider Engagement Decision making, issue resolution
Perf. Monitoring (providers, outcomes) Care Advisory Board Utilization ManagementShared Savings Calculation, Baselines Training/Patient Workflow Patient Documentation
TPA – Gain Share Program/Distribution Referrals, Escalation, contacts ACO Quality Measures (33)/Patient Sat.Patient Outcomes Reporting/Regular updates What’s documented? Who? Shared? How?
Telecare Design Overview…
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Clinical
Social and Behavioral
Basic Needs
Coordinated CareManagement
Patient Outcomes
Shared Savings
Alignment
Care Decision Making
Based on Patient Recovery Factors – http://patientrecovery.org/index.php?title=Patient_Recovery_Factors
Get to know the patient, their needs; thenbuild a care system around them
What Is C2CARE?
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FinanceCounse
l
Care Delivery Information (CDI) Exchange Platform
Remote Patient MonitoringInteractive VoiceRecognition
Interactive ClinicalSupport Services
Patient and Family/Care Provider Engagement
24x7RemoteM
DServices
In-HomeNursingService
Discharge
Planning
PatientEducation
IntakeAssess
HomeAssess
MedsRecon-cilliation
SocialServices
Program Management and Coordination
A Framework forComprehensive Coordinated CARE
(C2CARE)
Analytics Services
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What is theC2CARE Framework?The model provides an approach for supporting thetransformation of the care delivery process withmobile services that use…iNDIVIDUALLY focusediNFORMATION to radicallyiMPROVE healthcare withiNNOVATIVE and
iNTELLIGENTiNTERVENTIONS
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What are the elements of theC2CARE Framework?
Continuity – the provision of services over time by professional CAREcoordinators who serve as extensions of the traditional care delivery providers
Adherence – the use of client approved guidelines and protocols provide afoundation of care delivery that integrates with ongoing workflow of theCARE delivery organization
Results – monitored, measureable outcomes in the care delivery processresult in enhanced services, greater satisfaction, increased quality andreduced costs in the CARE delivery process
Effectiveness – the ability to successfully and continuously produceintended outcomes in the CARE delivery process
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Nearly 2,000 studies in last six years describing resultsfrom the application of various technologies supportingremote care
Several hundred specific each to Diabetes, COPD, HeartFailure, Psychiatric applications, and tele-rehabilitation
But, <10% well-crafted RCT studies Wide range of interventions have been reviewed
• Televideo to supplement in-person encounters• On-line disease literacy applications• Inclusion of store-and- forward biometric monitoring
devices into clinical workflows• Interactive text messaging applications• Interactive Voice Response applications to solicit self-
reported symptoms and behavior data
TelecareLiterature Results…
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Majority positive:
Decreased mortality Improved biometrics (reduced risk) Improved QOL and satisfaction Reduced utilization (admissions, ER use, SNF use,
other unplanned care) Reduced readmissions Reduced lengths-of-stay Reduced costs Productivity increases (mostly increased touches) Improved disease literacy Equivalent efficacy as face-to-face care Improved quality metrics (HEDIS, STARs)
TelecareLiterature Results…
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Not enough ask about productivity
Most results relatively short term (median durationof 6 months or less)
Very few studies on cost-effectiveness
Formal studies under optimal conditions shed littlelight on real-world practice
Scant information provided on the craft of telecaremanagement
Telecare ResultsSome Deficiencies…
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Graham, J. et. al. Postdischarge Monitoring Using Interactive VoiceResponse System Reduces 30-Day Readmission Rates in a Case-
managed Medicare Population. Medical Care. Volume 50, No 1.January, 2012
Geisinger Health System
Threading IVR into transition of care best practices
Leveraging automation to extend RN reach
19.5% reduction in all-cause 30-day readmissions
44% reduced probability of any readmission (p<0.05)
ROI’s north of 6:1
Telecare Case Study #1Post-Acute Application
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Alrajab, S. et. al. 2012. A Home Telemonitoring ProgramReduced Exacerbation and Healthcare Utilization Rates in
COPD Patients with Frequent Exacerbations. Telemedicine ande-Health. December 2012, 18(10): 772-776.
Veterans Health Administration database of COPD patientsenrolled in Care Coordination Home Telehealth program.
N=1,133 COPD patients enrolled between 2005 and 2009.
Of 369 patients who had at least one exacerbation per year inthe year prior to enrollment, 71.5% had a reduction innumbers of ED visits and exacerbations requiringhospitalizations after enrollment in the program
Average number of hospital admissions, ED visits, and totalexacerbations were all reduced (p<0.01)
Telecare Case Study #2COPD Application
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McFarland, M. et. al. Use of Home Telehealth Monitoring withActive Medication Therapy Management by Clinical Pharmacists
in Veterans with Poorly Controlled Type 2 Diabetes MellitusPharmacotherapy. J. of Human Pharmacology and Drug Therapy
Vol. 32, Issue 5, pages 420–426, May 2012
103 Diabetics assigned to intervention or control
Messaging device used for interactive consults between MDs,pharmacists and patients
Pharmacists used data to adjust meds / relay information tocare managers for execution
Intervention group:• Significantly better HbA1c at 3 & 6 months (p<.001)• Higher percentage reached goals (p=.001)• More time spent with care managers overall (p<.001)• More Rx changes made (p<.0001)
Telecare Case Study #3ADiabetes Application: Acute Intervention
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Remote Monitoring of High-Risk Patients: TelehealthProtocols for Chronic Care Management profiles a
successful eight-year initiative by New York City Health andHospitals Corporation's (NYCHHC) House Calls Telehealth
ProgramHealth Information Network -
http://store.hin.com/product.asp?itemid=5008
Telecare Case Study #3BDiabetes Application – Chronic LT Mgmt
An innovative hybrid of technology and human touchpoints,over a two-year period
76% of 769 monitored patients experienced improved A1Csalmost every three months
All A1Cs over 13.1 were reduced to 10.2 – on average
91% of individuals with A1Cs between 11 and 13 experiencedan improvement
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Maeng, D. et. al. Can Telemonitoring reduce Hospitalizationand Cost of Care? A Health Plan’s Experience in Managing
Patients with Heart Failure. Population Health Management.August, 2014.
Geisinger Medicare Advantage Plan
N=541 CHF members tracked for 70 months (24 months onmonitoring)
Telehealth scales and IVR
Results• Hospitalization rate on RPM = 23% lower• 90-day readmission rate on RPM = 38% lower• 11.5% additional cost savings (3.3 to 1 ROI) – on top of the
pre-existing program
Telecare Case Study #4CHF Application
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TelePsych ApplicationChoi, N. et. al. Telehealth Problem-Solving Therapy for Depressed
Low-Income Homebound Older Adults. Amer. J. of GeriatricPsychiatry. Vol.22, Issue 3, March 2014
121 homebound individuals (scoring 15+ on HamiltonRating Scale for Depression) compared Tele-problemsolving therapy (PST) with In-Person PST and telephonesupport calls
In-Person PST = 6 sessions vs. Tele-PST = 2-6 sessionsvia Skype video call
HAMD scores of Tele-PST and In-Person PST participantsat 12-week follow-up = significantly lower than telephonesupport call participants + treatment effects maintained at24-week follow-up
No difference in HAMD scores for Tele- and In Person PSTparticipants
Telecare Case Study #5
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Commonalities of Successful Programs The technology per se can never be the focus. Programs
require putting accurate/meaningful information in front of theclinician – a synthesis of data.
Information gathering technologies will change with greatfrequency, information types far less
Remote care delivery must be embedded into the caremanagement workflow
Data informs and improves disease literacy
Real- or near-real-time data can drive physician and patientbehavior with positive interventions
Disciplined candidate selection criteria yields better results
Telecare Common Themes
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It’s the People and Process…Then theTechnology
Successful programs combined technology with humaninteraction
Very low-cost programs that rely on technology alone,are not always effective
People and Process costs more than equipment
The key is striking the right balance: Human touch to make the program effective Technology to make it efficient
Telecare Common Themes
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Outcomes in the literature show results across multiplecare delivery environments IF the requirements for
(C)2CARE are met…
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…use of aComprehensive
Coordinated CareFramework transformscare delivery through
the appropriateapplication oftechnology…
Decrease costs>35%
ROIs exceeding3:1
Reduce all-cause 30-dayreadmissions
Enhance caredelivery
efficiency
Improvebiometrics +reduce risks
Reduce hospitalALOS
Reduce requiredin-home nurse
visits >50%
Increase patientcompliance
>80%
Telecare Summary Results…
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IMPROVE QUALITY OF CAREIdentify issues, resolve them on timely basis
Better care management with real time information
REDUCE COST OF CAREAvoid unnecessary services and complications
Avoid inappropriate ER visits, hospital admissions, re-admissions
ENHANCE PATIENT SATISFACTIONHelp patients manage their chronic conditions
Provide a safe environment for “care” in the comfort of the home
44The Obvious Solution…Telecare
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• Leverage the capabilities of your organization to simultaneouslyimpact avoidable costs and improve outcomes.- Develop a “telecare” team- Focus on “process” and “people” – not technology- Expand your vision to include post-acute, transition and chronic care
• Ensure EMR use is effective in driving improved patient outcomes• Define value and track patient outcomes
- “Patient-centricity”- “Patient empowerment”- Education- Team capability- Partner selection and management
What Three Things To Do Right Away?
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Your Feedback?47
Discussion
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Kevin Fickenscher, MDPresident/CEO
(301) 540-0795 – Assistant: Susan Seiger(415) 450-1515 – Mobile