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Advanced Telehomecare for Chronic Condition Management
- 1. Advanced Telehomecare REMOTE VITAL SIGN MONITORING WITH INTEGRATED BI-DIRECTIONAL VIDEO FOR CHRONIC CONDITION MANAGEMENT PRESENTERS: Ellen Bolch President/CEO THA Group RightHealth Max E. Stachura, MD Director Center for Telehealth, Georgia Regents University and Principal RightHealth
- 3. RIGHTHEALTHÂź THE FUTURE OF HEALTH CARE The Power of RightHealthÂź RightHealthÂź is a population health delivery model with leading edge technologies, such as remote monitoring (including bi-directional video), and medication management that powers tiered, longitudinal, chronic care coordination across health service settings through: ï§ A focus on chronic disease management ï§ A proprietary patient stratification tool that utilizes predictive analytics ï§ Physician-led multi-discipline teams ï§ A focus on care transitions that allows patients to move smoothly from one care setting to another
- 4. ï± Remote Telemonitoring ï± Remote Medication Adherence Devices & Integration with Pharmacy Database ï± Personal Electronic Health Record ï± Video âVirtual Visitsâ ï± Integrated Clinical Data Analytics & the EHR System ï± 24/7 RN Telephony Triage System ï± Remote ADL Monitoring ï± Biometric Monitoring Producing Personalized Predictive Analytics The Right Technology: ï± Clinical Decision Support System
- 5. 0% 20% 40% 60% National Benchmark Pilot Program Chronic Disease Re- Hospitalization Follow-Up 0% 10% 20% 30% 40% National Benchmark Pilot Program Chronic Disease Re- Hospitalization Rate Primary Care Physician Groups Study I* Intervention Phase Results Pilot Rate: 7% Medicare Claims Data Rate: 34% Follow Up Phase Results Pilot Rate: 23% Medicare Claims Data Rate: 50% The Right Results 50% 23% 34% 7% (3 Months) *6-Month Intervention Phase & 6-Month Follow Up Phase (12 Months) (12 Months)(6 Months)
- 6. ï§ Hospital awarded American Heart Association Gold award for reductions The Right Results Regional Hospital #1 YEAR # PTS ADMITTED WITH CHF #PTS READMITTED WITH CHF OVERALL RATE PERCENT VARIANCE 2011 43 2 5% 85% REDUCTION 2010 119 15 12% 65% REDUCTION 2009 147 50 34% 2008 97 33 34% 2007 124 41 33% Source: Medisolv Report www.HospitalCompare.gov CHF Readmission Rate Comparison Graph 2007-2011 THA Groupâs proprietary CHF program implemented Readmission Rate within 30 days
- 7. Regional Hospital #2 The Right Results 90 Day Phase Patients / Phase Patients/ Phase (excl. Outlier) Total Charges (excl. Outlier) 1 â Pre - THA 10 9 $321,787 2 â Active - THA 10 9 $217,851 180 Day Class IV CHF Study (Medicare charges on pilot patients) 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 90 Day Pre Pilot 90 Day Active Pilot 90 Day Post Pilot 270 Day ED Recidivist Pilot Study HospitalCharges($) ï§ Outcome: 32% reduction in Medicare charges or $11.5K/patient. Potential annual savings to Medicare on all CHF admissions for this hospital - $4M ï§ Able to directly correlate charges to interventions ï§ Outcome: Significantly reduced hospital charges by 85% ï§ âWorst Offendersâ ï§ Self-funded ï§ Multiple chronic conditions ï§ Major psychosocial challenges
- 8. Continual Risk Stratification Based on Continuous Patient Assessment 5% of Patients Account for 50% of Costs Typical Distribution 5% 15% High Risk Medium Risk RightHealthÂź Data Analytics RightHealthÂź Tiered Best Practices Applied by Patientâs Level of Risk 80% Low Risk Continuous Reassessment
- 9. Continuous Reassessment âą Domains assessed Data Analytics - Clinical (Current/Previous Hx) - Functional, cognitive - Self help/care abilities/health literacy - Psychosocial needs âą Plan Generation based on - Evidence-based best practices - Care needs assessment - Family/Social/community supports for keeping patient in the community - Patient/family/physician review and approval âą Providers of care & service - Clinical (medical & behavioral) - Community - Waiver type service - Integrated Technology Data Driven Identification Assessment Integrated Care Plan Integrated Care Coordination
- 10. ED @ Homeâ Solutions Telemedicine Technology for Virtual Consultation with Physician via RN Emergent changes in Patient Status ï¶ Telemonitoring Biometric Trends Analysis: Blood Pressure, Heart Rate and Rhythm, Pulse Oximetry, and Weight â Allows for early detection of chronic disease exacerbation and ultimate reduction of exacerbations over time ï Keeping Patients/Clients Safely @ Home ï¶ Bluetooth Peripherals for Consultation & Visualization: A âVirtual Visitâ to the Physician for Examination when Emergent changes in patient condition lead the uniquely trained nurses to seek consultation ï Bringing Patients to the MD via Technology
- 11. ED @ Homeâ Solutions Telemedicine Technology for Virtual Consultation with Physician via RN Emergent changes in Patient Status ï¶ Capacity for MD Ordered Interventions ï§ Diagnostic Tests â ECG, Portable X-rays ï§ Placement of Indwelling Urinary Catheters ï§ Administration of Intravenous Loop Diuretics ï§ Intravenous Hydration and Electrolyte Replacement ï§ Parenteral Administration of Analgesics ï§ Administration of Intravenous Antibiotics ï§ Delivery and Administration of Oxygen ï§ Administration of Intravenous Cardiac Therapeutic Drugs, Rhythm Management, and Inotropics ï§ Administration of Intravenous Steroids ï§ Advanced Wound and Ostomy Therapy including Wound VACs
- 12. THA Group Partnering Proposal For Innovative Payment Program BPCI Model 3 âRetrospective Post-Acute Care Onlyâ - A retrospective bundled care arrangement - Actual expenditures reconciled against an episode of care target price (Target Price = total cost of the 60-day home care episode plus 30 additional days) - Triggered by an in-patient hospital stay. Included post-acute care services must begin within 30 days of discharge from hospital and end 90 days after initiation of episode. Proposal Aims Monitor, track, and prevent re-hospitalization over the 90-day episode for the following clinical conditions (DRGs): - Acute Myocardial Infarction - Coronary Artery Bypass Graft - Cardiac Defibrillator - Cardiac Valve - Congestive Heart Failure - COPD, Bronchitis/Asthma - Diabetes - Percutaneous Coronary Intervention - Simple Pneumonia and Respiratory Infections
- 13. VIDEO
- 14. Principle: Continual Risk Stratification Based on Continuous Patient Assessment Question: What is normal?
- 15. What is normal?
- 16. What is normal for me?
- 17. Changed! Normal. But not normal for me!
- 18. Principle: Continual Risk Stratification Based on Continuous Patient Assessment Questions: What is normal for me? From what baseline are you evaluating whether your assessment of me today identifies a problem requiring action?
- 19. Brunett et al, J Telemed Telecare, 2015 Use of a voice and video Internet technology as an alterntive to in-person urgent care clinic visits. ï¶ 478 patient visits ï¶ 82 patients recommended for in-person evaluation ï¶ None of patients recommended for in-person evaluation required an ED referral or hospitalization âWe conclude that real-time on-line primary and urgent care Visits are feasible, safe, and potentially beneficial.â Background Literature
- 20. Chi & Demeris, J Telemed Telecare, 2015 A systematic review of telehealth tools and interventions to support family caregivers. ï¶ 52 experimental & 11 evaluation studies ï¶ Technologies included video, web-based, telephone- based, & telemetry/remote monitoring. âMore than 95% of the studies reported significant Improvements In the caregiversâ outcomes and that caregivers were satisfied and comfortable with telehealth.â âTelehealth can positively affect chronic disease care, home care and hospice care.â Background Literature
- 21. Peetoom et al Diasabil Rehabil Assist Technol, 2014 Literature Review on monitoring technologies and their outcomes in independently living elderly people. âConclusions: Monitoring technology is a promising field, with applications to the long-term care to elderly persons. However, monitoring technologies have to be brought to the next level, with longitudinal studies that evaluate their (cost-) effectiveness to demonstrate the potential to prolong independent living of elderly persons.â Background Literature
- 22. Finkelstein et al, Tmed J and e-Health, 2004 Telehomecare: Quality, Perception, Satisfaction. Background Literature 2. Attention to concerns 3. Dependability of staff 4. Respect shown by staff 5. Knowledge of health problems 6. Choices about care 7. Feeling safe 8. Know contact person 9. Ability to meet needs 10. Response to concerns 11. Scheduling 12. Consistency in staffing
- 23. Theoretical Advantages ï¶ Social ï¶ Signs/symptoms patients either do not recognize or ignore ï¶ Behavior changes not reflected in vital signs ï¶ Patient affect/demeanor ï¶ CHANGE in any of the above. Why Video - General
- 24. Potential specific advantages ï¶ Inspection ï¶ Affect suggesting Depression ï¶ Signs of Right Heart Failure ï¶ Signs of Left heart Failure ï¶ Work of Breathing ï¶ Edema ï¶ Cyanosis ï¶ CHANGE! Why Video â COPD
- 25. + âI hate being on camera, but video is better. I like to deny when I am getting worseâŠshe would see me shakingâŠor depressed.â + ââŠshe could tell if I was bluer in the face.â + âI donât think I have COPD. I broke 4 ribsâŠso I failed the O2 test because it hurt to breathe. Even if the nurse didnât believe me, she could see how much it hurt.â + ââŠI kind of miss seeing my nurse now that the monitor is gone.â THA Experience: COPD Patients + Video
- 26. - âIt was good. It would have been good. But I had to move It and then it didnât work.â - âItâs not better than a telephone because a telephone is more secureâŠother people canât see you.â - âIt worked at the beginningâŠand then it was a hidden voice.â - âI donât want to change the function settings more than once.â THA Experience: COPD Patients + Video
- 27. + âI like talking to people face-to-face. I would be more forthcoming with information if I knewâŠif I could seeâŠwho it is Iâm talking to.â + âI know I try to hide my reactionsâŠand Iâm good at it over The phone. If she could see me though, she would probably KnowâŠespecially if it was the same nurse every timeâŠ. That Would be betterâŠeven though I would not like getting caught.â THA Experience: COPD Patients - Video
- 28. - âMy wife is taking a napâŠbut I hook everything up for her. Fancy video would not be good for herâŠmaybe for some peopleâŠprobably for some peopleâŠbut they (THA) would have to choose the peopleâŠThey (THA) could not expect the patient or the family to make the choiceâŠMaybe they (THA) could do that when they first met you in the hospital.â THA Experience: COPD Patients - Video
- 29. + âIâm rather new at this. One-on-one is better. You can get to be direct.â + âItâs very important that itâs the same nurse. She would see that Iâm getting depressed.â + âIf it was the same nurse, she would come to careâŠshe wouldnât just be meeting some criteriaâŠshe would be meeting you as a personâŠin your spaceâŠwe would have goals⊠together.â + âWhen itâs the same nurse it gets personalâŠshe treats you like a king.â THA Experience â Same Nurse?
- 30. - âIf they were really good nurses, it wouldnât make any difference if it was the same one every timeâŠI donât see the same doctor every time and itâs OK when theyâre really good⊠and really good nurses wouldnât need the videoâŠthey would know how to ask the right questions on the telephone.â THA Experience â Same Nurse?
- 31. âVideo can add social value and provide comfortâ âSo long as you have vital sign monitoring, telephone can be enough if you are a good clinician with good interview skills.â âVideo could be good for select patientsâŠwound careâŠself- treatment procedures like insulin administrationâŠfamily support for family of poorly communicating hospice patients. Video is not needed for everyoneâŠprovided you are a good clinician.â âVideo can help you see changes that a patient might not recognizeâŠpatients can ignore symptoms when they start gradually and slowly progress.â THA Experience â Nurse Provider
- 32. âA poor clinician with poor interview skills would do no better with video than with a simple telephone. In fact, the video might make it easier for a poor clinician with poor interview skills to let the skills they did have slip away.â THA Experience â Nurse Provider
- 33. Not every patient â select the right patient for video Not every nurse clinician â the ability to look does not necessarily equate with the ability to see. The case of the non-skid slipper sox. THA Lessons Learned
- 34. Not every patient â select the right patient for video Not every nurse clinician â the ability to look does not necessarily equate with the ability to see. The case of the non-skid slipper sox. THA Lessons Learned
- 35. Tiered assessment of patient need Tiered delivery of patient services matched to need and delivered by tiered professional competencies Tiered use of technology to monitor and manage, incorporating early recognition of clinically significant change. One coordinated, standardized, and integrated process of care THA Lessons Learned
- 36. âŠand it is not a new idea!