Presentation by Bonnie Britton, MSN, RN, ATAF Telehealth Program Administrator, Vidant Health

2. 

Discussing Vidant Health’s Telehealth &
Care Transitions Program
Discussing VH’s Telehealth Outcomes

4. ◦ 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

5. Patient Risk Assessment
Completed by Hospital Case Managers
Hi Risk
Medium
Low Risk
Risk
Telehealth &
Transitions in Care
Program
Daily
biometric
data
Social
Issues/
Non
VMG
patient
VMG
patient
TH
Transitions
in Care
TIC
Services
TIC services
Consider
TIC services
Frailty
Health
Coach
Consider
Telephonic
Service
Telephonic
Services

6. ◦ PAM
I & II
◦ Dx
Any chronic disease
◦ Readmissions
< 30 day
◦ ED visits
4+
◦ Medications
6+
◦ Social issues
Homeless
No PCP
No Transportation
Un/underinsured
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7. ◦ 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
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8. ◦ 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

9. Primary Insurance
22%
Medicare
10%
56%
12%
Medicaid
No Insurance/Self
Commerical

10. Patient Gender
44%
56%
Male
Female

11. Patient Diagnosis
2%
4% 3%
1% 3%
HTN
HF
COPD
33%
54%
CHF/HTN
Asthma
Asthma/ HTN
HF/HTN

12. N= 926
Patient Age Range
3%
18%
13%
19%
23%
24%
18-49
50-59
60-69
70-79
80-89
90-99

13. N= 926
Average Time Patient Utilizing Monitor
< 30 days
30 days
60 days
90 days
current
2%
9%
9%
18%
34%
28%
> 90 days

14. 1%
43%
56%
STRONGLY AGREE
AGREE
DISAGREE
14

15. Discharge Patients N=544
900
800
772
700
600
90 Days Prior
500
400
300
200
During
257
143
30 Days Post
100
0
Reductions Of Hospitalizations
Decreased by 69% Prior to During
Decreased by 76% Prior to Post
15

16. Discharged Patients N=544
4,000
3,458
3,000
90 Days Prior
2,000
1,124
1,000
753
During
30 Days Post
0
Hospital Bed Days
Decreased by 67% Prior to During
Decreased by 81% Prior to Post
16

17. Discharge Patients N=544
8,000,000
7,000,000
8,000,000
6,761,227
7,000,000
6,000,000
5,000,000
90 Days Prior
4,000,000
During
1,504,206
3,000,000
90 Days Prior
4,000,000
30 Days Post
3,000,000
1,000,000
6,969,198
6,000,000
5,000,000
2,000,000
Discharge Patients N=544
2,000,000
During
2,257,620
1,722,502
875,895
1,000,000
Hospitalization Costs
Reimbursement
30 Days Post

18. 
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
Multiple PCPs
Relay on others
Inability to pay
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19. 
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

20. 
PAM
III or IV

Dx
TBD

Readmissions
0

ED visits

Medications
<6

Social Issues
Stable housing
0-1
PCP
Insurance
20

21. 
Telephonic follow-up/education

Patient identified in-hospital & clinic
21