discussing vidant health’s telehealth & care transitions program discussing vh’s telehealth...

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

4

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

14

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

Bonnie Britton, RN, MSN, ATAFbonnie.britton@vidanthealth.com