using telehealth to achieve the triple aim · identify how telehealth provides opportunities to...

USING TELEHEALTH

TO

ACHIEVE THE TRIPLE AIM

TERRY YONKER, RN, MS, FNP-BC

TELEMEDICINE CLINICAL CARE COORDINATOR

FINGER LAKES COMMUNITY HEALTH

Objectives 1. Discuss applications of telehealth in primary care

2. Identify how telehealth provides opportunities to

increase access to care

3. List ways in which telehealth has tangible and

intangible cost benefits

4. Explain how telehealth programs can improve

quality of care

Disclosure

I have no financial relationship with a commercial entity

producing health-care related products and/or services

relative to the content I am presenting

Who We Are… • Community/Migrant Health Center Program

• Migrant Voucher Program in 42 Counties

• Clinical Sites: 9 Health Center Sites

• Administrative Office: Penn Yan, NY

Where We Are…

• Transportation barriers

• Language differences

• Cultural beliefs

• Cost of health care services

• Uninsured/Underinsured

• Lack of trust in health care

system

• Poverty

• Migrant lifestyle

Challenges in Providing Health Care to Rural Poor

FINGER LAKES COMMUNITY HEALTH –

HIT INFRASTRUCTURE DEVELOPMENT

USDA – Distance Learning and Telemedicine

HRSA – Rural Network Development

Federal Communications Commission – Rural Healthcare

Broadband Project

NYS DOH

Telehealth Program Development Funding Sources

Teledentistry

Telepsychiatry

Telemental Health

Tele-ENT

TeleDiabetes (DRS)

TelePeds

Neurology

TelePulmonology

TeleAC

TeleRD

TeleMD

TeleHCV

Telehealth Programs at FLCH

Patients /Families

Reduced travel

Timely appointments

Services in their

community

Additional support

Benefits of Telehealth

Providers

Direct patient interaction

Expanded Services

Access to other experts

Access to CME

Health Care Systems

Improved access

Improved outcomes

Resources utilization

Cost and Time efficient

The Triple Aim

1 •IMPROVE ACCESS

2 •IMPROVE QUALITY

3 •DECREASE COST

HOW TO ACHIEVE THE TRIPLE AIM

PART 1

PROGRAM DEVELOPMENT

GUIDING PRINCIPLES

#1 Telemedicine is a tool

#2 Program Management can uncover strengths and

weaknesses in operations

#3 Quality Improvement is Forever

#4 Management by facts = DATA

#5 Need to see cost benefits from different perspective

#6 Keep a sense of humor!

TELEMEDICINE AS A TOOL

• Identify gaps in service

• Tap the resources

• Champions are your best friend

IT’S NOT ABOUT THE GADGETS, IT’S ABOUT THE CARE

PROGRAM PLANNING

• Administration – IT – Clinical – Operations – Quality

• Spend time with specialty provider

• Pay attention to details

• Document clinical workflow

• Always do a pilot – start small, think big

• Goal is to integrate into operations of a PCMH

• Change Theory

QUALITY IMPROVEMENT

• Data Collection

• Monitor and Report Outcomes

• Continuous Quality Improvement (PDSAs)

• Regularly Evaluate Program

MANAGE BY FACTS

• Data! Data! Data!

• Facts can trump emotion

• Facts = Outcomes

And remember:

A Vision Without a Plan is a Hallucination!

COST BENEFIT IS NOT ALWAYS IN

REAL $$$

• Saved travel time/gas for families and enabling staff

• Less lost work time for families

• Increased volume of visits to PCMH

• Relationships between primary care and specialty care

• PCP job satisfaction and morale

• Changing health care delivery system and policy

KEEP A SENSE OF HUMOR

CHANGE THEORY HELPS!

• Start Small, Think Big

• Communicate for Success & Celebrate Victories

• Pause Points: What is working? What is not working?

What could be done better?

• Identify and Deal with Fears/Concerns

• Keep Decision Makers in the Loop

• Keep Process Moving Down the Track

• Give Feedback (timelines, performance measures)

There is no such thing as a small problem

HOW TO ACHIEVE THE TRIPLE AIM

PART 2

FRONT LINE STAFF HOLD THE KEYS

Excellence in Patient Care Drives Everything

MR #

Last visit A1C Date Result B/P date Result LDL Date Result

Malb Date Result

DR Date Result

Foot Exam

Smoke

A07362500 10/20/11 10/20/11 7.3 10/20/79 124/79 4/11/11 71 7/26/11 <6 7/26 mild

NPDR 6/21/11 N

A07343203 11/28/11 11/28/11 10.3 11/28/11 124/80 3/1/11 38 11/28/11 150 1/5 mild

NPDR 3/3/11 N

A07317705 11/15/11 11/15/11 5.9 11/15/11 107/72 6/20/11 59 4/8/11 13 7/21 neg 4/8/11 N

3617386 11/01/11 9/8/11 14 11/1/11 106/66 9/25/11 231 9/8/11 <6 9/29 ?glauco

ma 9/8/11 N

10002 12/06/11 12/6/11 6.4 12/6/11 126/83 12/6/11 ACE-I N

A07273833 10/25/11 8/25/11 7.3 10/25/11 129/80 6/2/11 85 8/25/11 16 8/25 neg 8/25/11 yes

A07228967 12/29/11 11/22/11 7.7 12/29/11 145/85 12/1/11 100 8/16/11 131 8/2 mild

NPDR 11/22/11 N

Create a Registry

*Scheduling

*Pre-Visit Requirements

*Concurrent Chart Review

*Coordinate with PCMH

Team/Specialty Team

*Quality Assurance Reports

*Lead Case Conferences

*Quality Improvement PDSA

Care Coordination

History

Exam

Treatment

Train Telepresenter

• Outreach

• Insurance Access

• Transportation

• Language/Cultural Interpretation

• Motivational Interviewing/Pt Centered Goals

• Education

Relationships = Trust

Actively Decrease Barriers to Care

Here are some examples……

The Finished Product…

Finger Lakes Community

Health

Eastman Institute for Oral Health

TeleDentistry

EARLY CHILDHOOD CARIES IN MIGRANT CHILDREN

Early onset & increased severity due to cultural

feeding practices

Prevalence:

Migrant > Underserved urban > US general population

Mobile Dental Services

**FLCH mobile dental teams and primary prevention strategy has

decreased rate from 60% to 22%**

***For children with advanced decay, pediatric dentist and

treatment under sedation or general anesthesia***

For those requiring treatment of ECC…..

15% COMPLETION RATE

• * Lake Ontario ABCD * Red Creek ABCD

• *Migrant Summer Schools (Sodus, North Rose, Red Creek)

LIVE VIDEOCONFERENCING

TELEDENTISTRY

Intraoral Camera

Digital Images

Real Time Images

Bilingual/Bicultural Community Health Workers

Outreach

Insurance Access

Transportation

Language/Cultural Interpretation

Pediatric Dentistry Access

Education

Relationships = Trust

Triaged Correctly = 88% Decreased travel costs

Decrease in lost work time

Improved access to care

Decreased time to treatment

Decrease no show rates

Increased interaction between dental providers

94% COMPLETION RATE

4/10 – 4/14

N = 290 consults

54% require treatment under general anesthesia

TeleDentistry Outcomes

Finger Lakes Community

Health

URMC

Child Neurology

TelePeds Neurology

Site Visit – Create Remote Office – Registry – Care

Coordination – IT Connectivity – Train PA in Neuro Exam –

Use PCMH Team – Leverage HIT – Case Conference –

Monitor Outcomes – Ongoing QI

2013 Pilot Outcomes: *** Decreased time to treatment (38d vs 60d)

*** Exceeded national averages on NCQA performance measures

*** 75% had changes or additions to their med regimens

*** 87.5% diagnosed with mental health co-morbidity

*** 100% referred to behavioral health

*** 63% showed improvement in function at school and home

*** High provider and patient satisfaction

TelePeds Neurology

Finger Lakes Community

Health

Trillium

Health

TeleAC (HIV/AIDS Care)

TeleAC

Appointment Adherence

PCP 85% 57% 91%

AC 85% 86% 100% HIV CARE

CD4 >500 50% 29% 64%

CD4 >200 85% 86% 91%

Negative viral load 50% 29% 67%

HAART > 95% 85% 71% 73%

OI PCP if indicated 100% 100% 100%

Prevention Screening

TB Testing 85% 86% 80%

HCV Screening 85% 57% 100%

Cervical PAP 85% 66% 100%

Anal PAP 85%

Colon cancer screening 85% 86% 50%

Annual Lipid Screen 85% 100% 100%

Annual urinalysis 85% 71% 60%

A1C 85% 71% 100%

STD Screen 85% 86% 92%

PHQ 9 85% 29% 80%

TeleAC Pilot Program Clinical Measures

Indicator Goal Baseline 7/1/13 End Pilot 6/30/14

Finger Lakes Community

Health

FL Health

&

John D Kelly Behavioral Health Unit

TelePsychiatry

• 55% had decrease in PHQ9 scores

• Mean time to consult = 19 days

• Mean time to treatment = <24 hours

• High patient and provider satisfaction

• 39% lost to follow up

• 0% referred to ED

• 17% referred to higher level of care

(Article 31)

TelePsychiatry Outcomes 2010-2012

Fundus Photography in Primary Care

TeleDiabetes

Sodus Community Health Retinopathy Pilot

Screening Results

SODUS COMMUNITY HEALTH

DIABETES QUALITY INDICATORS

FLCMH 1.2012

0

10

20

30

40

50

60

70

80

90

100

A1C <

7

B/P <

130/80

LDL <

100

Kidney

check

Foot

Exam

DRS

May '11

March '12

June '12

National Committee on Quality Assurance(NCQA)

> 40% >25% >36% >80% >80% >60%

USING TELEHEALTH TO

ACHIEVE THE TRIPLE AIM

THANK YOU!

For more information:

TerryY@flchealth.org

585-314-7548