Strategies for Managing Chronic Diseases and Care Transitions in Telehealth

1. Combating The Rising Cost of Care:Care Coordination and Chronic Disease ManagementMATRC 2nd Annual SummitApril 18, 2013Bonnie Britton, MSN, ATAF VH Telehealth Administrator

2. Today’s talk involves…… • Discussing Vidant Health’s Telehealth & Care Transitions Program • Discussing VH’s Telehealth Outcomes

3. 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

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

6. VH Hi Risk Criteria • PAM I & II • Dx Any chronic disease • Readmissions < 30 day • ED visits 4 + • Medications 6+ • Social issues Homeless No Transportation No PCP Un/underinsured

7. 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

8. Metrics • 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. DemographicsN=926

10. DemographicsN=926

11. DemographicsN=926

12. Patient Age N= 926

13. Average time utilizing remote monitoring services N= 926

14. Patient Satisfaction SurveysN=325

15. Hospital AdmissionsTotal Patients=695 Decreased by 69% Prior to During Decreased by 76% Prior to Post

16. Hospital Bed DaysTotal Patients= 695 Decreased by 67% Prior to During Decreased by 81% Prior to Post

17. Hospital Cost and ReimbursementTotal Patients =695

18. 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 others Multiple PCPs Inability to pay

19. 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

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

21. Low risk patient referred to: • Telephonic follow-up/education • Patient identified in-hospital & clinic

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