bacc_execsummary_chf_ami-final
TRANSCRIPT
Dynamic Post Acute Care Coordination
“The key to successful telehealth enabled post-acute care services is in the well planned and comprehensive program design and execution. Done well, the results are higher quality care, better outcomes and improved economics.”
Guiding Principle
C3 Program Solution Telehealth Enabled Care - Well-designed coordination of technology and services - Platform fully integrated with EMR - Robust data compilation and analytics - Cost-effective way to improve post-acute care
PCP
Coordination
OutcomesReporting
Improvement
Home Setup& Orientation
PatientCoaching
RemoteMonitoring
Population Risk Analysis
TargetedEnrollment
Anal
ytic
s & Reporting Patient Identification
Care Coordination Care Tra
nsitio
n
RESULTS 90% Patient Compliance with Monitoring
45% All Payer 30-Day Readmission Rate Reduction - HF, AMI, PN, COPD (12 month results)
30% CMS Rate Reduction
37% Medicare HF 30-Day Readmission Rate Reduction - (program-to-date)
16% Medicare AMI 30-Day Readmission Rate Reduction - (program-to-date)
Digital Health Platform
CARE TRANSITION
OUTCOMES REPORTING
CARE COORDINATION
Patient “Activation”
Installation Management
Patient Vitals
Summary
Monthly Results
Trend Analysis
Remote Monitoring
SECURE INFORMATION GATEWAY
COBALT APPLICATION
Patient Management
COBALT DB COBALT DATA WAREHOUSE
Data Analytics & Reporting
Clinicians C3 Report
Health System Partners
PATIENT ENROLLMENT
• Identify patients • Risk Stratify • Enroll pts • Home “kit”
CARE TRANSITION
• Initial contact with patient
• Identify follow up and service needs
CARE COORDINATION
• Monitor daily vitals • Coordinate at-risk
patient interventions
OUTCOMES REPORTING
• Readmissions
• Compliance
• Trend Analysis
COMPREHENSIVE PROGRAM
WHO: PATIENT
NAVIGATOR
WHAT:
• Assess risk levels (functional status, home/social, co-morbidities)
• Provide patients with program materials
• Secure consent
PRE-DISCHARGE TIMELINE: CHF/AMI
30 DAYS POST-DISCHARGE
• Discharge with required devices based on monitoring ”tier”
• C3 clinician coaches on the monitoring process
• Assess patient post-discharge environment and support needs
• Manage by exception – out of range per parameters
• Report summaries to providers integrated with EMR
• Escalate care for at risk patients with involvement of cardiologist and/or other providers
• Periodic C3 clinician check-in/reinforcing calls
• Summaries at population and individual patient level
• Review/analysis of readmissions, compliance & important clinical outcomes
Meaningful Data Integrated with the EMR
Readmission Analytics – And Where C3 Has Helped
• Recurrent HF
Original Diagnosis
Contributing
Factors
• Patient non-compliance (esp. meds and diet) • Lack of understanding of discharge
instructions
Most common avoidable readmission diagnosis
Heart Failure
AMI • HF • Noncardiac chest pain • AMI
• Lack of early post-discharge follow up to assess post MI heart muscle function and titrate/initiate CHF medications
• Failure to implement CHF medications prior to
discharge in patients with reduced EF • Poor patient understanding of discharge instructions
re: sodium/fluid restrictions • Patient anxiety about symptoms • Patient non-compliance with anti-platelet agents
C3 Readmission Feedback Catalyzes System Improvement
C3 Data Analysis:
Causes of Readmissions
Post-AMI Clinic (launched 3/18/15)
• Cardiology appointment within 7 days of discharge
• Appointment includes consult with cardiologist, Cardiac Rehab, Nutritionist, and PharmD (medication dosing and cost optimization)
• Evidence-directed treatment plan for each patient sent to primary cardiologist and PCP
• Strategy ensures timely follow up, early
engagement with support services, and medication affordability and compliance
Clinicians
C3 Reporting
Health System Creates New Post-
Acute Initiative
Post-AMI Clinic Model
Changing Economics Drive New Care Approaches
CMS PENALTY CONDITIONS (5)
Episodic, 30-day PAC focus
READMISSION PENALTIES
50% of Hospitals Paying – 20% Annual Increase
$490M – 2015 Penalties
Episodic, 30-90 day PAC focus
BUNDLED PAYMENT
$8B Spend on PAC
$26B – 2014 Spend on Joints & CHF Patients
CMS BUNDLE PLANS (48)
Readmission Penalties
+ SNF Stays
Remain Key Cost Drivers
Flexible Platforms for Patient Engagement
Bridging Consumer Apps & Secure Clinical Data
SECURE INFORMATION GATEWAY
COBALT APPLICATION
Patient Management
COBALT DB COBALT DATA WAREHOUSE
Data Analytics & Reporting
Clinicians C3 Report
Devices Interfaces
Remote Monitoring
Vital Signs
Apple Health Kit
Google Fit
PHOTOS
VIDEO CONFERENCE
PULSE/OX
ACTIVITY
WEIGHT
BLOOD PRESSURE
Performance Based Contracting
RECRUIT & TRAIN CLINICAL CARE COORDINATION
STAFF
DEFINED ROLES AND RESPONSIBILITIES
REPLICABLE OPERATING PROCEDURES
ENROLLMENT, LOGISTICS, CARE COORDINATION
EMR INTEGRATION, COBALT, BIOMETRIC DEVICES
CRITICAL TECHNICAL INFRASTRUCTURE
COMPREHENSICE DATA ANALYSIS
& REPORTING
ACTIONABLE INFORMATION &
RELEVANT PATIENT DATA
