ellen bolch & max stachura advanced telehomecare
TRANSCRIPT
Advanced TelehomecareREMOTE VITAL SIGN MONITORING WITH INTEGRATED BI-DIRECTIONAL
VIDEO FOR CHRONIC CONDITION MANAGEMENT
PRESENTERS:
Ellen Bolch
President/CEO
THA Group
RightHealth
Max E. Stachura, MD
Director
Center for Telehealth,
Georgia Regents
University
and
Principal
RightHealth
RIGHTHEALTH®
THE FUTURE OF HEALTH CARE
The Power of RightHealth®
RightHealth® is a population health delivery
model
with leading edge technologies, such as remote
monitoring (including bi-directional video), and
medication management that powers tiered,
longitudinal, chronic care coordination across
health service settings through:
A focus on chronic disease management
A proprietary patient stratification tool that
utilizes predictive analytics
Physician-led multi-discipline teams
A focus on care transitions that allows
patients to move smoothly from one care
setting to another
Remote Telemonitoring
Remote Medication Adherence
Devices & Integration with
Pharmacy Database
Personal Electronic Health Record
Video “Virtual Visits”
Integrated Clinical Data Analytics &
the EHR System
24/7 RN Telephony Triage System
Remote ADL Monitoring
Biometric Monitoring
Producing Personalized
Predictive Analytics
The Right Technology:
Clinical Decision Support System
0%
20%
40%
60%
NationalBenchmark
Pilot Program
Chronic Disease Re-Hospitalization Follow-Up
0%10%20%30%40%
NationalBenchmark
Pilot Program
Chronic Disease Re-Hospitalization Rate
Primary Care Physician Groups Study I*
Intervention Phase Results Pilot Rate: 7%Medicare Claims Data Rate: 34%
Follow Up Phase ResultsPilot Rate: 23%Medicare Claims Data Rate: 50%
The Right Results
50%23%
34%
7%
(3 Months)
*6-Month Intervention Phase & 6-Month Follow Up Phase
(12 Months)
(12 Months)(6 Months)
Hospital awarded American Heart Association Gold award for reductions
The Right ResultsRegional Hospital #1
YEAR # PTS ADMITTED WITH CHF
#PTSREADMITTED WITH CHF
OVERALLRATE
PERCENTVARIANCE
2011 43 2 5% 85% REDUCTION
2010 119 15 12% 65% REDUCTION
2009 147 50 34%
2008 97 33 34%
2007 124 41 33%
Source: Medisolv Reportwww.HospitalCompare.gov
CHF Readmission RateComparison Graph 2007-2011
THA Group’s proprietary CHF program implemented
Readmission Rate within 30 days
Regional Hospital #2
The Right Results
90 Day Phase
Patients / Phase
Patients/Phase(excl. Outlier)
TotalCharges(excl. Outlier)
1 – Pre - THA 10 9 $321,787
2 – Active - THA 10 9 $217,851
180 Day Class IV CHF Study(Medicare charges on pilot patients)
0
10,000
20,000
30,000
40,000
50,000
60,000
70,00090 Day PrePilot
90 DayActivePilot90 DayPost Pilot
270 Day ED Recidivist Pilot Study
Ho
spita
l C
ha
rge
s ($
)
Outcome: 32% reduction in Medicare charges or
$11.5K/patient. Potential annual savings to Medicare
on all CHF admissions for this hospital - $4M
Able to directly correlate charges to interventions
Outcome: Significantly reduced hospital charges by 85%
“Worst Offenders”
Self-funded
Multiple chronic conditions
Major psychosocial challenges
Continual Risk Stratification Based on Continuous
Patient Assessment
5% of Patients Account for 50% of Costs
Typical
Distribution
5%
15%
High
Risk
Medium
Risk
RightHealth®
Data Analytics
RightHealth®
Tiered Best Practices Applied by Patient’s Level of Risk
80%Low
Risk
Co
ntin
uo
us
Re
ass
ess
me
nt
Continuous
Reassessment• Domains assessed
Data Analytics
- Clinical (Current/Previous Hx)- Functional, cognitive- Self help/care abilities/health
literacy- Psychosocial needs
• Plan Generation based on- Evidence-based best practices- Care needs assessment- Family/Social/community supports
for keeping patient in the community
- Patient/family/physician
review and approval
• Providers of care & service- Clinical (medical & behavioral)- Community- Waiver type service
- Integrated Technology
Data Driven Identification
Assessment
Integrated Care Plan
Integrated Care
Coordination
ED @ Home℠ Solutions
Telemedicine Technology for Virtual Consultation with Physicianvia RN Emergent changes in Patient Status
Telemonitoring Biometric Trends Analysis: Blood Pressure, Heart Rate and Rhythm, Pulse Oximetry, and
Weight – Allows for early detection of chronic disease exacerbation and ultimate reduction of exacerbations
over time
Keeping Patients/Clients Safely @ Home
Bluetooth Peripherals for Consultation & Visualization: A “Virtual Visit” to the Physician for Examination when
Emergent changes in patient condition lead the uniquely trained nurses to seek consultation
Bringing Patients to the MD via Technology
ED @ Home℠ Solutions
Telemedicine Technology for Virtual Consultation with Physicianvia RN Emergent changes in Patient Status
Capacity for MD Ordered Interventions
Diagnostic Tests – ECG, Portable X-rays
Placement of Indwelling Urinary Catheters
Administration of Intravenous Loop Diuretics
Intravenous Hydration and Electrolyte Replacement
Parenteral Administration of Analgesics
Administration of Intravenous Antibiotics
Delivery and Administration of Oxygen
Administration of Intravenous Cardiac Therapeutic Drugs, Rhythm Management,
and Inotropics
Administration of Intravenous Steroids
Advanced Wound and Ostomy Therapy including Wound VACs
THA Group Partnering Proposal For
Innovative Payment Program
BPCI Model 3
“Retrospective Post-Acute Care Only”
- A retrospective bundled care arrangement
- Actual expenditures reconciled against an
episode of care target price (Target Price =
total cost of the 60-day home care episode
plus 30 additional days)
- Triggered by an in-patient hospital stay.
Included post-acute care services must begin
within 30 days of discharge from hospital and
end 90 days after initiation of episode.
Proposal Aims
Monitor, track, and prevent re-hospitalization
over the 90-day episode for the following
clinical conditions (DRGs):
- Acute Myocardial Infarction
- Coronary Artery Bypass Graft
- Cardiac Defibrillator
- Cardiac Valve
- Congestive Heart Failure
- COPD, Bronchitis/Asthma
- Diabetes
- Percutaneous Coronary Intervention
- Simple Pneumonia and Respiratory
Infections
Principle:
Continual Risk Stratification Based on
Continuous Patient Assessment
Question:
What is normal?
What is normal?
What is normal for me?
Changed! Normal. But not normal for me!
Principle:
Continual Risk Stratification Based on
Continuous Patient Assessment
Questions:
What is normal for me?
From what baseline are you evaluating
whether your assessment of me today
identifies a problem requiring action?
Brunett et al, J Telemed Telecare, 2015
Use of a voice and video Internet technology as an alterntive
to in-person urgent care clinic visits.
478 patient visits
82 patients recommended for in-person evaluation
None of patients recommended for in-person evaluation
required an ED referral or hospitalization
“We conclude that real-time on-line primary and urgent care
Visits are feasible, safe, and potentially beneficial.”
Background Literature
Chi & Demeris, J Telemed Telecare, 2015
A systematic review of telehealth tools and interventions to
support family caregivers.
52 experimental & 11 evaluation studies
Technologies included video, web-based, telephone-
based, & telemetry/remote monitoring.
“More than 95% of the studies reported significant
Improvements In the caregivers’ outcomes and that caregivers
were satisfied and comfortable with telehealth.”
“Telehealth can positively affect chronic disease care,
home care and hospice care.”
Background Literature
Peetoom et al Diasabil Rehabil Assist Technol, 2014
Literature Review on monitoring technologies and their
outcomes in independently living elderly people.
“Conclusions: Monitoring technology is a promising field, with
applications to the long-term care to elderly persons. However,
monitoring technologies have to be brought to the next level,
with longitudinal studies that evaluate their (cost-) effectiveness
to demonstrate the potential to prolong independent living
of elderly persons.”
Background Literature
Finkelstein et al, Tmed J and e-Health, 2004
Telehomecare: Quality, Perception, Satisfaction.
Background Literature
2. Attention to concerns
3. Dependability of staff
4. Respect shown by staff
5. Knowledge of health problems
6. Choices about care
7. Feeling safe
8. Know contact person
9. Ability to meet needs
10. Response to concerns
11. Scheduling
12. Consistency in staffing
Theoretical Advantages
Social
Signs/symptoms patients either do not recognize
or ignore
Behavior changes not reflected in vital signs
Patient affect/demeanor
CHANGE in any of the above.
Why Video - General
Potential specific advantages
Inspection
Affect suggesting Depression
Signs of Right Heart Failure
Signs of Left heart Failure
Work of Breathing
Edema
Cyanosis
CHANGE!
Why Video – COPD
+ “I hate being on camera, but video is better. I like to deny
when I am getting worse…she would see me shaking…or
depressed.”
+ “…she could tell if I was bluer in the face.”
+ “I don’t think I have COPD. I broke 4 ribs…so I failed the O2
test because it hurt to breathe. Even if the nurse didn’t believe
me, she could see how much it hurt.”
+ “…I kind of miss seeing my nurse now that the monitor
is gone.”
THA Experience: COPD Patients + Video
- “It was good. It would have been good. But I had to move
It and then it didn’t work.”
- “It’s not better than a telephone because a telephone is
more secure…other people can’t see you.”
- “It worked at the beginning…and then it was a hidden voice.”
- “I don’t want to change the function settings more than once.”
THA Experience: COPD Patients + Video
+ “I like talking to people face-to-face. I would be more
forthcoming with information if I knew…if I could see…who
it is I’m talking to.”
+ “I know I try to hide my reactions…and I’m good at it over
The phone. If she could see me though, she would probably
Know…especially if it was the same nurse every time…. That
Would be better…even though I would not like getting caught.”
THA Experience: COPD Patients - Video
- “My wife is taking a nap…but I hook everything up for her.
Fancy video would not be good for her…maybe for some
people…probably for some people…but they (THA) would
have to choose the people…They (THA) could not expect the
patient or the family to make the choice…Maybe they (THA)
could do that when they first met you in the hospital.”
THA Experience: COPD Patients - Video
+ “I’m rather new at this. One-on-one is better. You can get
to be direct.”
+ “It’s very important that it’s the same nurse. She would see
that I’m getting depressed.”
+ “If it was the same nurse, she would come to care…she
wouldn’t just be meeting some criteria…she would be meeting
you as a person…in your space…we would have goals…
together.”
+ “When it’s the same nurse it gets personal…she treats you
like a king.”
THA Experience – Same Nurse?
- “If they were really good nurses, it wouldn’t make any
difference if it was the same one every time…I don’t see the
same doctor every time and it’s OK when they’re really good…
and really good nurses wouldn’t need the video…they would
know how to ask the right questions on the telephone.”
THA Experience – Same Nurse?
“Video can add social value and provide comfort”
“So long as you have vital sign monitoring, telephone can
be enough if you are a good clinician with good interview skills.”
“Video could be good for select patients…wound care…self-
treatment procedures like insulin administration…family support
for family of poorly communicating hospice patients. Video is
not needed for everyone…provided you are a good clinician.”
“Video can help you see changes that a patient might not
recognize…patients can ignore symptoms when they start
gradually and slowly progress.”
THA Experience – Nurse Provider
“A poor clinician with poor interview skills would do no better
with video than with a simple telephone. In fact, the video
might make it easier for a poor clinician with poor interview
skills to let the skills they did have slip away.”
THA Experience – Nurse Provider
Not every patient – select the right patient for video
Not every nurse clinician – the ability to look does not
necessarily equate with the ability to see.
The case of the non-skid slipper sox.
THA Lessons Learned
Not every patient – select the right patient for video
Not every nurse clinician – the ability to look does not
necessarily equate with the ability to see.
The case of the non-skid slipper sox.
THA Lessons Learned
Tiered assessment of patient need
Tiered delivery of patient services matched to need and
delivered by tiered professional competencies
Tiered use of technology to monitor and manage, incorporating
early recognition of clinically significant change.
One coordinated, standardized, and integrated process of care
THA Lessons Learned
…and it is not a new idea!