Course

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Course 191Let Your Fingers Do the Walking

• Staying Connected Through Telehealth

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HOUSE KEEPING

• Welcome
• This is a 1.5 hour class
• Please silence your cell phones and pagers.
• If you must answer a call, please leave the
  room.
• Thank you.

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Questions?

• Please,
• Hold your questions during the presentation.
• Questions written on the 3X5 cards provided will
  be answered at the conclusion of the
  presentation.
• For questions not answered,
• the question and the answer will be available on
  the web.

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Learning Objectives

• Define Care Coordination Home Telehealth, and
  its benefits to Veterans, caregivers, and the
  health care team
• Discuss the utilization of technology to enhance
  the management of the Veterans chronic illness
  at home
• Present clinical and utilization outcomes
  associated with the CCHT program

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Objectives continued

• Describe clinical and business lessons learned
  from CCHT program implementation
• Identify the mechanisms for the provision of
  nursing assessment, intervention, advice and
  disposition of patients via the telephone
• Apply processes managed by telephone which can
  lead to improved coordination and continuity for
  patients across the healthcare continuum.

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Presenters

• Nancy H. Prewitt, B.S.N., R.N.C., C.N.A.
• Nurse Manager, Primary Care
• Lexington, Kentucky
• Carla L. Anderson, M.S.N., R.N.
• Director of Clinical Operations
• VISN 8 Community Care Coordination Service
• Carol A. Rice, M.A., B.S.N., R.N.
• Lead Care Coordinator, Pre-diabetes
• Care Coordination Home Telehealth
• Orlando, Florida

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Telephone Access

• Did you ever think you would be caring for
  patients and managing them remotely?
• Has your idea of patient care changed
  dramatically over the past 10 years?
• Are we plugged in as a society, and has our
  practice followed suit?

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Did you say plugged in?

• Telephone access
• In home monitoring for falls
• Immediate access to 911
• Remote monitoring of disease states
• blood pressure, blood glucose,
  weight, mood, respiratory status
• Long distance assessment and advice
• VISN after-hours access
• Telemedicine
• Links to Performance Measures and Chronic Disease
  Indicators
• Other technological advances

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So what has all this meant to our patients?

• Reduced travel and inconvenience
• Management of care at home
• Standardization of care as appropriate
• Data driven care
• Improved safety
• Improved outcomes
• Improved satisfaction with care

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And what does all this mean to us?

• Improved teamwork
• Innovative approaches to care
• Management of larger panels of patients
• Case / Care Management of patients
• Improved efficiency and productivity
• Continual feedback on performance

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Telephone Access

• Administrative / Non-clinical calls
• Clinically related calls non-urgent / no change
  in condition questions related to care
• Clinical Call urgent / new symptom or change
• Clinical Call emergent change in condition

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Clinical Assessment and Disposition

• Assessment of symptoms / changes
• Utilization of triage software / protocols for
  advice and disposition
• Documentation

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Triage Protocols Veterans Health Gateway
DSHI
Systems, Inc.
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Veterans Health GatewayDSHI Systems, Inc.
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Veterans Health GatewayDSHI Systems, Inc.
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Veterans Health GatewayDSHI Systems, Inc.
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Veterans Health GatewayDSHI Systems, Inc.
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Acute and Chronic Disease Management

• Education regarding new results or diagnoses
• Follow up of chronic and/or poorly controlled
  disease states
• Improved continuity and coordination of patient
  care

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Role of Case / Care Manager

• Many possible combinations of Case / Care
  Managers
• -Specialty- intensive management of smaller
  numbers of patients over shorter duration of time
• -Primary Care management of larger
  numbers of patients over the lifespan of the
  patient and across the continuum of care
• -CCHT management of disease specific care
  associated with continuous data collection

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Care Coordination Home Telehealth
(CCHT)
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Care Coordination Home Telehealth and The
Veterans We Serve
Heroes, both young and old
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The Healthcare Impact

• CDC 2000 2 out of 3 Americans have a chronic
  illness.
• VHA translates 4 million veterans with 1 or more
  chronic illnesses.
• VHA 2001-061 75 of Long Term Care provided is
  institutional care.

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What is the Ripple Effect on care, cost and other
resources?
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No One Grows Old Saying, Gee, I Hope I End Up
in a Nursing Home !

Jonathan B. Perlin, MD, PhD, MSHA, FACP The
Former Under Secretary for Health Veterans Health
Administration Department of Veterans Affairs
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Moving the Wagner Model of Chronic Care
Forward
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From Health Care Delivery To Patient-Centered
Care

• Patient-Centered Care
• Support patients with safe, high-quality care, in
  health and disease, at the time place, and in
  the manner patient desires
• Care extends from hospital clinic to home
  community
• Using Information Technologies for Creating
  Effective Relationships between Patients,
  Caregivers and the Health System

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So what are we aiming for?

• To establish and support a Continuous Healing
  Relationship
• To integrate into both the Clinical and Home
  Environment
• To be characterized by the proactive delivery of
  evidence-based healthcare and follow-up.
• ..And what does this look like?
• to the extent to which patient care services are
  coordinated across people, functions, activities
  and sites over time to maximize the value of
  services delivered to patients. Shortell (2000)

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Care Coordination History

• Mission
• To provide the Right Care, at the Right Place,
  at the Right Time
• Vision
• The place of residence is the site of care.
• History of model development
• From RFP in 1999 in V8 to National roll out in
  2003 to 34000 veterans enrolled in 2008

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Care Coordination Strategic Model
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Care Coordination

• Increases access to appropriate services
• Predicts patient care needs proactively through
  technology and manages resources to meet them
• Takes teamwork to be successful

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Care Coordination Components

• Disease management
• Symptom, education, health factors
• Care/case management
• Across the VHA continuum
• Self management of chronic disease
• Tools for self care
• Technology delivers components

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Care Coordination

• Professional Definition
• Care Coordination is the wider application of
  care and case management principles to the
  delivery of health services using health
  informatics, disease management and Telehealth
  technologies to facilitate access to care and to
  improve the health of designated individuals and
  populations with the specific intent of providing
  the right care in the right place at the right
  time.
• Patient Definition
• Care Coordination is the use of new information
  technologies that connect people to health care
  services that help ensure the right care happens
  in the right place at the right time.

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Care Coordination

• MONITOR EDUCATE
• teach patients self-
• management behaviors
• collect objective and
• subjective data
• visibility

• REDUCED COST
• reduced operational and medical costs
• improved care manager productivity efficiency
• potential for reduction in hospital ER
  utilization

• FOCUSED CARE
• more effective use of limited care management
  resources
• focuses attention on patients who need help the
  most

• EMPOWER PATIENTS
• improved motivation
• more effective daily self care
• increased satisfaction with quality of care

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Self Management

• Shift patients into a more active role
• Informed decision maker
• Monitors self
• Capabilities and actions produce desired outcomes
  Self Efficacy
• Adoption of health protective behaviors
• Adjustment to chronic diseases

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CCHT Innovations

• Patient Self Management Toolkit
• Easy access on CCS website
• Rollout Campaign

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Care Coordinator Role Multi-Professional
Perspective

• Basic skills needed
• Assessment, communication, critical thinking,
  negotiation, collaboration
• Disciplines include
• Social Work, Nursing, Rehab, Pharmacy,
  Dietetics, Chaplain

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Care Coordination
P R O C E S S
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Interdisciplinary Team
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National CCHT Scorecard 2007
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Care Coordination Serves as a Resource and a
Partner

• Extends Case Management
• Reduces the need for Home Visits
• Vital Signs at a click data at a click
• Place of residence is not limiting
• The Focus is self management

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Veterans, in the drivers seat of care
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Home Telehealth Devices
Messaging
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Home Telehealth Devices
Monitoring
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Darkins Theory

• Its not the Box but what you do with it.

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Developing the clinician-veteran
Partnership

• Partner with veterans by increasing levels of
  shared health care decision making
• Provide educational materials and preventative
  and specific chronic disease wellness reminders
  to veterans

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Disease Management Focus Areas of Care
Coordination Home Telehealth

• Diabetes
• CHF
• COPD
• PTSD
• Pain
• Depression

• Substance abuse
• Advanced Illness/Palliative care
• MOVE
• Rehab/Polytrauma

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Disease Management Protocols

• Evidenced Based questions
• Symptoms/numeric data
• Education
• Health Factors
• A few minutes to complete on a daily basis

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Examples of Messaging questions
A new set of questions every day
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Patient response and numeric data uploads to
database and then to clinician
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Daily Monitoring Record Data
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Example of Disease Management Protocol and
Patient Response
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Example of Disease Management Protocol and
patient response related to spirituality in the
DMP for Advanced illness and palliative care
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Screen shot of vendor data report in CPRS
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Clinical Measures 2007


CCCS Overall Medication Adherence

96 HTN Hypertension SBP
89 DM Glycemic control Hgb A1c value 89 CHF
patients prescribed ACE Inhibitors or BETA
blockers 97 414 CCHT Patients have a
primary or secondary Dx of COPD (11) During 1
year period May 06 Apr 07 BDOC for COPD
during 1 yr period 7 COPD readmissions
within 30 days 0
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Pre and Post Utilization CCHT Trends 2003-2007
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Benefits of Care Coordination Home Telehealth

• Setting mutual goals help EMPOWER patients
• Offering right choices gives options to patients
• Working on a plan together helps motivate
  patients
• Veterans learn what resources are available
• Care coordinators act as patient advocates

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More Great Benefits

• Great success in assisting patients access to
  adequate emotional support in a timely manner
• Provides timely interventions
• Provides opportunity to develop patient self
  management skills
• Provides opportunity to collaborate with other
  professionals

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Lessons Learned

• Give 100 to every patient. Several times the
  patient who was negative and seemed closed off
  was the very one with the greatest success.
• Empower the patient with knowledge. They will
  respond when they feel in control.
• Develops patients skills and boosts confidence to
  use other tools such as My HealtheVet

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Lessons Learned

• Learning how to handle a disease process is a
  VERY valuable tool. Once the person understands
  WHY something needs to be done they often will
  make the changes.
• You can teach an old vet new tricks! Many LOVE
  their Telehealth equipment and are very willing
  to try new ways to manage their health

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Continuity after discharge from Care
Coordination to My HealtheVet

• Encourage veterans to keep health journals and to
  learn more about health and wellness
• Have access to a more comprehensive online health
  record
• Gain a more complete understanding of the
  veterans health status
• Evaluate veterans self-entered health
  information

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Today
From the comfort of home Access to health
information is a few clicks away!!
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Care Coordination Home Telehealth Making the
Connection
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Questions?