1

Care CoordinationCare CoordinationThrough the Use of Home TeleHealth Through the Use of Home TeleHealth

TechnologiesTechnologies

VHA Care Coordination ProgramVHA Care Coordination Program

VA Healthcare Network of Upstate NYVA Healthcare Network of Upstate NY

Pamela Page, APRN, BCPamela Page, APRN, BC

Behavioral Health Clinical Nurse SpecialistBehavioral Health Clinical Nurse Specialist

2

VHA’s Domains of ValueVHA’s Domains of Value

QualityQuality

AccessAccess

SatisfactionSatisfaction

Functional StatusFunctional Status

Cost EfficiencyCost Efficiency

Building Healthy CommunitiesBuilding Healthy Communities

3

Mission:Mission: Coordinating the Right CareCoordinating the Right Care

at the Right Placeat the Right Place

at the Right Timeat the Right Time

Vision:Vision: The place of residence is the place of careThe place of residence is the place of care

4

Lifelong Health RecordLifelong Health Record

Intake - Baseline

Training

Assignments

Deployment

Demobilization

Discharge

Retiree / Veteran

Past Events InformFuture Care

Risks

Injury

Exposure

Illness

Late Illness

Care Coordination: DefinitionCare Coordination: Definition

“The ongoing monitoring and assessment of selected patients using telehealth technologies to proactively enable prevention, investigation, and treatment that enhances the health of patients and prevents unnecessary and inappropriate utilization of resources. Care Coordination uses best practices derived from scientific evidence to bring together health care resources from across the continuum of care in the most appropriate and effective manner to care for the patient”

Care Coordination: DefinitionCare Coordination: Definition

“The ongoing monitoring and assessment of selected patients using telehealth technologies to proactively enable prevention, investigation, and treatment that enhances the health of patients and prevents unnecessary and inappropriate utilization of resources. Care Coordination uses best practices derived from scientific evidence to bring together health care resources from across the continuum of care in the most appropriate and effective manner to care for the patient”

Care Coordination: DefinitionCare Coordination: Definition

“The ongoing monitoring and assessment of selected patients using telehealth technologies to proactively enable prevention, investigation, and treatment that enhances the health of patients and prevents unnecessary and inappropriate utilization of resources. Care Coordination uses best practices derived from scientific evidence to bring together health care resources from across the continuum of care in the most appropriate and effective manner to care for the patient”

6

The Essence of The Essence of Care CoordinationCare Coordination

Patient FocusedPatient Focused Assessment: Clinical needs,functional Assessment: Clinical needs,functional

status,social & status,social & environmental issues environmental issues

Matching: Clinical care from across the Matching: Clinical care from across the VHA continuum and VHA continuum and

Monitoring: Patient use, outcomes and Monitoring: Patient use, outcomes and quality of life. quality of life.

7

Care Coordination ComponentsCare Coordination Components

Disease ManagementDisease Management– Knowledge / Patient EducationKnowledge / Patient Education– SymptomSymptom– BehaviorBehavior

Case ManagementCase Management– High users ( ER), high risk, frequent High users ( ER), high risk, frequent

admissionsadmissions Self Management of Chronic DiseaseSelf Management of Chronic Disease Quality,Access, Satisfaction, ValueQuality,Access, Satisfaction, Value

8

Goals of Case ManagementGoals of Case Management

Quality of CareQuality of Care CollaborationCollaboration Fiscal ResponsibilitiesFiscal Responsibilities Patient AdvocacyPatient Advocacy Outpatient ManagementOutpatient Management Professional Nursing PracticeProfessional Nursing Practice

9

Sense of UncertaintySense of Uncertainty

Reading the organizational thermostatReading the organizational thermostat Nurturing the system to embrace innovationNurturing the system to embrace innovation Doing business differentlyDoing business differently Establishing credibility through qualityEstablishing credibility through quality

– Evidence-based approachEvidence-based approach Building a bridge of trustBuilding a bridge of trust Educating staff to acceptanceEducating staff to acceptance

“Quality and Trust are first cousins.”Dr. Donald Berwick

10

Targeted PopulationsTargeted Populations

Congestive Heart Failure ( CHF)Congestive Heart Failure ( CHF) Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease

(COPD)(COPD) Diabetes and HypertensionDiabetes and Hypertension Major DepressionMajor Depression Advanced Illness/ Palliative CareAdvanced Illness/ Palliative Care PTSD PTSD Caregiver Support – Alzheimer’s, DementiaCaregiver Support – Alzheimer’s, Dementia

11

Patient Selection Criteria For Patient Selection Criteria For CHF, COPD, DM/HTNCHF, COPD, DM/HTN

Diagnosis: COPD, CHF, or DM/HTN Diagnosis: COPD, CHF, or DM/HTN (with or without dementia)(with or without dementia)

Greater than or equal to 2 hospital Greater than or equal to 2 hospital admissions or ER visits (VA and nonVA) admissions or ER visits (VA and nonVA) in 1 year for the selected diagnosis in 1 year for the selected diagnosis

Greater than or equal to 6 OPT visits for Greater than or equal to 6 OPT visits for CHF, COPD, or DM/HTN in the last CHF, COPD, or DM/HTN in the last yearyear

12

Patient Selection Criteria (cont.)Patient Selection Criteria (cont.)

Patient/caregiver able to provide signed Patient/caregiver able to provide signed consent and adhere to responsibilitiesconsent and adhere to responsibilities

Patient/caregiver has the ability to operate Patient/caregiver has the ability to operate technologytechnology

Safe home environment (adequate Safe home environment (adequate electrical/phone services, scales, BP cuffs, electrical/phone services, scales, BP cuffs, batteries).batteries).

13

Patient Selection Criteria For Patient Selection Criteria For DepressionDepression

More than 2 ER visits for depression or more than More than 2 ER visits for depression or more than 2 off-hours calls to address depressive symptoms2 off-hours calls to address depressive symptoms

1 admission to Inpatient Psychiatry within 12 1 admission to Inpatient Psychiatry within 12 months months 

GAF = 35-50GAF = 35-50 Depression a problem for more than 6 monthsDepression a problem for more than 6 months Decreased behavioral control in clinic settingsDecreased behavioral control in clinic settings ECT within the past year ECT within the past year

14

Exclusion CriteriaExclusion Criteria

History of behavior that would impact History of behavior that would impact the safety of staff or equipmentthe safety of staff or equipment

Unable to read or operate equipment Unable to read or operate equipment No phone accessNo phone access Depression with Psychotic featuresDepression with Psychotic features

(specific to depression module)(specific to depression module)

15

Health Buddy System Components: Match Standard Practice Guidelines

16

DataCenter

Store & SendTechnology

In-home MessagingIn-home Messaging

17

18

Technology Solutions for Health Technology Solutions for Health Monitoring Monitoring

Health HeroHealth Hero®® Network Network

Confidential

19

The system includes monitoring technologies, clinical information databases, Internet-enabled decision support tools, health management programs, and content development tools.

Health Buddy® System

Congestive Heart Failure

COPD

Coronary Artery Disease

Hypertension

Co-Morbid Hypertension/Chronic Obstructive Pulmonary

Co-Morbid Congestive Heart Failure/Diabetes

Diabetes

Co-Morbid Diabetes/ Hypertension

Co-Morbid CAD/Angina

Adult Asthma

Depression

Bi-polar Disorder

Senior Wellness

Disease Management ProgramsDisease Management Programs

21

Device Integration OpportunitiesDevice Integration Opportunities

Blood Pressure

Monitors*

Blood GlucoseMonitors

CoagulationMeters*

PeakFlow

Meters*

DigitalWeightScale

Open architecture can be developed to interface to a variety of home medical devices from multiple manufacturers.

Multiple licensing, marketing, and distribution opportunities with medical device manufacturers

22

SimpleSimple

4 button self-explanatory action4 button self-explanatory action

No computer skills required & easy to set upNo computer skills required & easy to set up

FlexibleFlexible

Patients respond at their conveniencePatients respond at their convenience

No missed phone calls/appointmentsNo missed phone calls/appointments

Port for connection to medical devicesPort for connection to medical devices

TimelyTimely

Immediate call-back or;Immediate call-back or;

Escalations based on patient responsesEscalations based on patient responses

Monitoring Technologies: Monitoring Technologies: Health Buddy Health Buddy ®® Appliance Appliance

23

Daily Daily Risk StratifiedRisk StratifiedView of Patient View of Patient

CaseloadCaseload

iCare DesktopiCare Desktop™™ Work List Work List

24

Daily Daily Risk StratifiedRisk StratifiedView of Patient View of Patient

CaseloadCaseload

Decision Support Tools:Decision Support Tools:iCare DesktopiCare Desktop™™ Application Application

Work ListWork List

25

Detailed View Detailed View of Patient Resultsof Patient Results

Decision Support Tools:Decision Support Tools:iCare DesktopiCare Desktop™™ Application Application

ResultsResults

26

View of Key View of Key Clinical Indicators Clinical Indicators

Over TimeOver Time

iCare DesktopiCare Desktop™™ Trends Trends

27

Choose your own Choose your own graphs and view graphs and view multiple sets of multiple sets of

data in chart data in chart formatformat

Decision Support Tools:Decision Support Tools:iCare DesktopiCare Desktop™™ Application Application

TrendsTrends

28

Health Buddy System Health Buddy System Components: Health Components: Health

Management ProgramsManagement Programs Health Management Programs: Interactive scripted content based on Health Management Programs: Interactive scripted content based on

standard practice guidelines for over 45+ disease states is delivered via standard practice guidelines for over 45+ disease states is delivered via our monitoring technologies to educate patients, enhance medication our monitoring technologies to educate patients, enhance medication compliance, and improve patient behavior. compliance, and improve patient behavior.

Heart Failure *

Hypertension*

COPD*

Diabetes*

Major Depressive Disorder*

* Included in VA contract, matches VHA Practice Guidelines

29

Content Development ToolsContent Development Tools Content Development Tools: Robust software tools enable Content Development Tools: Robust software tools enable

health management program development, with dynamic health management program development, with dynamic branching logic, flexible question taxonomy, and the ability to branching logic, flexible question taxonomy, and the ability to collect variable patient responses. collect variable patient responses.

30

Health management programs built using standard practice Health management programs built using standard practice guidelines with focus on key aspects of care including signs guidelines with focus on key aspects of care including signs and symptoms, behavior, and knowledgeand symptoms, behavior, and knowledge

Rich variety of question typesRich variety of question types

Question taxonomy is dynamically branching to varied Question taxonomy is dynamically branching to varied responses with associated risk tagsresponses with associated risk tags

Built-in outcomes measures Built-in outcomes measures including utilization and patient including utilization and patient satisfaction, quality of life, medication compliance and satisfaction, quality of life, medication compliance and individual patient population reporting (SF36v, SF12, individual patient population reporting (SF36v, SF12, Minnesota Living with Heart Failure Assessment)Minnesota Living with Heart Failure Assessment)

Customization and personalization of health management Customization and personalization of health management programs to fit programs to fit policies and procedures for any disease policies and procedures for any disease

Online review of health management programs Online review of health management programs

Content Development Tools:Content Development Tools:Care ComposerCare Composer™™ Software Software

31

Question and Response TypesQuestion and Response Types

Multiple Choice

ExtendedMultiple Choice

32

Question and Response TypesQuestion and Response Types

Numeric

Range/Scale

33

Question and Response TypesQuestion and Response Types

Binary

34

Question and Response TypesQuestion and Response Types

Prompt / Education / Information

35

Provider Station Patient Station

Audio/Visual/Real-time

36

AVIVA Pilot ProjectsAVIVA Pilot Projects

Specialty services to includeSpecialty services to include– Consultation from Tertiary site to CBOC Consultation from Tertiary site to CBOC

ex: Cardiology VA Bath/Buffaloex: Cardiology VA Bath/Buffalo– Increase access to care by extending services to Increase access to care by extending services to

remote areasremote areas– Increased patient satisfaction by reducing travel Increased patient satisfaction by reducing travel

requirementsrequirements– Potential reduction in fee costsPotential reduction in fee costs

37

Outcome Measurement SystemOutcome Measurement System

Utilization Measures - Pre and Post Utilization Measures - Pre and Post technologytechnology

Clinical MeasuresClinical Measures Business and Efficiency MeasuresBusiness and Efficiency Measures Patient, Caregiver, Provider and Staff Patient, Caregiver, Provider and Staff

satisfaction satisfaction

38

UtilizationPre and Post Program

EnrollmentER VisitsAdmissions to Acute CareNumber of Clinic Visits

Clinical Pre and Post Program

EnrollmentCPG’s for:CHFCOPDDM/HTNMajor DepressionPalliative Care

Care CoordinationCare CoordinationPerformance and Quality PlanPerformance and Quality Plan

SatisfactionPatient Survey / May ’04Provider SurveyCare Giver SurveyStaff Survey

Business Total # of CCHT encountersPanel Size% patient using technology(P)

39

OUR PROMISE TO OUR OUR PROMISE TO OUR VETERANSVETERANS

To empower our patients and the people To empower our patients and the people who care for themwho care for them

Focus on prevention not rescueFocus on prevention not rescue

Respond with the Right Care, Right Place, Respond with the Right Care, Right Place, Right TimeRight Time

Clinical Settings

Clinical services

Care Coordination: Making the Connection

Provider

Patient at Home

Technology