In-Home Monitoring 2.0

Redefining Care with Remote Monitoring to Reduce Readmissions

2013 Care Transitions Statewide SummitEast Lansing, MI

05.29.13

Disclosures

• The speakers are employed by Residential Home Health or Critical Signal Technologies.

• The speakers do not have any relevant financial relationships with any commercial interests.

Objective• Explain how an in-home monitoring system

can positively impact care transitions

• Review two forms of in-home monitoring (aka telehealth)– Personal emergency response system (PERS)– Daily vital sign monitoring – weight, blood

pressure, pulse ox, heart rate and relevant health status questions

Presenters

• Ms. Teresa McDaniel, RN, BSN, MS, Vice-President of Clinical Operations & Care Transitions, Residential Home Health

• Ms. Teresa Spencer, Director of Community Outreach & CareForce, Residential Home Health

• Jeff Prough, J.D., MBA, President & CEO, Critical Signal Technologies

Discussion Agenda

• Review of Post-Acute Chronic Care Challenges

• Review of Secondary Research Regarding Managing Readmissions & Telehealth Efficacy

• Residential’s Investment in Telehealth

• Review Residential Nurse Alert

• Review Telehealth Component of CHAMP

Today’s Post-Acute Care Challenge – Coordinating Care in a FFS Environment

Hospitals

Nursing Facilities

PhysiciansPatient Home

Typical Home Health

Typical Hospice

Typical Medicare Post-Acute Patient

• Multiple conditions• Numerous physicians• Poly-pharmacy• Caregiver support• Family resources ($)

Key Care Mgmt Issues• Poor care coordination• Misaligned incentives• Poor communication, disconnected EMRs• Under-utilization of post-acute services• Timely PCP access

• Lack of evidenced-based clinical programs• Lack of clinical capacity to respond timely• Lack of technology to manage utilization/cost• Lack of resources for care transition & service coordination

Medicare patients now see an average of seven

physicians, including five specialists from four different practices.

A typical PCP coordinated with an average of 229 other physicians in 117

different practices just for Medicare patients.

Penalties & Hold-Backs to HospitalsPayors are targeting inefficiencies and improved management of care transitions in the current FFS reimbursement structure:

Hospitals Need to More Actively Manage Post-Acute Care Networks as Scope of Penalties and Hold-Backs Will Increase

3. Re-Admission PenaltiesUp to 3% by FY 2015

2. Value-Based PurchasingUp to 2% by FY 2017

1. Related DRGRe-Admission No-Pay

Typical Medicare Hospital Discharge Dispositions

Source: Health Market Resources, Inc, 2010 Medicare Claims Data, Jencks et. al.

30-Day Re-Admit Exposure

Typical U.S. Hospital

Avg. LOS 5 days

~$12K Claim

20% of Discharges

50+% of Discharges

20% of Discharges

2% of Discharges

8% of Discharges

Home with No Post-Acute Services

Home with Home Health ServicesAvg. LOS 90 days

Facility – ECF/SNFAvg. LOS 20 days

HospiceAvg. LOS 90 days

Other

H

It’s no longer just about a discharge.What’s your 30-day post-acute plan?

~55% of Medicare patients readmit within one year.

30-Day Mortality & Readmissions

Source: CMS, Hospital Compare Data, 2009; analysis compiled by Greater Hospital Association of NY

• 11 states with lowest 30-day mortality rates had the highest readmissions and 12 states with highest 30-day mortality rates had mixed readmission rates

• Similarly, Cleveland Clinic found that hospitals with higher readmission rates actually had lower 30-day mortality rates, (NEJM, 2010)

Patient Characteristics & Health Conditions Role in Readmissions

• Patient’s life characteristics– Income– Social support

• Health conditions– # of co-morbidities– Depression– Demographic factors – age, gender, race,

geographic region

More Chronic Conditions the Greater Likelihood of Readmission

Source: Gilmer and Hamblin, Dec, 2010. Center for Health Strategies – New Jersey

Medicaid Beneficiaries Have Higher Readmission Risk than Privately Insured

Source: Jiang and Wier, (April, 2010). Agency for Healthcare Research and Quality

Case Study – Fairfield, CT vs Bronx, NY

Source: Bhalla and Kalkut, Annals of Internal Medicine, 2010

Telehealth Case Study – Veterans Health Administration

• Largest telehealth user in the world

• ~70,000 veteran patients using telehealth technologies– 85% using systematic vital sign monitoring with surveys and

nurse triage

• 85% patient satisfaction with telehealth

• 40% reduction in hospital bed days as compared to pre-enrollment figures

• 12.7% 30-day, all-cause readmission rate in 2009

VHA Telehealth Program Reduces Acute Care Utilization

Spectrum of Telehealth Solutions

Video-Based Care

Management

Phone-Based Care

Management

Patient Self-Reporting

Vitals

Systematic Vital Sign Collection with Surveys

Cost & Patient Engagement Low High

“You cannot reduce post-acute risk if you do

not actively manage post-acute risk.”

David Curtis, President, RHH

Residential’s CHAMP Program

• Demonstration of Daily Vital Sign Monitoring Solution - Video– Installation, Set-Up, Costs– Patient Profile– Wellness Monitoring– Clinical and Non-Clinical Triage and Response

• Review of Program Expenses

• Patient Satisfaction Results

• Admission Avoidance Results

Residential’s CHAMP Program• Demonstration of Daily Vital Sign Monitoring Solution - Video

– Installation, Set-Up, Costs– Patient Profile– Wellness Monitoring– Clinical and Non-Clinical Triage and Response

• Review of Program Expenses– $110 per unit per month with scale, BP cuff, pulse ox and base station with

landline or cellular option– Includes 365 nurse triage

• Patient Satisfaction Results

• Admission Avoidance Results

Overview of Home Health EMR & Telehealth Integration

Field Point-of-Care

Office Work Flow Manager

Patient Satisfaction

Wound Care

Clinical Outcomes

Operations Data Warehouse

Physician Portal

TeleHealth

Pharmacy Mgmt

CRM & Service Automation

Daily Triage & Care Coordination

Patient

Physicians

Field CliniciansNursing, Therapy

& Social Work

Reduced 30-Day Unplanned Readmissions12% All Cause

~300 monitors deployed at any

one time

365 day monitoring of weight, BP, oxygen

saturation, heart rate and other health status

questions

Telehealth NurseTriage Team – 365 days

CoordinateConsulting

Coaching for Behavior ModificationDiet, Medications, Symptom Mgmt

Telehealth is provided with no cost to patient or physician, and no incremental reimbursement

from CMS/other payors.

100% of Telehealth

Patients Report in On Daily Basis

(By 11 am)

Up to 300 patients

~40% Require Triage by

Telehealth RNEducation, MD Coordination,

Additional Visit

10% Prevented Readmit in 24 Hours

Daily Triage & Care Coordination

Residential Nurse Alert

• Demonstration of Solution - Video– Installation, Set-Up, Costs– Patient Profile– Wellness Monitoring– Clinical and Non-Clinical Triage and Response

• Review of Program Expenses

• Patient Satisfaction Results

• Admission Avoidance Results

Bringing the hospital call button home to prevent hospital readmissions

Teresa Spencer, Director of Community Outreach, Residential Home HealthJeff Prough, CEO and President, Critical Signal Technologies

But Then What Happens…

Traditional Personal Emergency Response System

Nurse Alert Is Different from Traditional PERS

Caregiver(s)

EMS Dispatch

Physician’s Office

Nurse Available 24/7

Care Support at Call Center

Nurse Alert – Customized Care Protocols• Customized protocols for every patient on service

– Examples: • Caregiver(s) may request to be notified prior to EMS dispatch• Patient can indicate protocols of how to get into the house in case of emergency, what to do

with pets, etc.

• Residential is immediately notified of any EMS dispatch (regardless of if there is a transport)

• Proactive approach to care as patients are encouraged to press their button for anything from “I want to schedule a doctor’s appointment” to “ I need my daughter to come and fill my medications”

• Preprogrammed customized messages added to the base unit. Example: medication reminders can be set up to alert patient at specified times.

• Wellness checks done throughout care plan to encourage patient compliance

Nurse Alert Has Reduced Unnecessary Hospitalizations by Incorporating Protocols that Involve Patient

Caregivers and Residential Nurses

EMS T

ransp

ort

EMS N

o Transp

ort

Caregiv

er/Nurse

Interve

ntion0

20406080

100120

October 2012-March 2013

October 2012-March 2013

Example of a Scenario that Prevented a Hospital Admission

• 3/2/2013 at 2:27 a.m. -Patient Pat, pressed button and indicated she had fallen and wanted her daughter to be called.

• As part of the patient’s protocol , it was noted the patient had a history of falls. The daughter lived nearby and if patient was responding she wanted to attend to her mother rather than having EMS dispatched.

• Daughter was contacted and went to home to assist patient. • The Residential Nurse Alert call center waited to receive confirmation

from the daughter that EMS did not need to get dispatched and then closed the call.

• Residential Home Health was immediately notified that there was an alarm activation due to a fall and a Residential nurse was sent to the home the next day to check on the patient

Recommended for Any Patient Experiencing the Following

• Chronic illness• Weakness or mobility problems• Taking multiple medications• High risk for falls• Cognitive impairment• Vision deficiencies• Recovering for surgery• Lives alone• No caregiver support

Scheduled Communications With Patient• First call made to patients within one week of start of care.

In addition Check in to see how the patient is doing.On-Board follow up

• Purpose: Call to make sure the patient understands how to use the unit and to encourage them to press the button if they need anything

3 day follow up after Install

• Purpose: Wellness Check-check on patient’s health status and to ensure they have had a follow up physician’s appiontment scheduled.

5-7 day follow up after install

• Purpose: Check to see how the patient is doing towards the end of their care plan and to see if the patient would like to continue to have Residential Nurse Alert

Day 50-54 Service Status call

Example of Wellness Call Questions

1. Do you have a moment to review Residential Nurse Alert with me? I just want to make sure we have all the necessary information to assist you properly.

2. Do you have a date set for your next follow physician appointment?o If not, I would be happy to give your doctor’s office a call to set up your appointment.

3. Do you have any questions regarding your medications or scheduled home visits?o If so, I can get you in touch with your Home Health Nurse or Care Coordinator to answer any specific questions you may have.

4. Have you been happy with the services we have been providing to you?

5. Please be sure that you keep the box the unit came in, at any time you wish to cancel all you have to do is unplug the unit, put it back in the box and stick the pre-paid label on top of the box and put it outside by your mailbox. Your postman will pick it up and send it back to us at no cost to you

6. Is there anything else we can do for you today?

Residential Home Health Includes As Part of Every Patient’s Care Plan

60% of patients extend the service beyond their care plan and choose to privately pay for the unit.

Area Agency on Aging 1-B Case Study• Area Agency on Aging 1-B (AAA 1-B) is a non-profit agency responsible for

services to more than 453,000 persons age 60 and over residing in several counties in Michigan.

• AAA 1-B recruited individuals in its region who were on the wait list and offered them a PERS unit for one-year at no cost. The study had a total of 55 participants ranging in ages from 53 to 110, with an average age of 78.2 years. Sixty four percent of respondents lived alone.

Results • Respondents experienced a 20% decrease in the number of emergency

room visits six months after receiving PERS. • Hospital admissions decreased by 27% after six months. Further, the

number of days spent in the hospital decreased 22%.

Thank You

• Please direct all follow-up inquiries to tspencer@residentialhomehealth.com

• Learn more at www.resdentialhomehealth.com