Pediatric post acute care in 2008

St. Marys Telehealth Program for the Medically Complex Population

Elvira F. Roveto, FNP B-C Home Care Administrator, DPS

Donna Mapp-Reid, RNC, CCM Telehealth Supervisor

1St. Marys Telehealth ProgramIn July 2014, St. Marys was awarded $928,668 from the NYS Balancing Incentive Program Innovation Fund (BIP)

Grant allows St. Marys to enhance its home care services through the use of an Interactive Voice Response System (IVR)

Original BIP contract period August 1, 2014 to September 30, 2015. DOH extension through 2016

BackgroundThis is the first program of its kind in New York State for medically complex children. This program is unique in that it provides an interactive voice response system versus a biometric measurement employed in other programs. For example instead of taking your blood pressure and sending those results to an MD/RN you receive an automated call.

The original grant period was from August 1, 2014 through September 30, 2015. We recently received confirmation that the NY State Department of Health has extended the grant through 2016 due to the preliminary successes patients have experienced.

2St. Marys Telehealth ProgramDecrease the risk of re-hospitalizations

Increase medication adherence

Increase patient/family satisfactionGoals

St Marys Healthcare consistently strives to achieve positive patient outcomes, high levels of patient satisfaction while providing cost effective care.

Aligned with Triple Aim Framework for healthcare developed by The Institute for Healthcare Improvement (IHI), -an independent not-for-profit organization focused on health care improvement and optimizing health system performance. The Triple Aim framework strives to improve the health of a given population and the population as a whole, to enhance the patient experience, and to reduce the per capita cost of health care. We set our goals to align with Triple Aim

At St Mary's the telehealth program has improved communication and involvement between our patients, their caregivers and our clinical team. Studies have shown improved patient satisfaction not only leads to an enhanced patient experience but also is associated with improved treatment outcomes.

3Telehealth TargetsThe program targets children with medical complexity, with diagnoses including but not limited to:

Seizure DisorderAsthmaRespiratory (non-asthma)Dehydration

St. Marys Telehealth ProgramSince the project was initially limited to 500 patients, we determined we would prioritize enrollment, starting with the patients on our home care program who are most at risk for re-hospitalizations. These are some of the most medically complex children in New York State.

This includes children with:

SeizuresAsthmaRespiratory problems unrelated to asthmaDehydration

In addition to receiving nursing and rehabilitation home care visits, these patients and caregivers receive regular, automated calls from an IVR system.4How IVR worksPatients / Caregivers sign consent to participate in the programPatients / Caregivers agree to accept calls and they specify day/time/frequency that is most convenient for them Automated calls are scheduled and monitoredAlerts are triggered based upon responses Action is taken based on the type of alert

St. Marys Telehealth Program

IVR, Interactive Voice Response system is a user-friendly program. We partnered with AMC (Advancing Monitored Care) who has extensive experience with IVR systems.

In an effort to increase compliance with the program and reach our goals, the team works with the families during the enrollment process to select best time and day to receive the automated calls

Patients receive a 2-3 minute automated call and respond to questions using the keypad on their phone. No equipment required to be set up in the home. There is no capital expense.

If the patient answers Yes to a question, an alert is triggered & the team is notified.

The Telehealth Team triages the calls and makes a determination about what steps to take next. 5Actions Taken When Alerts are Received Each family that has triggered an alert receives a call by a Registered Nurse with extensive pediatric experience to determine appropriate interventions.Common interventions resulting from the follow-up calls include:Educating about the disease process, complications, and when to contact healthcare provider or seek emergency treatment Providing education regarding medications and treatments Identifying the need for an unscheduled home visit from their primary care Nurse.Contacting the physician, pharmacy or vendor

6General Interactive Call Demonstration

St. Marys Telehealth ProgramInteractive Voice Response (IVR) allows patients to have St. Marys eyes & ears in the home in addition to regular scheduled in-person visits.Although St. Marys is currently assigning unique templates based on the 4 most common diagnoses we mentioned earlier, every IVR call that goes out contains a standard set of questions that are common to every patient. These questions capture critical information regarding changes in the patients health or medications.

The best way for you to understand how easy and smooth the process is for the patient is to listen to an IVR call, so I will now play a demonstration IVR call for you.

7Sample Template (Asthma)Asthma Program: Is the patient having any of the following: Coughing at night?Fast breathing?Noisy breathing or wheezing?Less physical activity?Using the rescue inhaler more than usual?Signs of a cold or flu?If yes for any above, alert triggered:Yes: Alert Level: High We will let the nurse know No: Alert Level: None

St. Marys Telehealth Program

After the standard questions are asked, questions related to specific diagnosis follow if they indicated a change in status.

This shows sample questions patients are asked when assigned to the Asthma template as an example of a template.

Different sets of questions unique to each of the most prevalent diagnoses are assigned including:

Seizures, Dehydration and Respiratory Non-asthma

8St. Marys Telehealth Program

This chart shows types or reasons for alerts for the first year; both total numbers and percentages.

1844 alerts were received which means that 1844 contacts were made by phone after alert was received.

The greatest number of alerts was for changes in clinical status representing 45% of all alerts, follow by medication related which together represent 29% of alerts.

9Medication AdherenceSt. Marys recognize the correlation between medication adherence and positive patient outcomes including reduced costs & increased satisfaction associated with fewer hospitalizations and ED usage. Medication teaching and monitoring is a key component of patient care. This program is an opportunity to influence medication adherence more consistently.All patients in the Telehealth program are asked questions about medication.

As mentioned earlier, Medication non-adherence has been shown to be related to increased health care use in children and adolescents who have a chronic condition or are medically complex.

Because much of healthcare utilization (including the use of emergency rooms and hospitalizations) is attributed to non-adherence with medications, this is an area where costs can be reduced, and patient outcomes can improve.10Medication Adherence: Outcomes We monitor adherence with 100% of our Telehealth patients. Medication questions are incorporated in all IVR templates.Regardless of the primary diagnosis or reason they are on the Telehealth Program, patients are asked questions about medications on every call. First Year Alerts: 1844528 or 29% were medication related More than 90% of these were for new or changed medicationsEach followed up with a phone call to the home 528 instances of communication with the home

11St. Marys Telehealth ProgramFor the first year we built and refined our data collection methods.==Working with AMC and industry consultants we have built a data base of key performance measures.To assess the impact on hospitalizations we identified 266 patients that were active on the CHHA the first quarter of 2014 before the telehealth program started . And that were also enrolled and active in the TH program the first quarter of 2015. This allowed for a before and after comparison of the same patient during the same time of year.

Here we have 2 of the key metrics we identified related to hospitalizations: First: Hospitalizations per patient : you can see the average number of hospitalizations per patient during this quarter dropped from 8.6 per patient to 6 per patient after telehealth.Second you can see that the percent of the total patients that were hospitalized during the period dropped from 6.4 percent to 4.9 percent after telehealth.

12St. Marys Telehealth ProgramProgram Achievements500 patients enrolled

Successful DOH onsite survey - March 30, 2015

Patient and staff satisfaction has improved

Decrease in avoidable hospitalizations & medication issues

In addition to using the IVR to prevent unnecessary hospitalizations and medication issues, our goal was to also improve patient satisfaction.

Throughout the grant period, weve documented numerous success stories in the areas noted above.

We have heard from several patients about how the program has given them the extra benefit of having access to speak to the Telehealth nurse whenever the need arises. Some examples of success stories and testimonials follow.

13Medication Success Story B.C. is a 14-year-old medically complex female with diagnoses of Cerebral Palsy, Asthma and Epilepsy. She is developmentally delayed, non-verbal and non-ambulatory. In the 12 months before her enrollment in the Telehealth Program, she had 6-8 E.R. visits. During the past year she only had one visit to the ER which resulted in hospitalization. An alert was generated and from the follow up call the TH RN learned that the mom used the long acting corticosteroid during an acute asthma attack and the child went to the ER. The TH RN reviewed med changes and side effects with mom and information was to the clinical team.The TH RN educated the mother about the difference in asthma meds, about the use of long-acting corticosteroid versus the rescue inhaler. The TH RN also informed the CHHA nurse who visited the patient and reviewed the use of the medications, reinforcing education provided by Telehealth Nurse. The interventions resulting from the IVR alerts led to the childsrespiratory status remaining stable.Follow-up by the Telehealth Nurse determined that Mom had inadvertently used the long acting Corticosteroid during an acute asthma attack and ended up in ER. The frequency of calls were increased and Home care RN visits were increased to monitor medication compliance. The interventions resulting from the IVR alerts led to the childs respiratory status remaining stable and the patient has had no further ER visits or hospitalizations in 3 months.

14Another Success StoryN.E. is a 7-year-old medically complex female with diagnoses of Anoxic Brain Damage and Epilepsy. She is developmentally delayed, non-verbal and non-ambulatory. In the 12 months before her enrollment in the Telehealth Program, she had 4 Hospitalizations. In the 12 months she has been on the program, she has had two hospitalizations. Follow-up to a Telehealth alert indicated that she was having increased seizure activity and had been evaluated by the Neurologist and anti-seizure medication doses were increased. TH RN reviewed med changes and side effects with the father and information was transmitted via email to the clinical team.Home care RN made an added nursing visit and med reconciliation was performed.

Due to the medical complexity of our patients some hospitalizations are unavoidable. Our goal remains to decrease the frequency of hospitalizations or ED visits in our Telehealth patients. 15Testimonials

The Telehealth program has helped so much, I am able to explain problems to the Nurse and the interventions on the phone help and prevent me from going to the ER. Having the Nurse come out to visit after the phone call is also very helpful. I love the fact that someone always calls back and I am not alone. The program helps me, once I took him to Urgicenter but he was still not better. The call came and it was helpful to speak to the Nurse on the phone and then have another nurse visit. This stopped me from having to take him back to the ER. My child is not normal so the additional expert advice benefits him.

The program makes me feel safe.

I have come to rely on the program, knowing I am not alone and have help even when life gets so busy.

St. Marys Telehealth Program

One of our most important goals was to raise our patient satisfaction levels by offering Telehealth as an enhancement to their current program services.

Id like to introduce you to one of the program participants here today to tell you about her experience. I would like to introduce you to Mrs. Perez, mother of a child who has been enrolled on our program since October 2014

CAREGIVER speaks here.

In addition, use of the IVR has helped us achieve increased staff satisfaction as well. IVR has resulted in closer collaboration between the Telehealth Team and the field RNs who often now rely on the Telehealth Team to provide more timely information about patient issues and clinical changes to be addressed.

16The FutureUse the data from this grant to help develop a care management model that will allow us to provide those services under managed care in the future for our children.

Currently grant funded- Our ultimate goal is to work with Managed Medicaid and insurers to recognize the importance of the program in reducing hospitalizations and costs - and make this a reimbursable service.

Our goal is to continue to innovate and find cost effective ways to better serve our medically complex children.St. Marys Telehealth Program

Working with our IVR partner AMC, we are currently in the final stages of development of an analytical tool to present additional outcomes both pre and post telehealth.

As soon as the tool is completed and the first years data analyzed, St. Marys will publish a report to present to Managed Care and Managed Medicaid providers to present the case for reimbursement for Telehealth Services for all patients on program.

17A costly ER visit or hospitalization can be avoided by the push of a button.

St. Marys at your fingertips is the solution.

St. Marys Telehealth Program

18St. Marys Healthcare System for ChildrenElvira Fardella-Roveto, FNP B-C718-281-8723 eroveto@stmaryskids.org

Donna Mapp-Reid, RNC, CCM718-281-8935 dmapp-reid@stmaryskids.orgwww.stmaryskids.orgBIP Transformation Grant utilizes Federal funding per section G, page 20 of 26 of the Master Contract for Grants.1964584.0