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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
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VHA’s Domains of ValueVHA’s Domains of Value
QualityQuality
AccessAccess
SatisfactionSatisfaction
Functional StatusFunctional Status
Cost EfficiencyCost Efficiency
Building Healthy CommunitiesBuilding Healthy Communities
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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
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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”
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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.
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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
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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
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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
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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
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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
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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).
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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
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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)
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Health Buddy System Components: Match Standard Practice Guidelines
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DataCenter
Store & SendTechnology
In-home MessagingIn-home Messaging
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Technology Solutions for Health Technology Solutions for Health Monitoring Monitoring
Health HeroHealth Hero®® Network Network
Confidential
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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
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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
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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
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Daily Daily Risk StratifiedRisk StratifiedView of Patient View of Patient
CaseloadCaseload
iCare DesktopiCare Desktop™™ Work List Work List
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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
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Detailed View Detailed View of Patient Resultsof Patient Results
Decision Support Tools:Decision Support Tools:iCare DesktopiCare Desktop™™ Application Application
ResultsResults
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View of Key View of Key Clinical Indicators Clinical Indicators
Over TimeOver Time
iCare DesktopiCare Desktop™™ Trends Trends
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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
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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
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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.
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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
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Question and Response TypesQuestion and Response Types
Multiple Choice
ExtendedMultiple Choice
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Question and Response TypesQuestion and Response Types
Numeric
Range/Scale
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Question and Response TypesQuestion and Response Types
Binary
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Question and Response TypesQuestion and Response Types
Prompt / Education / Information
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Provider Station Patient Station
Audio/Visual/Real-time
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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
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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
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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)
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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