What We're Working On Now: Getting the "System" to be a Real System for Heart Failure Patients

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What We're Working On Now: Getting the "System" to be a Real System for Heart Failure Patients

  1. 1. What We’re Working On Now *moderator or couple of respondents?* - Getting the “System” to be a Real System for Heart Failure Patients – Douglas McClure Corporate Manager, Operations & Technology, Center for Connected Health ALL PROCEEDINGS WILL BE VIDEO RECORDED
  2. 2. System “partners” @ Partners • High Performance Medicine – Care Coordination for Special Populations • Allison McDonough, MD, Medical Director of Population Management • Partners HomeCare • Judith Flynn, BSN, MBA, Chief Clinical and Compliance Officer • Center for Connected Health • Corporate Manager, Technology and Operations
  3. 3. What have we achieved so far …
  4. 4. Enrollment Month CCCP HC Oct-07 8 47 Nov-07 19 75 Dec-07 24 110 Jan-08 43 134 Feb-08 55 162 Mar-08 71 192 Apr-08 84 242 May-08 115 259 Jun-08 145 270 Jul-08 174 293 Aug-08 201 301 Sept-08 220 318
  5. 5. Readmission Outcomes - 180 days 0.8 0.7 Control Intervention Refused Mean 180 days readmissions 0.6 0.5 0.4 0.3 0.2 0.1 0 All-cause CHF
  6. 6. Heart Failure Population Overview, Partners • 30,000+ heart failure patients under care within Partners • 2,700 admits per year • 25-30% deceased within 1 year of discharge (no national benchmarks) • >90% connected to heart failure management program after discharge • 400+ under active management by heart failure NP at any given time • 1,300+ patients followed by Partners Home Care each year • 300+ have been followed by telemonitoring in past year (~ 60 active at any given time)
  7. 7. Disease Management Approaches Low High Engagement Engagement Risk Screening Remote Monitoring High Tech Stratify patients for different Use devices to monitor patients program interventions based on at home (Emerging) medical criteria NP Clinic, Practice-based Case managers Supported by real-time alerts, workflow software, clinical decision support Population Screening Call Center Target patients by disease and Centralized case managers call age group patients to monitor progress Low Tech (Traditional) Patient Education Guidelines/Support Distribute brochures on how to Promote best practices among manage chronic disease providers Concept Source: California HealthCare Foundation
  8. 8. Heart Failure Program Components: System-wide Reach
  9. 9. A Coordinated and Targeted Program 2,700 Discharges 2,100 Patients Triage Home Care Remote Monitoring ~60 days Continuing Cardiac Care ~4 months Step Down Monitoring ~1 year Health Coaching Under Development
  10. 10. There are challenges ☺
  11. 11. Challenge Enrollment & Recruitment
  12. 12. Heart Failure Population Overview, Partners Approximately 50% of DRG 127 discharges have a Partners PCP
  13. 13. Challenges of HF Dz Mgt •Patient Identification •Choosing an intervention •Reaching and Engaging •Patient and MD barriers to engagement
  14. 14. ID Partners HF patients appropriate for telemonitoring Send file to CCH Note: HPM 4 team has experience “Opt-in” note sent to MD: with this and will work closely with CCH to •Can pt be enrolled? develop •Would you like to enroll other appropriate HF patients? Approved patients Key are enrolled in telemonitoring HPM Team 4 HPM4 and CCH will work CCH together to refine criteria (if necessary), consider HPM Team 4 & CCH expansion to other PHS sites, Monitor & and measure outcomes of these uniquely enrolled Evaluate patients
  15. 15. Challenge Managing the Patient Efficiently and Effectively
  16. 16. Managing the Patient Efficiently and Effectively • Determining Who best to Manage the Patient – Longitudinal care is difficult in the existing fragmentation and silos – Multiple care providers all trying to direct care • Finding the Right Mode of care delivery impacted by – Patient acuity, ability and preference – Location of care – Acceptance of intervention by patient and physician – Effectiveness of intervention – Coordination of various interventions has been challenging within a large and complex system. • Ensuring High Reliability in Care – Requires Coordinated delivery across disparate systems
  17. 17. Managing the Patient Efficiently and Effectively • Relative cost effectiveness of various interventions unknown – Cost savings remain undetermined • Discharge process marked by – Inpatient-outpatient discontinuity – Changes and discrepancies in care plan/medications – Problems with self-care and social support – Ineffective physician-provider communication
  18. 18. Managing the Patient Efficiently and Effectively Nurse Practitioners (1998) 4 NPs at each of 4 sites, focus on the most acutely ill Number of current active patients ~450 Cumulative enrollment since 2004 ~1,400 Partners Home Care (2004) Integration of field staff (400 RNs) who serve 1,200 HF pts/yr Cumulative enrollment since 2004 ~4,000 Identify and Connect (2005) Assure >90% discharged patients at high risk of readmission are connected to longitudinal services Outcomes and process measures (2006) Measurement of readmission rates, mortality System-wide HF Registry (2006) Collaboration with Team 3, Partners IS, MGH LCS Telemonitoring (2006) Collaboration with Partners Center for Connected Health Physician and patient decision support tools (2009 and beyond)
  19. 19. Challenge Integrated Systems & Communications
  20. 20. Heart Failure Registry: A Multi-Year Project
  21. 21. Connected Health Care Suite Physicians Care Providers Care Givers Patients Care Portals (Diabetes, HF, etc.) Common Clinical CCH Apps Partners Enterprise Services Services Mgmt System Clinical Apps • Asset & Patient Mgmt • Program Mgmt & • LMR, CDR, EMPI Evaluation Decision Support Services Services Remote Monitoring Partners Entity Apps Services • Care Registries, PtCT, • RMDR, Internet 4Next 21
  22. 22. CHCS - CHF Care Portal

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