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John Williams - UPMC
 

John Williams - UPMC

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    John Williams - UPMC John Williams - UPMC Presentation Transcript

    • Are Our RoadMaps Going in the Right Direction?
      John P Williams, MD
      Peter and Eva Safar Professor
      Associate Scientific and Medical Director
      UPMC and University of Pittsburgh
    • Rare opportunity to quote a film and TV star....
    • History
      With apologies to Santayana...
      “If you don’t know where you’ve been, how do you know you haven’t been here before?”JPW
    • History
      The first thing we need is an example...
      How about Congestive Heart Failure (CHF)?
      Big problem
      Bad history
      Great opportunity
    • The most recent example...
      “Currently the NHS spends up to £1 billion a year, apparently on managing heart failure badly”
      Lancet 2010, 376: 2041
    • History
      Physicians/Other Professionals$1.6 billion
      Hospital/Nursing Home $15.4 billion
      7%
      Medications/Other Medical Durables$2.0 billion
      9%
      72%
      11%
      Home Health Care$2.4 billion
      Total Cost in 2005, 27.9 $Billion- US
    • History
      Rev Cardiovasc Med. 2002;3(suppl 4):S3-S9.
      So what drives those hospital/nursing home costs?
    • Can We Change?
      Skepticism, like chastity, should not be relinquished too readily”
      What make us think we can change in general?
      What make us think that eHealth in specific can change this?
    • Previous Studies
      “...it is evident that the use of telemanagement for CHF has demonstrated positive outcomes, including substantial reductions in hospital readmissions, emergency department visits, costs of care, and improvements in quality of life.”
      “In order to be successful and sustainable, telehealth requires integration into existing health structures and processes”
      Kleinpell and Avital, 2005
      Dansky 2008
      Alston 2009
      Hoover 2009
    • UPMC/Jefferson Regional Home Health, LP
      Located in Seven Fields, PA (suburb of Pittsburgh)
      Part of a large integrated health care system
      Joint Venture, Limited Partnership
      Medicare certified, JCAHO accredited
      Total Employees >697
    • UPMC/Jefferson Regional Home Health, LP
      Coverage area includes 10 Counties – PA; 3 - Ohio
      FY09 admissions – >33,085
      FY09 visits - >410,167
      FY09 Medicare episodes – 9,635
      FY09 net revenue - $57 million
      Average daily census –3,250
    • Heart Failure Initiative
      With adequate education, medication management, multi-disciplinary care and the implementation of a Telehealth program, Heart Failure patients that are provided appropriate and timely intervention will see a reduction in the exacerbation of disease process, costly readmissions to the hospital and frequent visits to the Emergency Department.
    • Heart Failure/Telehealth Program Goals
      Reduce re-hospitalizations within 30 days at targeted hospitals
      Reduce frequent unnecessary visits to the Emergency Department
      Provide appropriate and timely interventions to prevent exacerbation of disease process
      Use outcomes as marketing tool to partner with 3rd party payers.
    • Heart Failure/Telehealth Program Goals
      Increase patient compliance
      Improve patient quality of life
      Allow patient to remain independent
      Eliminate travel time for staff
      Assists in addressing the nursing shortage in specific geographic areas
    • Telehealth Program Expansion
      Partnership with Third Party Payers
      UPMC Health Plan
      Three year pilot
      25 monitors with peripherals
      Home Health –oversight and intervention
      Reimbursement for set-up/tear-down-$209.00
      Collaborative data collection/analysis based on high utilization of services
    • Heart Failure Statistics forRe-hospitalizations
    • eHealth Benefit
      Minimum savings of $312.50 per episode based on Cost Per Visit of $125.00
      Based on the average of 45 days and 100 monitors; each monitor could service approximately 8 patients/year freeing nursing staff to provide an additional 2000 visits (800 x 2.5) which results in $250,000/(2000 x $125.00) savings
    • Methods for Success
      Medication reconciliation
      Patient education specific to condition and co-morbidities
      Problem solving skills for changes in the patients condition post discharge
      Assessment of patient understanding
      Written discharge plan
      Discharge plan reconciled with National Guidelines
    • Methods for Success
      Discharge summary made available to PCP immediately upon patient discharge
      Post discharge telephone reinforcement and Get Abby survey
      Follow up physician appointment scheduling
      Outstanding testing and support scheduling
      Post discharge in home services: Safe Landing visit and Home Health care
      Palliative and Supportive Care Services
    • Discharge Plan
      24-48 hours: The DA follows up with the patient via phone call to reinforce understanding of the established discharge plan and provides any new care coordination or education
      2-3 days: The patient also receives a Safe Landing home visit to ensure that equipment, medications and supplies are present. The patient's understanding of their care and current health status are assessed. Home Health care is also a part of the care plan
      5-7 days: the patient is scheduled to visit the PCP for a post discharge appointment (partner with Central Scheduling)
      10 days post discharge, the patient receives a Get Abby phone survey to assess their current state of health
    • TIMELINE: CHF Post-Discharge Follow-Up
    • Discharge Advocate
      Ongoing medication reconciliation
      Medication education in conjunction with the unit based pharmacist
      Educates the patient and caregivers on the discharge plan
      Consults appropriate inpatient services to assist with management and education specific to patient’s needs
      Schedules post discharge follow up appointments for the patient
    • Discharge Advocate
      Facilitates a 30 day supply of medications prior to discharge in conjunction with the outpatient pharmacy
      Compiles a written, personalized discharge plan
      Contacts the patient 24-48 hours post-discharge to reinforce the established discharge plan and provide any needed care coordination or education.
      Sends inpatient information to the patient’s PCP
    • CHF Pilot Data
    • Next Steps
      Hardwire use of CHF Admission Order Sets
      Create care modules for co-morbid conditions (DM)
      Lessons learned from Safe Landing Visits
      Intervention post discharge: Day 14-30
      Medication adherence – pill station
      TeleHealth/TeleMonitoring
      Avatar: a usable and interactive patient education module
    • QUESTIONS?
    • Examples
      53 single male living alone
      SOC/ROC DATE: 05/16/2009 -
      DIAGNOSIS: CHF NEW NIDDM
      PT ADM WITH SOB DX CHF BNP 2200 ALSO AIC 8.9 UNDERWENT CARDIAC CATH 5/13/09 DILATED LV SEVERE LV DYSFUNCTION PT ALSO WITH SLEEP APNEA TO HAVE OUTPT SLEEP STUDY DONE PT NEW DM PT VERY CONCERNED WITH NEW DX CHF AND DM MANY QUESTIONS
      PAST MEDICAL HISTORY: CHF HTN THYROID NODULES CARDIOMEGALY
      HT: 5 FT. 7 IN.
      WT: 335 LBS.
      FUNCTIONAL LIMITATIONS: CARDIAC RESTRICTIONS
      AUG - ADMITTED WITH URINARY RETENTION,EDEMA LOWER LEGS, SHORTNESS OF BREATH, NAUSEA/VOMITING, ABDOMINAL DISTENTION. BNP-2320. TROPONIN ELEVATED. RENAL CONSULT-DR POWELL FOR CKD/PROTEINURIA. DIURESED. HAS RECURRENT RIGHT NECK WOUND/ABSCESS. EGD SHOWED ANTRAL EROSIONS, BARRETT–LIKE MUCOSA. BIOPSY DONE. SHOULD HAVE EP STUDIES AS OUTPATIENT- ? NEED FOR AICD.
    • Examples
    • Examples
      78 female with CHF, COPD, HTN, HYSTERECTOMY, OBSTRUCTIVE SLEEP APNEA, AFIB, CHF, DIABETES, HYPOTHYROIDISM
      - living in large suburban home with handicapped son until son married 1.5 years ago
      - first monitor in Aug 2005 then 5 additional times post hospital discharge
      -- no hospitalization while using monitor
      --Started with wt over 330 lbs and after removing monitor wt was 230
    • Examples
    • Examples
      Live audio/video interaction with patient
      Dedicated, secure telehealth database
      Color-coded data for ease of review
      Intuitive platform
      HL7 interface to EMR
    • Examples
      Designed to provide:
      Real-time, two-way audio/video
      Use of standard phone line
      Easy to use
      Integrated, patented Careton™ stethoscope
    • Examples
      Offers Face-to-face, personal interaction with accurate visual observation
      Provides Peace-of-mind
      Opportunity for immediate action for Alert conditions
      Visits can be documented with photographs.
      Ability to assess mental & physical acuity and behavioral changes
      Medications can be managed and problems caught BEFORE they reach crisis levels!