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John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
John Williams - UPMC
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John Williams - UPMC

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

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