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
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 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 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!