Innovation Panel
MATRC
March 16, 2012
Vidant Health

1
Vidant Health’s Approach
VH-hospital Care
Coordination

VH- In-home Care
Coordination

VMG In-clinic Care
Coordination

PC...
Phase Sites
Vidant Chowan
ECU Family Practice
Vidant Edgecombe
Vidant RoanokeChowan
ECHI at VMC

Cardiovascular /
Pulmonar...
Telehealth and Care Coordination Goals
• Access to enhanced care coordination and post d/c remote
monitoring for high-risk...
Inclusion Guidelines
• CVD and Pulmonary Disease patients who experience
frequent:
– hospitalizations
– ER visits
– less t...
Exclusion Criteria
Insufficient home electrical service to operate
the system

6
The Model
In-hospital Care
Coordination

• Hi-risk pt.
Identification
• Patient referral
• Pt enrollment/
education
• Sche...
Evaluation
• Demographics
• Objective clinical data
– Height
– Weight
– Blood Pressure
– Pulse
– Pulse Oximeter
– LDL (eve...
Evaluation
• Subjective clinical data
– Medication compliance

– Nutrition compliance
– Patient’s knowledge of red flags

...
Evaluation
• Financial data
• Hospitalizations
– Number of hospitalizations
– Patient bed days
– Total charges for Hospita...
Contact Information
Bonnie Britton, MSN, ATAF
Bonnie.britton@vidanthealth.com
252-847-6419

11
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Innovation Panel - Vidant Health

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Presentation by Bonnie Britton, RN, MSN, ATAF, Vidant Health

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Innovation Panel - Vidant Health

  1. 1. Innovation Panel MATRC March 16, 2012
  2. 2. Vidant Health 1
  3. 3. Vidant Health’s Approach VH-hospital Care Coordination VH- In-home Care Coordination VMG In-clinic Care Coordination PCP Telehealth CM Telehealth Daily care coord. Med. Rec Equip. Install 2
  4. 4. Phase Sites Vidant Chowan ECU Family Practice Vidant Edgecombe Vidant RoanokeChowan ECHI at VMC Cardiovascular / Pulmonary Homebound Patients Cardiovascular / Pulmonary Cardiovascular / Pulmonary Heart Failure 45 25 50 30 50 3
  5. 5. Telehealth and Care Coordination Goals • Access to enhanced care coordination and post d/c remote monitoring for high-risk high-cost CVD and pulmonary patients • Expand and improve the quality of health information available to health care providers, patients and their families • Reduce health care expenditures by reducing 30-day readmissions, bed days and ER visits • Improve clinical outcomes • Improve the patient’s perception of care and patient’s quality of life. 4
  6. 6. Inclusion Guidelines • CVD and Pulmonary Disease patients who experience frequent: – hospitalizations – ER visits – less than 30 day readmissions and – require daily monitoring, health assessment and education. • Patient Activation Measurement score of Level 1 or 2 5
  7. 7. Exclusion Criteria Insufficient home electrical service to operate the system 6
  8. 8. The Model In-hospital Care Coordination • Hi-risk pt. Identification • Patient referral • Pt enrollment/ education • Schedules PCP visit • Medication Rec. • Schedules inhome visit In-home Care Coordination In-clinic Care Coordination Telehealth Daily care coord. • PCMH • Health Coaches Med. Rec Equip. Install • • • • • Sets parameters Daily remote monitoring Sets Weekly goals Pt. Assessment/Education PCP notification via EHR • Med. Rec • post d/c • post 1st PCP visit • Reinforces equipment instruction • Equipment install • Competency Validation 7
  9. 9. Evaluation • Demographics • Objective clinical data – Height – Weight – Blood Pressure – Pulse – Pulse Oximeter – LDL (every 6 months if elevated, or otherwise indicated) • A1C for uncontrolled diabetes 8
  10. 10. Evaluation • Subjective clinical data – Medication compliance – Nutrition compliance – Patient’s knowledge of red flags 9
  11. 11. Evaluation • Financial data • Hospitalizations – Number of hospitalizations – Patient bed days – Total charges for Hospitalization • Emergency Department – Number ED visits – Total charges for ED 10
  12. 12. Contact Information Bonnie Britton, MSN, ATAF Bonnie.britton@vidanthealth.com 252-847-6419 11
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