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HAWAI‘I ISLAND CARE COORDINATION SERVICES
OUTCOMES REPORT
September 2013
Complex Care
Coordination for Private
Practicing ...
Executive Summary
 Enrolled a total of 78 patients of private Primary
Care Physicians (PCPs)
 Double-digit improvements ...
Patient Enrollment
 78 patients with complex care needs due to
chronic diseases such as diabetes
 High-cost, high-risk p...
Physician Participation
 29 Physicians Participated
• 13 PCPs in East Hawaii
• 16 PCPs in West Hawaii
 Physician Role
• ...
Care Coordinator
Participation
 Registered Nurse (RN) assigned
to each patient to create a
service plan to improve
his/he...
Use of Monitoring Technology
 42 patients received, at no charge, use of
Ho‘okele’s iHealthHome® in-home monitoring
techn...
HICCS HbA1c – 36% Better
IMPROVED HEALTH
Mean
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
Baseline Post Sustained
Hb...
HICCS Ttl Cholesterol – 19% Better
IMPROVED HEALTH
Mean
0.00
20.00
40.00
60.00
80.00
100.00
120.00
140.00
160.00
180.00
Ba...
HICCS LDL – 10% Better
IMPROVED HEALTH
Mean
70.00
72.00
74.00
76.00
78.00
80.00
82.00
84.00
Baseline Post Sustained
LDL Le...
HICCS HDL – 13% Better
IMPROVED HEALTH
Mean
36.00
38.00
40.00
42.00
44.00
46.00
48.00
Baseline Post Sustained
HDL Level
HICCS Triglycerides – 37% Better
IMPROVED HEALTH
Mean
0.00
50.00
100.00
150.00
200.00
250.00
Baseline Post Sustained
Trigl...
HICCS Systolic BP – 11% Better
IMPROVED HEALTH
Mean
110.00
115.00
120.00
125.00
130.00
135.00
140.00
Baseline Post Sustain...
HICCS Diastolic BP – 13% Better
IMPROVED HEALTH
Mean
64.00
66.00
68.00
70.00
72.00
74.00
76.00
78.00
80.00
82.00
Baseline ...
HICCS Weight – 9% Better
IMPROVED HEALTH
Mean
165.00
170.00
175.00
180.00
185.00
190.00
195.00
Baseline Post Sustained
Wei...
IP Admits – 29% Reduction
IMPROVED HEALTH
ER Visits – 25% Reduction
IMPROVED HEALTH
Physicians See Changes
Patients who were calling or
coming in to the office frequently
were able to reduce their visits to...
Patients Feel the Difference
It seems that healthcare is a pile of jigsaw pieces My
care navigator helped to show me how t...
MAHALO
Dew-Anne Langcaon, Ho‘okele Health Innovations
dewanne@hookelehealth.com
Ken Ono, West Hawai‘i Home Health Services...
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Complex Care 
Coordination for Private Practicing Physicians
 on Hawai‘i Island

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Transcript of "Complex Care 
Coordination for Private Practicing Physicians
 on Hawai‘i Island "

  1. 1. HAWAI‘I ISLAND CARE COORDINATION SERVICES OUTCOMES REPORT September 2013 Complex Care Coordination for Private Practicing Physicians
  2. 2. Executive Summary  Enrolled a total of 78 patients of private Primary Care Physicians (PCPs)  Double-digit improvements in health outcomes including HbA1c, cholesterol, triglycerides, blood pressure and weight CONCLUSION: Care Coordination WORKS!
  3. 3. Patient Enrollment  78 patients with complex care needs due to chronic diseases such as diabetes  High-cost, high-risk patients identified by PCPs and Health Plans  High use of emergency departments and inpatient care  Average age 69.8  83% overall enrollment rate / 79% completion rate
  4. 4. Physician Participation  29 Physicians Participated • 13 PCPs in East Hawaii • 16 PCPs in West Hawaii  Physician Role • Active participation in selecting and enrolling their patients into the program, intro to care coordinator • Availability for care coordinator questions • Longer appointment visits if necessary • Access to PCP records by care coordinator
  5. 5. Care Coordinator Participation  Registered Nurse (RN) assigned to each patient to create a service plan to improve his/her health • Provided education about his/her complex conditions • Assisted with access to specialists, keeping track of prescriptions and appointments • Health Coach provided support to make lifestyle changes
  6. 6. Use of Monitoring Technology  42 patients received, at no charge, use of Ho‘okele’s iHealthHome® in-home monitoring technology for one year.  Enabled patients to take biometric readings at home for blood pressure, blood sugar and weight, which was submitted to the R.N.  Empowered patients to log their own food, exercise and activities and to communicate with the R.N via video calls.
  7. 7. HICCS HbA1c – 36% Better IMPROVED HEALTH Mean 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 Baseline Post Sustained HbA1C Baseline 7.80 Post 5.04 Sustained 4.99 36.0% PctImprovement 6.63 t-value 0.00 p-value
  8. 8. HICCS Ttl Cholesterol – 19% Better IMPROVED HEALTH Mean 0.00 20.00 40.00 60.00 80.00 100.00 120.00 140.00 160.00 180.00 Baseline Post Sustained Total Cholesterol
  9. 9. HICCS LDL – 10% Better IMPROVED HEALTH Mean 70.00 72.00 74.00 76.00 78.00 80.00 82.00 84.00 Baseline Post Sustained LDL Level
  10. 10. HICCS HDL – 13% Better IMPROVED HEALTH Mean 36.00 38.00 40.00 42.00 44.00 46.00 48.00 Baseline Post Sustained HDL Level
  11. 11. HICCS Triglycerides – 37% Better IMPROVED HEALTH Mean 0.00 50.00 100.00 150.00 200.00 250.00 Baseline Post Sustained Triglycerides Baseline 193.22 Post 145.52 Sustained 122.00 36.9% PctImprovement 6.75 t-value 0.00 p-value
  12. 12. HICCS Systolic BP – 11% Better IMPROVED HEALTH Mean 110.00 115.00 120.00 125.00 130.00 135.00 140.00 Baseline Post Sustained Systolic BP
  13. 13. HICCS Diastolic BP – 13% Better IMPROVED HEALTH Mean 64.00 66.00 68.00 70.00 72.00 74.00 76.00 78.00 80.00 82.00 Baseline Post Sustained Diastolic BP
  14. 14. HICCS Weight – 9% Better IMPROVED HEALTH Mean 165.00 170.00 175.00 180.00 185.00 190.00 195.00 Baseline Post Sustained Weight Baseline 190.77 Post 185.09 Sustained 173.99 8.8% PctImprovement 2.74 t-value 0.00 p-value
  15. 15. IP Admits – 29% Reduction IMPROVED HEALTH
  16. 16. ER Visits – 25% Reduction IMPROVED HEALTH
  17. 17. Physicians See Changes Patients who were calling or coming in to the office frequently were able to reduce their visits to every 3-4 months. PERSPECTIVES
  18. 18. Patients Feel the Difference It seems that healthcare is a pile of jigsaw pieces My care navigator helped to show me how the pieces fit into a map of health. It helped to prioritize these, that allows my family and I to make better choices for me. 87% of patients agree that My RN Navigator helped me to better understand my medical condition and what I needed to do to take care of myself. PERSPECTIVES
  19. 19. MAHALO Dew-Anne Langcaon, Ho‘okele Health Innovations dewanne@hookelehealth.com Ken Ono, West Hawai‘i Home Health Services kenono@hawaii.rr.com Susan Hunt, Hawai‘i Island Beacon Community susanbh@hawaii.edu
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