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Vitral Care Services and Domincan Sisters ONC Pres

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Winner presentation for ONC

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Vitral Care Services and Domincan Sisters ONC Pres

  1. 1. ONC  Pilot  Challenge:      Total  Population  Health  Management  Delivery  Model     for  Care  Coordination  in  Underserved  Communities Innovator:  Vital  Care  Telehealth  Services Host:  Dominican  Sisters  Family  Health  Service
  2. 2. Priority  Areas Care  Coordination •  Increase  healthcare  access •  Improve  delivery  of  care   •  Enhance  quality  of  care   •  Community  engagement •  Reduce  hospital  re-­‐‑admissions •  Lower  healthcare  costs •  Improve  post-­‐‑acute  care •  Coordinate  quality  care   Underserved  Communities
  3. 3. •  Identify  need •  Community  workers •  Community-­‐‑based   engagement Access Quality Affordable  Care •  Care  based  on  risk   stratification  level o  Preventative   care o  Transitional   care o  Chronic  disease   management •  Remote  patient   monitoring •  Care  Coordination •  Wellness  and   Prevention Purpose
  4. 4. Assisted   Telehealth   Nurse   Review   Wellness   Coaching   Clinical   Feedback   Vital  Signs   Ques.ons   Social  Support     Engagement   Educa.on   Hospitals   Physicians   Nurses   Social  Workers   Case  Managers   Tablet  Applica.on   Cloud  Hos.ng   Care  Coordina.on   Monitoring   Management   Patients  Providers
  5. 5. Care  Communication   and  Connectivity Level  1 Level  2 Care  Coordination   and  Monitoring Community  Based  Model •  Monthly  Monitoring •  Stable  chronic   disease  participants •  Weekly  Monitoring •  High  clinical/behavioral   risk  participants Benefits  Check  and  Assessment   Assisted  Telehealth  Monitoring Clinical  Coordination  of  Care Trend  Analysis  and  Interventions
  6. 6. Community  partner  buy-­‐‑in  formed  early  and  will  be  integral  partners  in   weekly  project  management  and  program  evaluation  meetings Strategic  partnership  combining  health  IT  and  clinical  care  delivery  to  bring   an  interoperable  total  population  care  for  care  continuum Health  connectivity  established  for  400  participants  with  outcomes   documented  and  reported  to  ONC Pilot  to  demonstrate  an  innovative  total  population  care  model  to  serve  a   vulnerable  and  underserved  population  that  can  be  replicated  nationwide Summary
  7. 7. Thank  you       Christopher Gaur Vital Care Telehealth Services Chris@myvics.com | www.myvics.com Dr. Louis L. Harris Dominican Sisters Family Health Service LHarris@dsfhs.org | www.dsfhs.org

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