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

Discussing Vidant Health’s Telehealth &
Care Transitions Program

Discussing VH’s Telehealth Outcomes
◦ Shift focus from hospital to coordinating patient care transitions
◦ Define & implement standardized risk stratification...
Patient Risk Assessment
Completed by Hospital Case Managers

Hi Risk

Medium

Low Risk

Risk

Telehealth &
Transitions in ...
◦ PAM

I & II

◦ Dx

Any chronic disease

◦ Readmissions

< 30 day

◦ ED visits

4+

◦ Medications

6+

◦ Social issues

H...
◦ Remote Patient Monitoring
 Referred from hospital or clinic
 Enrolled in hospital or home
 Home Visit- Med. Rec. & tr...
◦ Clinical Data
 LDL, BP, Pulse, Height, Weight, HgA1c, oxygen
saturation
◦ Patient Satisfaction
◦ Financial Outcomes- 90...
Primary Insurance
22%
Medicare

10%

56%
12%

Medicaid
No Insurance/Self
Commerical
Patient Gender

44%
56%

Male
Female
Patient Diagnosis
2%
4% 3%

1% 3%

HTN
HF
COPD

33%

54%

CHF/HTN
Asthma
Asthma/ HTN
HF/HTN
N= 926
Patient Age Range

3%

18%

13%
19%

23%
24%

18-49

50-59

60-69

70-79

80-89

90-99
N= 926
Average Time Patient Utilizing Monitor
< 30 days

30 days

60 days

90 days

current

2%

9%

9%
18%

34%

28%

> 9...
1%

43%
56%

STRONGLY AGREE

AGREE

DISAGREE

14
Discharge Patients N=544
900
800

772

700
600
90 Days Prior

500
400
300
200

During

257
143

30 Days Post

100
0
Reduct...
Discharged Patients N=544
4,000

3,458

3,000
90 Days Prior

2,000
1,124
1,000

753

During
30 Days Post

0
Hospital Bed D...
Discharge Patients N=544
8,000,000

7,000,000

8,000,000
6,761,227

7,000,000

6,000,000

5,000,000
90 Days Prior

4,000,0...


PAM

III



Dx

Dementia, Mental Illness, Substance Abuse, new
chronic disease



Readmissions

<30 day with Obs. Wit...


Remote Patient Monitoring- Transitions in Care



Care Transitions services
◦
◦
◦
◦
◦
◦



Enrolled in hospital
Hospi...


PAM

III or IV



Dx

TBD



Readmissions

0



ED visits



Medications

<6



Social Issues

Stable housing

0-1...


Telephonic follow-up/education



Patient identified in-hospital & clinic

21
Combating the Rising Cost of Care
Combating the Rising Cost of Care
Combating the Rising Cost of Care
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Combating the Rising Cost of Care

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Presentation by Bonnie Britton, MSN, RN, ATAF Telehealth Program Administrator, Vidant Health

Published in: Health & Medicine
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Combating the Rising Cost of Care

  1. 1.   Discussing Vidant Health’s Telehealth & Care Transitions Program Discussing VH’s Telehealth Outcomes
  2. 2. ◦ Shift focus from hospital to coordinating patient care transitions ◦ Define & implement standardized risk stratification tools ◦ Standardize post acute care services  Remote patient monitoring services  Transitions in care  Chronic Disease Management  Care Transitions  Health Coaches  Telephonic follow-up 4
  3. 3. Patient Risk Assessment Completed by Hospital Case Managers Hi Risk Medium Low Risk Risk Telehealth & Transitions in Care Program Daily biometric data Social Issues/ Non VMG patient VMG patient TH Transitions in Care TIC Services TIC services Consider TIC services Frailty Health Coach Consider Telephonic Service Telephonic Services
  4. 4. ◦ PAM I & II ◦ Dx Any chronic disease ◦ Readmissions < 30 day ◦ ED visits 4+ ◦ Medications 6+ ◦ Social issues Homeless No PCP No Transportation Un/underinsured 6
  5. 5. ◦ Remote Patient Monitoring  Referred from hospital or clinic  Enrolled in hospital or home  Home Visit- Med. Rec. & train/competency validate patient/home safety assessment  Daily biometric data monitoring / Daily phone calls for abnl parameters  Weekly telephonic assessment, education, coaching  Staff ratio: 1 -85 – 100 patients ◦ Care Transition Services     Enrolled in hospital Hospital visit Home Visit(s)- med. Rec. and patient education Phone Calls  Attend MD Visits  Staff ratio: 1- 18 – 30 patients 7
  6. 6. ◦ Clinical Data  LDL, BP, Pulse, Height, Weight, HgA1c, oxygen saturation ◦ Patient Satisfaction ◦ Financial Outcomes- 90 days pre TH, during TH, 30 days post TH  Hospitalizations  Bed Days
  7. 7. Primary Insurance 22% Medicare 10% 56% 12% Medicaid No Insurance/Self Commerical
  8. 8. Patient Gender 44% 56% Male Female
  9. 9. Patient Diagnosis 2% 4% 3% 1% 3% HTN HF COPD 33% 54% CHF/HTN Asthma Asthma/ HTN HF/HTN
  10. 10. N= 926 Patient Age Range 3% 18% 13% 19% 23% 24% 18-49 50-59 60-69 70-79 80-89 90-99
  11. 11. N= 926 Average Time Patient Utilizing Monitor < 30 days 30 days 60 days 90 days current 2% 9% 9% 18% 34% 28% > 90 days
  12. 12. 1% 43% 56% STRONGLY AGREE AGREE DISAGREE 14
  13. 13. Discharge Patients N=544 900 800 772 700 600 90 Days Prior 500 400 300 200 During 257 143 30 Days Post 100 0 Reductions Of Hospitalizations Decreased by 69% Prior to During Decreased by 76% Prior to Post 15
  14. 14. Discharged Patients N=544 4,000 3,458 3,000 90 Days Prior 2,000 1,124 1,000 753 During 30 Days Post 0 Hospital Bed Days Decreased by 67% Prior to During Decreased by 81% Prior to Post 16
  15. 15. Discharge Patients N=544 8,000,000 7,000,000 8,000,000 6,761,227 7,000,000 6,000,000 5,000,000 90 Days Prior 4,000,000 During 1,504,206 3,000,000 90 Days Prior 4,000,000 30 Days Post 3,000,000 1,000,000 6,969,198 6,000,000 5,000,000 2,000,000 Discharge Patients N=544 2,000,000 During 2,257,620 1,722,502 875,895 1,000,000 Hospitalization Costs Reimbursement 30 Days Post
  16. 16.  PAM III  Dx Dementia, Mental Illness, Substance Abuse, new chronic disease  Readmissions <30 day with Obs. Within 60 days  ED visits 2+  Medications Anticog./insulin/glycemic, Dig., Phenobarbital, Lithium  Social Issues Unstable housing Multiple PCPs Relay on others Inability to pay 18
  17. 17.  Remote Patient Monitoring- Transitions in Care  Care Transitions services ◦ ◦ ◦ ◦ ◦ ◦  Enrolled in hospital Hospital visit Home Visit(s)- med. Rec. and patient education Phone Calls Attend MD Visits Staff ratio: 1- 18 – 30 patients Health Coaches ◦ ◦ ◦ ◦ Enrolled in PCP Clinic Phone Calls Coaching- telephonic and in-clinic Coordination of services 19
  18. 18.  PAM III or IV  Dx TBD  Readmissions 0  ED visits  Medications <6  Social Issues Stable housing 0-1 PCP Insurance 20
  19. 19.  Telephonic follow-up/education  Patient identified in-hospital & clinic 21

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