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Innovation Panel - Vidant Health

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

Published in: Health & Medicine
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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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