This document describes a telehealth-enabled post-acute care program called C3. The program aims to improve care coordination, outcomes, and costs through remote patient monitoring, data analytics, and care coordination. Key elements include enrolling high-risk patients, monitoring vital signs at home, coordinating care for at-risk patients, and reporting outcomes like readmission rates to clinicians and health systems. Analysis of the program's data has helped identify readmission causes and catalyze new initiatives, like a post-heart attack clinic, to further reduce readmissions.

1. Dynamic Post Acute Care Coordination

2. “The key to successful telehealth enabled post-
acute care services is in the well planned and
comprehensive program design and execution.
Done well, the results are higher quality care, better
outcomes and improved economics.”
Guiding Principle

3. C3 Program Solution
Telehealth Enabled Care
- Well-designed coordination
of technology and services
- Platform fully integrated
with EMR
- Robust data compilation
and analytics
- Cost-effective way to improve
post-acute care
PCP
Coordination
Outcomes
Reporting
Improvement
Home Setup
& Orientation
Patient
Coaching
Remote
Monitoring
Population
Risk Analysis
Targeted
Enrollment
Analytics&
Reporting Patient Ide
ntification
CareCoo
rdination Care Tr
ansition

4. RESULTS
90% Patient Compliance with Monitoring
45% All Payer 30-Day Readmission Rate Reduction -
HF, AMI, PN, COPD (12 month results)
30% CMS Rate Reduction
37% Medicare HF 30-Day Readmission Rate Reduction -
(program-to-date)
16% Medicare AMI 30-Day Readmission Rate Reduction -
(program-to-date)

5. Digital
Health
Platform
CARE
TRANSITION
OUTCOMES
REPORTING
CARE
COORDINATION
Patient
“Activation”
Installation
Management
Patient Vitals
Summary
Monthly Results
Trend Analysis
Remote Monitoring
SECURE INFORMATION GATEWAY
COBALT
APPLICATION
Patient
Management
COBALT DB
COBALT DATA
WAREHOUSE
Data Analytics &
Reporting
Clinicians C3 Report
Health System Partners

6. PATIENT
ENROLLMENT
• Identify patients
• Risk Stratify
• Enroll pts
• Home “kit”
CARE
TRANSITION
• Initial contact
with patient
• Identify follow
up and service
needs
CARE
COORDINATION
• Monitor daily vitals
• Coordinate at-risk
patient interventions
OUTCOMES
REPORTING
• Readmissions
• Compliance
• Trend Analysis
COMPREHENSIVE PROGRAM
WHO:
PATIENT
NAVIGATOR
WHAT:
• Assess risk levels
(functional status, home/
social, co-morbidities)
• Provide patients with
program materials
• Secure consent
PRE-DISCHARGE
TIMELINE: CHF/AMI
30 DAYS POST-DISCHARGE
• Discharge with required
devices based on
monitoring ”tier”
• C3 clinician coaches on
the monitoring process
• Assess patient post-
discharge environment
and support needs
• Manage by exception –
out of range per parameters
• Report summaries to providers
integrated with EMR
• Escalate care for at risk patients
with involvement of cardiologist
and/or other providers
• Periodic C3 clinician check-in/
reinforcing calls
• Summaries at
population and
individual patient level
• Review/analysis of
readmissions,
compliance & important
clinical outcomes

7. Meaningful
Data
Integrated
with the EMR

8. Readmission Analytics
– And Where C3 Has Helped
• Recurrent HF
Original Diagnosis
Contributing
Factors
• Patient non-compliance (esp. meds and diet)
• Lack of understanding of discharge
instructions
Most common avoidable
readmission diagnosis
Heart Failure
AMI
• HF
• Noncardiac chest pain
• AMI
• Lack of early post-discharge follow up to assess
post MI heart muscle function and titrate/initiate CHF
medications
• Failure to implement CHF medications prior to
discharge in patients with reduced EF
• Poor patient understanding of discharge instructions
re: sodium/fluid restrictions
• Patient anxiety about symptoms
• Patient non-compliance with anti-platelet agents

9. C3 Readmission Feedback Catalyzes
System Improvement
C3 Data Analysis:
Causes of Readmissions
Post-AMI Clinic
(launched 3/18/15)
• Cardiology appointment within 7 days
of discharge
• Appointment includes consult with
cardiologist, Cardiac Rehab,
Nutritionist, and PharmD (medication
dosing and cost optimization)
• Evidence-directed treatment plan for
each patient sent to primary cardiologist
and PCP
• Strategy ensures timely follow up, early
engagement with support services, and
medication affordability and complianceClinicians
C3 Reporting
Health System
Creates New Post-
Acute Initiative
Post-AMI Clinic Model

10. Changing Economics Drive
New Care Approaches
CMS PENALTY
CONDITIONS (5)
Episodic, 30-day PAC focus
READMISSION
PENALTIES
50% of Hospitals Paying
– 20% Annual Increase
$490M – 2015 Penalties
Episodic, 30-90 day PAC focus
BUNDLED PAYMENT
$8B Spend on PAC
$26B – 2014 Spend on
Joints & CHF Patients
CMS BUNDLE PLANS
(48)
Readmission
Penalties
+
SNF Stays
Remain Key Cost
Drivers

11. Flexible Platforms for Patient Engagement

12. Bridging Consumer Apps & Secure
Clinical Data
SECURE INFORMATION GATEWAY
COBALT
APPLICATION
Patient
Management
COBALT DB
COBALT DATA
WAREHOUSE
Data Analytics & Reporting
Clinicians C3 Report
DevicesInterfaces
Remote Monitoring
Vital Signs
Apple
Health Kit
Google Fit
PHOTOS
VIDEO
CONFERENCE
PULSE/OX
ACTIVITY
WEIGHT
BLOOD
PRESSURE

13. Performance Based Contracting
RECRUIT & TRAIN
CLINICAL CARE COORDINATION
STAFF
DEFINED ROLES
AND RESPONSIBILITIES
REPLICABLE OPERATING
PROCEDURES
ENROLLMENT, LOGISTICS,
CARE COORDINATION
EMR INTEGRATION,
COBALT, BIOMETRIC DEVICES
CRITICAL TECHNICAL
INFRASTRUCTURE
COMPREHENSICE DATA
ANALYSIS
& REPORTING
ACTIONABLE INFORMATION
&
RELEVANT PATIENT DATA

14. Healthy at Home
Kirby Farrell
CEO
kfarrell@broadaxecc.com