Combating the Rising Cost of Care
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This document discusses Vidant Health's telehealth and care transitions program. It describes how the program aims to shift the focus from hospital care to coordinating patient care transitions. It outlines the risk stratification process used to determine which services patients receive, from remote patient monitoring and daily biometrics for high-risk patients, to telephonic follow-up for low-risk patients. It provides data on outcomes for patients in the program, showing reductions in hospitalizations, bed days, and costs after participating in the program.
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Combating the Rising Cost of Care
- 2. Discussing Vidant Health’s Telehealth & Care Transitions Program Discussing VH’s Telehealth Outcomes
- 4. ◦ 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
- 5. 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
- 6. ◦ 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
- 7. ◦ 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
- 8. ◦ 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
- 11. Patient Diagnosis 2% 4% 3% 1% 3% HTN HF COPD 33% 54% CHF/HTN Asthma Asthma/ HTN HF/HTN
- 12. N= 926 Patient Age Range 3% 18% 13% 19% 23% 24% 18-49 50-59 60-69 70-79 80-89 90-99
- 13. N= 926 Average Time Patient Utilizing Monitor < 30 days 30 days 60 days 90 days current 2% 9% 9% 18% 34% 28% > 90 days
- 15. 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
- 16. 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
- 17. 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
- 18. 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
- 19. 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
- 20. PAM III or IV Dx TBD Readmissions 0 ED visits Medications <6 Social Issues Stable housing 0-1 PCP Insurance 20
- 21. Telephonic follow-up/education Patient identified in-hospital & clinic 21