This document discusses using telehealth to manage congestive heart failure (CHF) patients. It provides background on the costs of CHF, highlights some successes of telehealth programs in reducing readmissions and costs. It then describes UPMC's telehealth program for CHF patients, including their goals of reducing readmissions and visits. It outlines their methods, such as medication management and education, and shares some pilot data results. It concludes by discussing next steps like standardizing order sets and exploring telehealth/telemonitoring.

1. Are Our RoadMaps Going in the Right Direction?John P Williams, MDPeter and Eva Safar ProfessorAssociate Scientific and Medical DirectorUPMC and University of Pittsburgh

2. Rare opportunity to quote a film and TV star....

3. HistoryWith apologies to Santayana...“If you don’t know where you’ve been, how do you know you haven’t been here before?”JPW

4. HistoryThe first thing we need is an example...How about Congestive Heart Failure (CHF)?Big problemBad historyGreat opportunity

5. The most recent example...“Currently the NHS spends up to £1 billion a year, apparently on managing heart failure badly”Lancet 2010, 376: 2041

6. HistoryPhysicians/Other Professionals$1.6 billionHospital/Nursing Home $15.4 billion7%Medications/Other Medical Durables$2.0 billion9%72%11%Home Health Care$2.4 billionTotal Cost in 2005, 27.9 $Billion- US

7. HistoryRev Cardiovasc Med. 2002;3(suppl 4):S3-S9.So what drives those hospital/nursing home costs?

8. Can We Change?Skepticism, like chastity, should not be relinquished too readily”What make us think we can change in general?What make us think that eHealth in specific can change this?

9. Previous Studies“...it is evident that the use of telemanagement for CHF has demonstrated positive outcomes, including substantial reductions in hospital readmissions, emergency department visits, costs of care, and improvements in quality of life.”“In order to be successful and sustainable, telehealth requires integration into existing health structures and processes”Kleinpell and Avital, 2005Dansky 2008Alston 2009 Hoover 2009

10. UPMC/Jefferson Regional Home Health, LPLocated in Seven Fields, PA (suburb of Pittsburgh)Part of a large integrated health care systemJoint Venture, Limited PartnershipMedicare certified, JCAHO accreditedTotal Employees >697

11. UPMC/Jefferson Regional Home Health, LPCoverage area includes 10 Counties – PA; 3 - OhioFY09 admissions – >33,085 FY09 visits - >410,167FY09 Medicare episodes – 9,635FY09 net revenue - $57 millionAverage daily census –3,250

12. Heart Failure InitiativeWith adequate education, medication management, multi-disciplinary care and the implementation of a Telehealth program, Heart Failure patients that are provided appropriate and timely intervention will see a reduction in the exacerbation of disease process, costly readmissions to the hospital and frequent visits to the Emergency Department.

13. Heart Failure/Telehealth Program GoalsReduce re-hospitalizations within 30 days at targeted hospitalsReduce frequent unnecessary visits to the Emergency DepartmentProvide appropriate and timely interventions to prevent exacerbation of disease processUse outcomes as marketing tool to partner with 3rd party payers.

14. Heart Failure/Telehealth Program GoalsIncrease patient complianceImprove patient quality of lifeAllow patient to remain independentEliminate travel time for staffAssists in addressing the nursing shortage in specific geographic areas

15. Telehealth Program ExpansionPartnership with Third Party PayersUPMC Health PlanThree year pilot 25 monitors with peripheralsHome Health –oversight and interventionReimbursement for set-up/tear-down-$209.00Collaborative data collection/analysis based on high utilization of services

16. Heart Failure Statistics forRe-hospitalizations

17. eHealth BenefitMinimum savings of $312.50 per episode based on Cost Per Visit of $125.00Based on the average of 45 days and 100 monitors; each monitor could service approximately 8 patients/year freeing nursing staff to provide an additional 2000 visits (800 x 2.5) which results in $250,000/(2000 x $125.00) savings

18. Methods for SuccessMedication reconciliationPatient education specific to condition and co-morbiditiesProblem solving skills for changes in the patients condition post dischargeAssessment of patient understandingWritten discharge planDischarge plan reconciled with National Guidelines

19. Methods for SuccessDischarge summary made available to PCP immediately upon patient dischargePost discharge telephone reinforcement and Get Abby surveyFollow up physician appointment schedulingOutstanding testing and support schedulingPost discharge in home services: Safe Landing visit and Home Health carePalliative and Supportive Care Services

20. Discharge Plan24-48 hours: The DA follows up with the patient via phone call to reinforce understanding of the established discharge plan and provides any new care coordination or education2-3 days: The patient also receives a Safe Landing home visit to ensure that equipment, medications and supplies are present. The patient's understanding of their care and current health status are assessed. Home Health care is also a part of the care plan5-7 days: the patient is scheduled to visit the PCP for a post discharge appointment (partner with Central Scheduling)10 days post discharge, the patient receives a Get Abby phone survey to assess their current state of health

21. TIMELINE: CHF Post-Discharge Follow-Up

22. Discharge AdvocateOngoing medication reconciliation Medication education in conjunction with the unit based pharmacistEducates the patient and caregivers on the discharge planConsults appropriate inpatient services to assist with management and education specific to patient’s needsSchedules post discharge follow up appointments for the patient

23. Discharge AdvocateFacilitates a 30 day supply of medications prior to discharge in conjunction with the outpatient pharmacyCompiles a written, personalized discharge planContacts the patient 24-48 hours post-discharge to reinforce the established discharge plan and provide any needed care coordination or education. Sends inpatient information to the patient’s PCP

24. CHF Pilot Data

25. Next StepsHardwire use of CHF Admission Order SetsCreate care modules for co-morbid conditions (DM)Lessons learned from Safe Landing VisitsIntervention post discharge: Day 14-30Medication adherence – pill stationTeleHealth/TeleMonitoringAvatar: a usable and interactive patient education module

26. QUESTIONS?

27. Examples53 single male living aloneSOC/ROC DATE: 05/16/2009 -DIAGNOSIS: CHF NEW NIDDMPT ADM WITH SOB DX CHF BNP 2200 ALSO AIC 8.9 UNDERWENT CARDIAC CATH 5/13/09 DILATED LV SEVERE LV DYSFUNCTION PT ALSO WITH SLEEP APNEA TO HAVE OUTPT SLEEP STUDY DONE PT NEW DM PT VERY CONCERNED WITH NEW DX CHF AND DM MANY QUESTIONS PAST MEDICAL HISTORY: CHF HTN THYROID NODULES CARDIOMEGALYHT: 5 FT. 7 IN.WT: 335 LBS.FUNCTIONAL LIMITATIONS: CARDIAC RESTRICTIONSAUG - ADMITTED WITH URINARY RETENTION,EDEMA LOWER LEGS, SHORTNESS OF BREATH, NAUSEA/VOMITING, ABDOMINAL DISTENTION. BNP-2320. TROPONIN ELEVATED. RENAL CONSULT-DR POWELL FOR CKD/PROTEINURIA. DIURESED. HAS RECURRENT RIGHT NECK WOUND/ABSCESS. EGD SHOWED ANTRAL EROSIONS, BARRETT–LIKE MUCOSA. BIOPSY DONE. SHOULD HAVE EP STUDIES AS OUTPATIENT- ? NEED FOR AICD.

28. Examples

29. Examples78 female with CHF, COPD, HTN, HYSTERECTOMY, OBSTRUCTIVE SLEEP APNEA, AFIB, CHF, DIABETES, HYPOTHYROIDISM- living in large suburban home with handicapped son until son married 1.5 years ago- first monitor in Aug 2005 then 5 additional times post hospital discharge-- no hospitalization while using monitor --Started with wt over 330 lbs and after removing monitor wt was 230

30. Examples

31. ExamplesLive audio/video interaction with patientDedicated, secure telehealth databaseColor-coded data for ease of reviewIntuitive platformHL7 interface to EMR

32. ExamplesDesigned to provide:Real-time, two-way audio/videoUse of standard phone lineEasy to useIntegrated, patented Careton™ stethoscope

33. ExamplesOffers Face-to-face, personal interaction with accurate visual observationProvides Peace-of-mind Opportunity for immediate action for Alert conditionsVisits can be documented with photographs.Ability to assess mental & physical acuity and behavioral changes Medications can be managed and problems caught BEFORE they reach crisis levels!