Extending Care from Hospital to Home
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Transcript of Extending Care from Hospital to Home
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Extending Care from Hospital to Home
CP338.01 5/3/13
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Agenda
• Changing trends in healthcare
• Identifying key pain points
• Partnering with home health
• Why telehealth
• Measuring outcomes
• Next steps
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The shift to a patient-centric model is creating a seismic change in Healthcare implementation
Source: Reflection on the Future of Disease Management by Sam Nussbaum, MD
A new definition of success in healthcare
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Drivers of patient-centric care
Patient population trends• Growth in chronic diseases • Increase in aging population
Increased patient engagement • Proactively involved with maintaining
health on a daily basis• Desire to live independently longer
CMS payment model• Penalties for readmission rates above the
national average• Value-Based Purchasing payments based on quality
of care vs. fee for service • Meaningful Use incentives for utilizing certified EHR’s
to capture and share health information with care providers and patients
Source: Center For Disease Control (CDC)
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Identifying industry pain points
Pain Points Top Initiatives
• Reduce readmissions to avoid reimbursement penalties
• Prepare for changing reimbursement models (value-based purchasing, bundled payments, shared savings)
• Maximize Value-based Purchasing incentives for meeting quality of care standards
Financial
Patient Satisfaction & Quality
• Improve satisfaction surveys results and patient engagement/loyalty to secure incentive payments
• Better patient oversight and care transitions to increase quality of care and improve patient acquisition costs
Operational & Clinical Efficiencies
• Utilize analytics to access patient care data to decrease staffing costs and length of stay
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Partnering with Home Health
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About (Your Agency Name Here)
(PLACEHOLDER: Include information about your agency including history, services, awards, and unique value/how you are different from other agencies)
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Patient populations that we serve
Patient Self-Managed
Value:
Enables Care Manager to offer support to Elders when and how they
need it
Population:
Mobile/Healthy Elder
Our fit: PERS
Mobile Healthy
Event-based
Value:
Event-initiated oversight and patient/disease management tools
Population:
mPERS/Disease Management/ Care Transitions
Our fit: PERS/Telehealth monitoring
At Risk
Full Clinical Oversight
Value:
Daily monitoring using telehealth products and services
Population:
Fragile, Homebound, Chronically Ill
Our fit: Telehealth monitoring
Fragile
• Mobile Healthy and At Risk patients who do not have a skilled need or are not homebound• Frequent fliers who need a daily connection to health monitoring to prevent emergent care use• Chronic disease patients who need assistance managing their care• Post acute patients not transferred to a SNF• Patients needing skilled nursing, PT/OT/MSW and/or daily monitoring services• (PLACEHOLDER: Add your other agency services here (home making/CNA /Hospice, etc.)
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How Home Health can help address your pain points
Daily health status monitoring • Patients can remain in their homes, and maintain their independence, while being monitored for changes
in health status• Changes in condition will trigger an action to review and modify the patient’s care plan, if needed, before
a re-hospitalization occurs
Education• We teach patients and families about their conditions, including compliance with care plans and how to
make better choices to improve their health
Transparent access to patient data• Co-case manage our mutual patient(s) by accessing patient data in real time• Review your patients’ information at any time with our analytics tools • Allowing family members to review care through secure online access to patient information
Improve patient satisfaction • Daily clinical oversight with remote monitoring provides patients with a sense of security and greater
peace of mind through interaction or human interaction
Result = Cost containmentThe value of daily health status monitoring helps control costs for your hospital
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Telehealth Solution Overview
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Demystifying “Tele-Confusion”
TelehealthTelemedicine Telecare
Health data transfer between care
providers & patient for diagnosis &
treatment via live connections
Description
Services & Devices
Use of telecom & IT to provide
remote access to care to chronic
populations
Services enabling elderly &
vulnerable to live independently
in home or facility
• Physician & Patient
teleconsulations
• Telesurgery, teleradiology, tele-
ICU
• Holter & CRM home monitor
• Video conferencing
• Full clinical oversight through full
vitals monitoring
• Data management platform
• Implementation services
• Decision support tools
• Disease management
• Video visits
• Activity & sensor monitoring
• Gas & smoke detection
• Medication management
• Personal Emergency Response
System (mPERS)
Remote Diagnostic & Treatment Remote Patient Monitoring Activity Monitoring & Sensing
Where does Telehealth fit?
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LifeStream Care Provider Software
Our Solution: LifeStream Health Management Platform
Patient Devices and Peripherals
Manager Connect
AnalyticsView
LifeStream MobileHelp mPERS
Genesis Touch Genesis DM
We utilize Honeywell HomMed’s LifeStream Health Management Platform, and our telehealth solutions are supported by their Clinical Consulting Services
Peripherals
Our Monitoring Services
Installation
Daily Monitoring Physician engagement
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Scheduled or unscheduled biometric collection: Walks patients through the process to assist with
compliance
Optimized for mobility: Honeywell HomMed devices can be used both inside or outside the home
Wired and wireless peripherals: Devices can be used in any room with or without
dedicated wired connectivity
Integrated video capabilities: Hold video visits and educational sessions with
patients, family members, and other care providers
Solution Overview: Patient Devices
Telehealth• Mobile & desktop• 3G/4G & WIFI• Range of peripherals
Telecare• Mobile wireless• Location services• Falls (Q313)
Applications• Video visits• Deliver educational materials
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We track and manage patient data through Honeywell HomMed’s software management
interface
• Single consolidated view of patient data: Review and manage patient data from
LifeStream’s clinical dashboard
• Flexible, efficient workflows: Schedule and customize patient biometric collection, ask
specific disease management questions, and deliver relevant education to the patient
• Integration with common HIT interfaces: Connect patient data with your health records
(EHR) and electronic medical records (EMR) with HL7, one-way, or two-way interfaces.
Solution Overview: Care Provider Software
LifeStream Care Provider Software
Manager Connect
AnalyticsView
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Daily Monitoring: Our clinicians review patient biometric data daily and respond to changes
directly with each patient
Physician Engagement: We will work with you to identify the reporting and communication
methods you prefer to stay informed about your patients.
Installation: We will install the telehealth monitor in the patient’s home
HomMed Clinical Consulting: We work closely with Honeywell HomMed to adopt rigorous
standards for our telehealth program and ensure our staff is properly trained
Solution Overview: Clinical and Monitoring Services
Our Monitoring ServicesInstallation
Daily Monitoring Physician engagement
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Measuring Outcomes
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Measuring a successful telehealth program
We benchmark our agency against the following criteria:
Readmission rate: How often are our patients re-admitted to the hospital and were any of the incidents preventable?
Quality of care and patient satisfaction: Are our patients satisfied with their care?
Operational and clinical efficiencies: Are we able to care for more patients and reach them more often with telehealth?
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Outcome Data: Home Health Compare
(PLACEHOLDER: Enter your agency’s outcome and home health compare data here)
http://www.medicare.gov/HomeHealthCompare
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Outcome Data: Our patient data examples
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Hospital Compare
(PLACEHOLDER: List the Hospital Compare data for the hospital you are presenting to)
http://www.medicare.gov/hospitalcompare/
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Telehealth Success Throughout the Industry
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“We believe that telehealth services are key building blocks required for the delivery of quality home healthcare.”
Wayne Bazzle, CEO of CareCycle Solutions, Dallas, TX
30-Day Rehospitalization Rates
Medicare Beneficiaries – US Average* 19.60%Texas Medicare Beneficiaries* 19.40%Louisiana Medicare Beneficiaries* 21.90%Home Healthcare Partner – Non-TeleHealth 14.89%CareCycle Solutions – TeleHealth 7.30%
In an ongoing look at 6,000+ patients, readmission rates for the first 30-days of care averaged 7.3% for monitored patients vs. 14.2% for patients that did not receive telehealth monitors.
Care Cycle Solutions Example
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Advanced Telehealth Solutions
Focusing on highest cost
members of a population
yields sustainable savings over time
ROI Example
=
=
$6,000 PM/PY Avg.$6,000,000
$3,300,000
Insurance Cost [PM/PM $500 x 12 Months]
1000 Lives x $6,0005% of People [50] generate 55% of total cost:
55% of cost [an opportunity for savings of] =
Karen Thomas, President, Advanced TeleHealth Solutions
50%Members
Preventative Risk Mitigation Telehealth
10% 10% 25% 30% 25%
20% 25% 4% 1%
Well Members
Prevention and Education
Low Risk Members
Optimize Resources in Acute Episodes
of Care, Population Care
Moderate Risk Members
DM and Education,Risk Avoidance
High Risk, Multiple Diseases
Episodic Care Mgmt Clinical Guidelines
High Risk DM
Complex and Intensive Care
Total Care Integration
Cost
Prevention and Early Identification Risk Avoidance
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Next Steps: Post-discharge process
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The handoff to home health
Recommended process for hospital and home health agency prior to patient discharge
24 hours prior to discharge: • Review patient care plan • Identify communication frequency/reporting plan• Deliver monitor to patient and provide telehealth education at
bedside, or develop a plan for in-home assessment depending on your preference
During monitoring:• Regular communication between hospital and home health according
to pre-discharge plans• Alert physicians to changes in health and revise care plan if needed• Evaluate need for video visits to reinforce care plans or introduce
additional educational information
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Testimonials
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What do patients and family members say about us?
(PLACEHOLDER: List 3 – 4 of your patient testimonials here)
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Thank you – How do we get started?