John Williams - UPMC
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Are Our RoadMaps Going in the Right
Direction?John P Williams, MD
Peter and Eva Safar ProfessorAssociate Scientific and Medical
DirectorUPMC and University of Pittsburgh
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Rare opportunity to quote a film and TV star....
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HistoryWith apologies to Santayana...
“If you don’t know where you’ve been, how do you know you haven’t been here before?”
JPW
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HistoryThe first thing we need is an example...
How about Congestive Heart Failure (CHF)?
Big problem
Bad history
Great opportunity
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The most recent example...“Currently the NHS spends up to £1 billion a year,
apparently on managing heart failure badly”Lancet 2010, 376: 2041
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History
72%
7%9%
11%
Hospital/Nursing Home $15.4
billion
Physicians/Other Professionals$1.6
billionMedications/Other
Medical Durables$2.0 billion
Home Health Care$2.4 billion
Total Cost in 2005, 27.9 $Billion- US
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HistorySo what drives those hospital/nursing home costs?
Rev Cardiovasc Med. 2002;3(suppl
4):S3-S9.
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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?
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Previous Studies
Kleinpell and Avital, 2005
Dansky 2008Alston 2009 Hoover 2009
“...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”
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UPMC/Jefferson Regional Home Health, LP
Located in Seven Fields, PA (suburb of Pittsburgh)
Part of a large integrated health care system
Joint Venture, Limited Partnership
Medicare certified, JCAHO accredited
Total Employees >697
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UPMC/Jefferson Regional Home Health, LP
Coverage area includes 10 Counties – PA; 3 - Ohio
FY09 admissions – >33,085
FY09 visits - >410,167
FY09 Medicare episodes – 9,635
FY09 net revenue - $57 million
Average daily census –3,250
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Heart Failure Initiative
With 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.
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Heart Failure/Telehealth Program Goals
Reduce re-hospitalizations within 30 days at targeted hospitals
Reduce frequent unnecessary visits to the Emergency Department
Provide appropriate and timely interventions to prevent exacerbation of disease process
Use outcomes as marketing tool to partner with 3rd party payers.
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Heart Failure/Telehealth Program Goals
Increase patient compliance
Improve patient quality of life
Allow patient to remain independent
Eliminate travel time for staff
Assists in addressing the nursing shortage in specific geographic areas
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Telehealth Program Expansion
Partnership with Third Party Payers
UPMC Health Plan
Three year pilot
25 monitors with peripherals
Home Health –oversight and intervention
Reimbursement for set-up/tear-down-$209.00
Collaborative data collection/analysis based on high utilization of services
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Heart Failure Statistics forRe-hospitalizationsSource FY 2009
UPMC/Jefferson Regional Home Health Heart Failure
Program9.4%
UPMC/Jefferson Regional Home Health Heart Failure
with Telehealth2.5%
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eHealth Benefit
Minimum savings of $312.50 per episode
based on Cost Per Visit of $125.00
Based 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
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Methods for SuccessMedication reconciliation
Patient education specific to condition and co-morbidities
Problem solving skills for changes in the patients condition post discharge
Assessment of patient understanding
Written discharge plan
Discharge plan reconciled with National Guidelines
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Methods for SuccessDischarge summary made available to PCP immediately upon patient discharge
Post discharge telephone reinforcement and Get Abby survey
Follow up physician appointment scheduling
Outstanding testing and support scheduling
Post discharge in home services: Safe Landing visit and Home Health care
Palliative and Supportive Care Services
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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 education
2-3 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 plan
5-7 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
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TIMELINE: CHF Post-Discharge Follow-Up
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Discharge AdvocateOngoing medication reconciliation
Medication education in conjunction with the unit based pharmacist
Educates the patient and caregivers on the discharge plan
Consults appropriate inpatient services to assist with management and education specific to patient’s needs
Schedules post discharge follow up appointments for the patient
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Discharge AdvocateFacilitates a 30 day supply of medications prior to discharge in conjunction with the outpatient pharmacy
Compiles a written, personalized discharge plan
Contacts 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
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CHF Pilot Data
Baseline Pilot
Patients (N) 411 134Average Length of Stay
(Days) 12.1 9.8Readmissions at 30 Days
(N) 94 17Readmission Rate (%) 22.9 12.7
Avg. time to readmission (Days) 14.9 12.3
Case Mix Index 2.8194 1.69Average Age 63 60
% Male 58 57% Female 42 43
Mortality (%) 6 0
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Next StepsHardwire use of CHF Admission Order Sets
Create care modules for co-morbid conditions (DM)
Lessons learned from Safe Landing Visits
Intervention post discharge: Day 14-30
Medication adherence – pill station
TeleHealth/TeleMonitoring
Avatar: a usable and interactive patient education module
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QUESTIONS?
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Examples53 single male living alone
SOC/ROC DATE: 05/16/2009 -DIAGNOSIS: CHF NEW NIDDM
PT 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 RESTRICTIONS
AUG - 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.
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Examples
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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
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Examples
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ExamplesLive audio/video interaction with patient
Dedicated, secure telehealth database
Color-coded data for ease of review
Intuitive platform
HL7 interface to EMR
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ExamplesDesigned to provide:
Real-time, two-way audio/video
Use of standard phone line
Easy to use
Integrated, patented Careton™ stethoscope
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ExamplesOffers Face-to-face, personal interaction with accurate visual observation
Provides Peace-of-mind
Opportunity for immediate action for Alert conditions
Visits 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!