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CARE COORDINATION Home Telehealth

CARE COORDINATION Home Telehealth. Pamela Canter, RN James H Quillen VA Medical Center. Definition of Care Coordination.

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CARE COORDINATION Home Telehealth

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  1. CARE COORDINATIONHome Telehealth Pamela Canter, RN James H Quillen VA Medical Center

  2. Definition of Care Coordination The wider application of care and case management principles to the delivery of healthcare services using health informatics, disease management and telehealth to facilitate access to care and to improve the health of designated individuals and populations with the specific intent of providing the right care in the right place at the right time.

  3. GOALS OF CCHT • Integration of healthcare environment to best meet the patient’s needs • Proactive delivery of evidence-based care & Establish continuous healing relationships • Follow-up

  4. EXPECTED OUTCOMES • Increased access and patient satisfaction • Enhanced functional status and quality of life • Increased Provider and CCHT staff satisfaction • Reduced admissions and bed days of care • Reduced clinic and ER visits • Reduced nursing home admission rates • Reduced overall costs for patients with history of frequent admissions and clinic visits.

  5. CCHT HISTORY • Established:2004 National roll-out began for CCHT. 1st enrollment for VISN 9 was February 2005. • Mission: To coordinate the right care, in the right place, at the right time. • Vision: The place of residence is the preferred place of care to provide the “just in time” approach for both the patient and caregiver. • Goal – Core Values: • Maximize access to VHA system • Patient Centric Programming • Integrity • Evidenced Based Practice • Teamwork/Collaboration • Flexibility/Sensibility • Support for Congestive Heart Failure and Diabetes

  6. ELIGIBILITY FOR CCHT • Have at least one of the following chronic conditions: congestive heart failure (CHF), diabetes mellitus (DM), hypertension (HTN) or chronic obstructive pulmonary disease (COPD) and may have conditions such that technology and care coordination could improve resource utilization and clinical outcomes. • Requires more than one home-health visit per week due to severity of illness and need for monitoring, management or education. • Patients will have had two (2) or more hospital admissions or emergency room visits in the preceding fiscal year. • Will be enrolled in a Primary Care Clinic with greater than eight (8) outpatient visits in the preceding fiscal year.

  7. Cont. ELIGIBILITY CCHT • Have greater than ten (10) active medication prescriptions. • The home environment is such that daily care and medical problems can be managed in the home. Access to utilities and safety concerns are addressed for appropriate installation of equipment. • The patient and caregiver accept the technology in the home. • The patient and caregiver demonstrate competency in using and maintaining telehealth equipment. • Other circumstances that may improve quality of life and improve clinical outcomes.

  8. VA Health Management Programs Single Programs COPD ** Cancer Care Acute General Caregiver Palliative Care Depression ** Cancer Care Maintenance Heart Failure Acute Polypharmacy Diabetes ** CHF Maintenance ** Heart Failure Maintenance Pre-Diabetes Heart Failure ** Coagulation Management Hepatitis PROMISE Hypertension ** Coagulation Mgmt Main. HIV PTSD Bipolar COPD Maintenance HTN Maintenance Schizophrenia CAD Dementia Low ADL Senior Wellness CAD Main. Diabetes Acute MI Substance Abuse Cancer Care Diabetes Maintenance ** Pain Management Weight Management Co-Morbid Programs Bipolar/Diabetes Depression/Pain Mgmt. Diabetes/HTN Acute Pre-Diabetes/COPD Bipolar/HTN Depression/HTN Diabetes/HTN Maintenance Pre-Diabetes/Hypertension CAD/Diabetes Depression/HTN/Diabetes HTN/Hyperlipidemia ** PTSD/COPD Cancer Care/HTN Diabetes/CHF ** MI/Diabetes PTSD/Diabetes Cancer Care HTN Main. Diabetes/CHF Acute MI/Diabetes/CHF PTSD/HTN CHF/COPD Diabetes/CHF Maintenance MI/CHF PTSD/HTN/Diabetes CHF/HTN ** Diabetes/CHF/HTN ** Pain Management/CHF Schizophrenia/Diabetes CHF/Hyperlipidemia ** Diabetes/CHF/HTN Acute Pain Management/Diabetes Schizophrenia/HTN COPD/HTN Diabetes/CHF/HTN Main. Pain Management/HTN Schizophrenia/HTN/Diabetes COPD/HTN Maintenance Diabetes/COPD Palliative Care/CHF Weight Management/CHF Depression/CHF Diabetes/COPD Main. Palliative Care/COPD Weight Management/COPD Depression/COPD Diabetes/COPD/CHF Palliative Care/Diabetes Weight Management/Diabetes Depression/COPD/HTN Diabetes/COPD/HTN Palliative Care/HTN Weight Management/HTN Depression/Diabetes Diabetes/HTN ** Pre-Diabetes/CHF ** Program available in Spanish

  9. Health Buddy 3 a Look Inside the Box

  10. Health Buddy 3 Power adapter Phone ports, one to wall and one to the phone DB-9 Serial Port 3 USB Ports HB 3 must have ROM Build number 49714 or greater to use Ethernet connection InfraRed sensor

  11. Whatdoes the patient need • 110V power outlet • Standard single-line telephone • Dial tone only (not pulse or VOIP) • Analog line (not digital) • No cellular connection • One digit outside line access code • DSL Filter - The Health Buddy appliance has a modem inside of the appliance that can interfere with telephone lines that also share a DSL connection. If a patient has a DSL line ask them to contact their DSL provider to install a filter. This picture is an example of a filter.

  12. Connecting the Health Buddy

  13. Connecting the Health Buddy and Phone

  14. Medical Devices Visit www.healthbuddy.com for a complete list of Medical Devices that can connect via a cable, Blue Tooth or InfraRed to the Health Buddy 2 and or Health Buddy 3

  15. The Patient’s First Experience Once the patient has successfully set up the Health Buddy and the green light is on, they press start to begin. The patient will be presented with a tutorial that guides them through how to use the 4 blue buttons to answer questions.

  16. Health Buddy® System Health Buddy Results are sent to a VA Secure Data Center where the Care Coordinator can access Health Buddy Patient Results on their computer.

  17. FY2009 – 1st quarter Bed Days of Care Cost Avoidance

  18. FY2009 – 6 months follow up Cost Avoidance

  19. Emergency Room/Primary Care Visits

  20. DISCHARGE FROM CCHT • Care Coordination/Home Telehealth may be terminated when: • 1) The patient is admitted to a nursing home setting as a long-term or permanent placement. • 2) The patient/caregiver no longer wish to participate in the project. • 3) The patient has permanently relocated outside of treatment area. • 4) The patient has achieved clinical goals.

  21. Remote Education- FindingsCHF/DIABETES • Enrolled patients had similar: • Achievement of behavior change goals • Decreased unscheduled PC visits • Improvement in HbA1c • Improvements in quality of life • High patient satisfaction

  22. Conclusions Telehealth is: • Feasible • Acceptable to patients & providers • Can improve care

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