2013 Care Transitions Statewide Summit East Lansing, MI 05.29.13

1. In-Home Monitoring 2.0 Redefining Care with Remote Monitoring to Reduce Readmissions 2013 Care Transitions Statewide Summit East Lansing, MI 05.29.13

2. Disclosures • The speakers are employed by Residential Home Health or Critical Signal Technologies. • The speakers do not have any relevant financial relationships with any commercial interests.

3. Objective • Explain how an in-home monitoring system can positively impact care transitions • Review two forms of in-home monitoring (aka telehealth) • Personal emergency response system (PERS) • Daily vital sign monitoring – weight, blood pressure, pulse ox, heart rate and relevant health status questions

4. Presenters • Ms. Teresa McDaniel, RN, BSN, MS, Vice-President of Clinical Operations & Care Transitions, Residential Home Health • Ms. Teresa Spencer, Director of Community Outreach & CareForce, Residential Home Health • Jeff Prough, J.D., MBA, President & CEO, Critical Signal Technologies

5. Discussion Agenda • Review of Post-Acute Chronic Care Challenges • Review of Secondary Research Regarding Managing Readmissions & Telehealth Efficacy • Residential’s Investment in Telehealth • Review Residential Nurse Alert • Review Telehealth Component of CHAMP

6. Today’s Post-Acute Care Challenge – Coordinating Care in a FFS Environment • Typical Medicare • Post-Acute Patient • Multiple conditions • Numerous physicians • Poly-pharmacy • Caregiver support • Family resources ($) • Key Care Mgmt Issues • Poor care coordination • Misaligned incentives • Poor communication, disconnected EMRs • Under-utilization of post-acute services • Timely PCP access Hospitals Physicians Nursing Facilities Patient Home Typical Home Health Typical Hospice Medicare patients now see an average of seven physicians, including five specialists from four different practices. A typical PCP coordinated with an average of 229 other physicians in 117 different practices just for Medicare patients. • Lack of evidenced-based clinical programs • Lack of clinical capacity to respond timely • Lack of technology to manage utilization/cost • Lack of resources for care transition & service coordination

7. Penalties & Hold-Backs to Hospitals Payors are targeting inefficiencies and improved management of care transitions in the current FFS reimbursement structure: 1. Related DRGRe-Admission No-Pay 2. Value-Based Purchasing Up to 2% by FY 2017 3. Re-Admission Penalties Up to 3% by FY 2015 Hospitals Need to More Actively Manage Post-Acute Care Networks as Scope of Penalties and Hold-Backs Will Increase

8. Typical Medicare Hospital Discharge Dispositions Facility – ECF/SNF Avg. LOS 20 days 20% of Discharges Home with Home Health Services Avg. LOS 90 days 20% of Discharges • Typical U.S. Hospital • Avg. LOS 5 days • ~$12K Claim Home with No Post-Acute Services 50+% of Discharges H Hospice Avg. LOS 90 days 2% of Discharges Other 8% of Discharges ~55% of Medicare patients readmit within one year. 30-Day Re-Admit Exposure It’s no longer just about a discharge. What’s your 30-day post-acute plan? Source: Health Market Resources, Inc, 2010 Medicare Claims Data, Jencks et. al.

9. 30-Day Mortality & Readmissions Source: CMS, Hospital Compare Data, 2009; analysis compiled by Greater Hospital Association of NY • 11 states with lowest 30-day mortality rates had the highest readmissions and 12 states with highest 30-day mortality rates had mixed readmission rates • Similarly, Cleveland Clinic found that hospitals with higher readmission rates actually had lower 30-day mortality rates, (NEJM, 2010)

10. Patient Characteristics & Health Conditions Role in Readmissions • Patient’s life characteristics • Income • Social support • Health conditions • # of co-morbidities • Depression • Demographic factors – age, gender, race, geographic region

11. More Chronic Conditions the Greater Likelihood of Readmission Source: Gilmer and Hamblin, Dec, 2010. Center for Health Strategies – New Jersey

12. Medicaid Beneficiaries Have Higher Readmission Risk than Privately Insured Source: Jiang and Wier, (April, 2010). Agency for Healthcare Research and Quality

13. Case Study – Fairfield, CT vs Bronx, NY Source: Bhalla and Kalkut, Annals of Internal Medicine, 2010

14. Telehealth Case Study – Veterans Health Administration • Largest telehealth user in the world • ~70,000 veteran patients using telehealth technologies • 85% using systematic vital sign monitoring with surveys and nurse triage • 85% patient satisfaction with telehealth • 40% reduction in hospital bed days as compared to pre-enrollment figures • 12.7% 30-day, all-cause readmission rate in 2009

15. VHA Telehealth Program Reduces Acute Care Utilization

16. Spectrum of Telehealth Solutions Phone-Based Care Management Patient Self-Reporting Vitals Systematic Vital Sign Collection with Surveys Video-Based Care Management Low Cost & Patient Engagement High

17. “You cannot reduce post-acute risk if you do not actively manage post-acute risk.” David Curtis, President, RHH

18. Residential’s CHAMP Program • Demonstration of Daily Vital Sign Monitoring Solution - Video • Installation, Set-Up, Costs • Patient Profile • Wellness Monitoring • Clinical and Non-Clinical Triage and Response • Review of Program Expenses • Patient Satisfaction Results • Admission Avoidance Results

19. Residential’s CHAMP Program • Demonstration of Daily Vital Sign Monitoring Solution - Video • Installation, Set-Up, Costs • Patient Profile • Wellness Monitoring • Clinical and Non-Clinical Triage and Response • Review of Program Expenses • $110 per unit per month with scale, BP cuff, pulse ox and base station with landline or cellular option • Includes 365 nurse triage • Patient Satisfaction Results • Admission Avoidance Results

20. Overview of Home Health EMR & Telehealth Integration CRM & Service Automation Physician Portal Patient Satisfaction Field Point-of-Care TeleHealth Wound Care Office Work Flow Manager Pharmacy Mgmt Clinical Outcomes Operations Data Warehouse

21. Daily Triage & Care Coordination 365 day monitoring of weight, BP, oxygen saturation, heart rate and other health status questions ~300 monitors deployed at any one time Patient • Coaching for Behavior Modification • Diet, Medications, Symptom Mgmt Telehealth Nurse Triage Team – 365 days Field Clinicians Nursing, Therapy & Social Work • Coordinate • Consulting Physicians Telehealth is provided with no cost to patient or physician, and no incremental reimbursement from CMS/other payors. Reduced 30-Day Unplanned Readmissions 12% All Cause

22. Daily Triage & Care Coordination 100% of Telehealth Patients Report in On Daily Basis (By 11 am) Up to 300 patients ~40% Require Triage by Telehealth RN Education, MD Coordination, Additional Visit 10% Prevented Readmit in 24 Hours

23. Residential Nurse Alert • Demonstration of Solution - Video • Installation, Set-Up, Costs • Patient Profile • Wellness Monitoring • Clinical and Non-Clinical Triage and Response • Review of Program Expenses • Patient Satisfaction Results • Admission Avoidance Results

24. Bringing the hospital call button home to prevent hospital readmissions Teresa Spencer, Director of Community Outreach, Residential Home Health Jeff Prough, CEO and President, Critical Signal Technologies

25. But Then What Happens…

26. Traditional Personal Emergency Response System

27. Nurse Alert Is Different from Traditional PERS Physician’s Office Caregiver(s) Nurse Available 24/7 EMS Dispatch Care Support at Call Center

28. Nurse Alert – Customized Care Protocols • Customized protocols for every patient on service • Examples: • Caregiver(s) may request to be notified prior to EMS dispatch • Patient can indicate protocols of how to get into the house in case of emergency, what to do with pets, etc. • Residential is immediately notified of any EMS dispatch (regardless of if there is a transport) • Proactive approach to care as patients are encouraged to press their button for anything from “I want to schedule a doctor’s appointment” to “ I need my daughter to come and fill my medications” • Preprogrammed customized messages added to the base unit. Example: medication reminders can be set up to alert patient at specified times. • Wellness checks done throughout care plan to encourage patient compliance

29. Nurse Alert Has Reduced Unnecessary Hospitalizations by Incorporating Protocols that Involve Patient Caregivers and Residential Nurses

30. Example of a Scenario that Prevented a Hospital Admission • 3/2/2013 at 2:27 a.m. -Patient Pat, pressed button and indicated she had fallen and wanted her daughter to be called. • As part of the patient’s protocol , it was noted the patient had a history of falls. The daughter lived nearby and if patient was responding she wanted to attend to her mother rather than having EMS dispatched. • Daughter was contacted and went to home to assist patient. • The Residential Nurse Alert call center waited to receive confirmation from the daughter that EMS did not need to get dispatched and then closed the call. • Residential Home Health was immediately notified that there was an alarm activation due to a fall and a Residential nurse was sent to the home the next day to check on the patient

31. Recommended for Any Patient Experiencing the Following • Chronic illness • Weakness or mobility problems • Taking multiple medications • High risk for falls • Cognitive impairment • Vision deficiencies • Recovering for surgery • Lives alone • No caregiver support

32. On-Board follow up • First call made to patients within one week of start of care. In addition Check in to see how the patient is doing. Scheduled Communications With Patient • 3 day follow up after Install • Purpose: Call to make sure the patient understands how to use the unit and to encourage them to press the button if they need anything • 5-7 day follow up after install • Purpose: Wellness Check-check on patient’s health status and to ensure they have had a follow up physician’s appiontment scheduled. • Day 50-54 Service Status call • Purpose: Check to see how the patient is doing towards the end of their care plan and to see if the patient would like to continue to have Residential Nurse Alert

33. Example of Wellness Call Questions 1. Do you have a moment to review Residential Nurse Alert with me? I just want to make sure we have all the necessary information to assist you properly. 2. Do you have a date set for your next follow physician appointment? o If not, I would be happy to give your doctor’s office a call to set up your appointment. 3. Do you have any questions regarding your medications or scheduled home visits? o If so, I can get you in touch with your Home Health Nurse or Care Coordinator to answer any specific questions you may have. 4. Have you been happy with the services we have been providing to you? 5. Please be sure that you keep the box the unit came in, at any time you wish to cancel all you have to do is unplug the unit, put it back in the box and stick the pre-paid label on top of the box and put it outside by your mailbox. Your postman will pick it up and send it back to us at no cost to you 6. Is there anything else we can do for you today?

34. Residential Home Health Includes As Part of Every Patient’s Care Plan 60% of patients extend the service beyond their care plan and choose to privately pay for the unit.

35. Area Agency on Aging 1-B Case Study • Area Agency on Aging 1-B (AAA 1-B) is a non-profit agency responsible for services to more than 453,000 persons age 60 and over residing in several counties in Michigan. • AAA 1-B recruited individuals in its region who were on the wait list and offered them a PERS unit for one-year at no cost. The study had a total of 55 participants ranging in ages from 53 to 110, with an average age of 78.2 years. Sixty four percent of respondents lived alone. Results • Respondents experienced a 20% decrease in the number of emergency room visits six months after receiving PERS. • Hospital admissions decreased by 27% after six months. Further, the number of days spent in the hospital decreased 22%.

36. Thank You • Please direct all follow-up inquiries to tspencer@residentialhomehealth.com • Learn more at www.resdentialhomehealth.com