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Patient Centered Medical Home and Telehealth Application MaryJo Vetter, MS RN, GNP Director of Clinical Product Development, Visiting Nurse Service of New York Christina Coons, RN, BSN Manager of Telehealth Services. Opportunity Knocks….

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Patient Centered Medical Home and Telehealth Application

MaryJo Vetter, MS RN, GNP

Director of Clinical Product Development, Visiting Nurse Service of New York

Christina Coons, RN, BSN

Manager of Telehealth Services

opportunity knocks
Opportunity Knocks…
  • Converging forces in healthcare today are placing great emphasis on efficiency and effectiveness of patient care
    • Chronic illness population with steep trajectory
    • Workforce shortages growing with increased demand
    • Technology adoption by end user more commonplace
    • Government funding has increased
    • Reimbursement strategy is changing
    • Self Management techniques are cutting edge
  • Healthcare organizations are presented with vital growth opportunities amidst the challenges
visiting nurse service of new york
Visiting Nurse Service of New York


VNSNY is the largest not-for-profit home health care

organization in the nation and was founded in 1893 by

Lillian Wald, the first public health nurse.

Serving:Bronx, Brooklyn, Manhattan, Queens, Staten Island, Nassau and Westchester counties

Chief Executive: Carol Raphael: President & CEO

Statistics (Calendar Year 2007):

  • Total Patients Served: 138,600
  • Total Professional Visits: 2,456,000
  • More than 25% of our patients spoke languages other than English
  • Diabetes and hypertension were among the most frequent diagnoses of our patients
  • On any given day, VNS has more than 30,000 patient in our care that’s more patients than are seen in one day in all NYC Hospitals


  • Has over 13,300 care givers.
  • Collectively, VNSNY staff members speak more than 50 languages
our major lines of business
Our Major Lines of Business


Research Center

Hospice /

Palliative Care


Private Care


  • Adult Care
  • Maternal Newborn
  • Pediatrics
  • Infusion
  • Managed LTC
  • Medicare Advantage
  • Advantage Plus
the scope of vnsny s services extends beyond traditional home care
The Scope of VNSNY’s Services Extends Beyond Traditional Home Care

Community Mental Health Services

FRIEND’s Clinic (Article 31) - Bronx

Centers of Excellence Programs

Advanced Illness Management


Diabetes Care

Heart Failure Care

Stroke Care


Wound, Ostomy and Continence Care

Children and Family Services

Bronx Fatherhood Program

Maternity, Newborn and Pediatrics

Community Care for Children

Early Intervention Program

Early Health Start Program and Early Steps Family Center

Father’s First Initiative

Nurse-Family Partnership

Medicaid and Medicare Health Plans




Acute Care

Skilled Nursing

Physical, Occupational and Speech Therapy

Social Work

Home Health Aide Services

Long Term Care

AIDS Long Term Home Health Care Program

Congregate Care (Geriatric:Adult Home Care)

Family Care Services

Long Term Home Health Care Program

Meals on Wheels

Nutrition Services

End of Life

Hospice Care

Palliative Care

Bereavement Services

Community Outreach

Community Connections TimeBank

Private Care

Skilled Nursing Care

Home Health Aide Services

Geriatric Case Management

medical home overview
Medical Home Overview
  • Patient Centered Medical Home was promoted by NCQA as an approach to providing comprehensive primary care for children, youth and adults
    • Developed in collaboration with the ACP, AAFP, AAP and AOA
    • First modeled in 1967 by AAP to enhance care coordination for special needs Peds
  • Partnership between individual patients, and their personal physicians, and when appropriate, the patient’s family.
  • Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.
  • NCQA provides verifiable certification of a host of best practices for ambulatory care
    • Practices will demonstrate that they meet certain standards and elements, which are then scored and assigned a level to become eligible for reimbursement
  • State, government, and commercial insurers are looking for ways to reimburse for processes that deliver better care


medical home s 7 core principles
Medical Home’s 7 Core Principles


optimal care requires a paradigm shift for all payers and providers
Optimal Care Requires a Paradigm Shift for all Payers and Providers

Wagner’s Chronic Care Model

Developed by the MacColl Institute for Healthcare Innovation®

VNSNY’s Chronic Care Program Can Provide Supporting Infrastructure to Medical Homes for Managing Patients with Chronic Illness at Home


Health Plan

VNSNY’s Chronic

Care Management

Patient Centered

Medical Home

vnsny s ccm program improves interactions between patients and healthcare providers
VNSNY’s CCM Program Improves Interactions between Patients and Healthcare Providers

VNSNY’s Core Elements of Chronic Care Management

Theory-Based Self




Oversight &

Decision Support




High Touch



  • Telemanagement
  • Clinical information
  • systems
  • Support of patient
  • registry
  • Use of data for care
  • coordination
  • Outcome data
  • measurement
  • Initial in-home
  • comprehensive
  • assessment
  • Proactive planned
  • phone visits
  • Telehealth
  • Interactions
  • In-home crisis
  • visits
  • Motivational
  • interviewing
  • Health coaching
  • Self management
  • education
  • Individualized-
  • goal oriented
  • Action Plan
  • Self-efficacy
  • improvement
  • APN specialist oversight
  • Medical management
  • via NP-MD collaboration,
  • when needed
  • Care coordination with
  • Primary Care/Specialty
  • Physicians
  • Use of evidence-based
  • guidelines and practice
  • Partnership
  • with payers &
  • community
  • agencies
  • Linkage of
  • members to
  • community
  • resources
vnsny telehealth background
VNSNY Telehealth Background
  • Program infrastructure established over past 5 years to support wide rollout and increased service offerings
    • Telehealth Equipment Vendor Contracts & Logistics Company (DME)
    • Training Courses and Materials: Patient/Member, Caregiver, Clinician, Physician
    • Policies, Procedures, Evidenced Based - Best practices
    • Research
    • Billing
    • VNSNY Telehealth Web Browser developed for clinicians at point of care
    • Physician Web Portal
  • Telehealth programs for VNSNY Internal and External customers
    • Based on Risk for Hospitalization & ER use
    • Specific disease focused – Diabetes, CHF, ESRD, Wound Care
    • Baseline safety tools- PERS
  • Wide involvement in NY state grants and HCA activities
    • HEAL 10
    • NYSDOH
    • HCA Telehealth Workgroup Member
  • National participation & partnerships with large Telehealth Corp.
    • Viterion Healthcare – Bayer, Intel Corporation, AMAC
    • American Telemedicine Association – Multiple SIG membership
    • NAHC Chronic Care Congress attendee
patients can answer questions based on branch logic education and assessment
Patients Can Answer Questions Based on Branch Logic Education and Assessment

* Enhances Self Care Techniques & Lifestyle Management, Promotes Health Coaching Opportunities

vital sign symptom data is transmitted in real time with automated clinical stratification
Vital Sign & Symptom Data is Transmitted in Real Time with Automated Clinical Stratification

*Promotes Targeted Interventions by Telehealth Staff and Facilitates Communication to Providers


Telehealth Trend Reports Are Created for Patients, Nurses, & Providers

* Prioritizes Clinical Decision Making

vnsny telehealth web browser gives access to patient data for all clinicians
VNSNY Telehealth Web Browser Gives Access to Patient Data for All Clinicians

VNSNY Telehealth Portal


Telehealth Intervention Overview

Based on the plan of care, the nurse will perform a range of interventions appropriate to meet the patients clinical needs

Patient vitals signs and symptoms are accessed and monitored daily by the nurse using the electronic tablet

A nurse assesses the patient in the home, coordinates the equipment set up, and education of the telehealth program

  • Conducting telephonic assessment and education with the patient
  • Customizing Telehealth clinical questions and messaging to be delivered via the Telehealth monitor to further assess and/or educate the patient
  • Provide a home for hands-on intervention or education as needed
  • Contacting the patients doctors to discuss further interventions
  • Sending the provider individual patient Telehealth trend data to facilitate clinical decision making

‘Medical Home’ and Telehealth Data Workflow Exchange

RHIO Network


Telehealth Vendor





Home Care Database





Patient Centered Medical Home


Patient Transmits Her Vital Sign Data Via Communication Method







case study of medical home and telehealth use
Case Study of Medical Home and Telehealth Use

Mrs. T is a 61 year old woman with Type 2 Diabetes who develops an

infected foot ulcer and presents to the ER. After a brief admission, she is

discharged to her patient centered medical home, where her PCP

coordinates home care to keep her from returning to the hospital.

  • VNSNY Home Care EHR extracts relevant patient info from the PCMH via the RHIO
  • After initial nursing assessment, patient receives telehealth monitoring and wound imaging, all incorporated from VNSNY Home Care EHR via the RHIO into the PCMH EHR
  • The VNSNY Wound Care Nurse Specialist provided recommendations of wound care through the RHIO
  • PCP made interim changes to the treatment plan through the RHIO
  • Mrs. T improves in her self care techniques, wound healing progresses, while she has minimal in-person doctors visits and is not rehospitalized.
  • The PCMH promotes operational, financial, and clinical efficiencies to achieve improved outcomes and contain costs.
Questions ?

MaryJo Vetter, MS, RN, GNP

212 609 6358

Christina Coons RN, BSN

212 609 6353