Presentation Transcript

1. National Association of State Veterans Homes Hospital Referrals via the Web February 28, 2013
2. Agenda Discharge Today How hospitals refer and discharge patients Total Living Choices (TLC) Who we are What we do Why we have been successful TLC and the VA Hospitals The Future of Discharge Care Coordination Health Care Partnerships NASVH’s role TLC Confidential & Proprietary
3. Today’s Struggle Discharge, the process of getting a patient out of the hospital, is characterized by difficulty It is a highly manual process It involves multiple parties (patient/family, hospital, potential post-acute facilities, nurses, discharge planners, social work, etc.) It is hard to place patients with complex clinical needs or poor financial status No clean technology solution exists Pay-to-play networks may create legal risk Following “in network” and “out of network” providers separately is double work The connection to clinical documentation is not straightforward Certain constituents are left out of the process (i.e., patient/family) TLC Confidential & Proprietary
4. TLC’s Story Ted Tanase, Founder
5. History 1999 Total Living Choices founded by Ted Tanase 2000 Began connecting families to every post-acute care facility in the U.S. 2006 Began connecting hospitals to every post-acute care facility in the U.S. 2012 Continue to expand throughout the U.S. and grow program offerings TLC has helped thousands of families and their loved ones find the best living solution TLC reaches 20 states and 95 hospitals 2013 TLC delivers new technology to drive true care coordination TLC Confidential & Proprietary
6. Total Living Choices’ Solutions Family Portal Provider Network TLC Confidential & Proprietary
7. Care Finder-Pro Easy-to-use online care management program that connects the hospital, patients, families and post-acute care providers Makes every licensed post-acute care provider in the nation instantly available 24/7 to hospital discharge and case management staff Provides immediate, qualified referrals to post-acute care providers TLC Confidential & Proprietary
8. Family Portal Total Living Choices is the only transitional care company to offer these free resources for families Embedded in hospital’s website Accessible 24/7 Matches an individual’s needs with the best living choices Educates patients and their loved ones on the complexities of the long-term care industry Helps family members living in different locations connect and communicate through one secure online resource Family Portal TLC Confidential & Proprietary
9. Family Portal Care Interpreter Generates free personal report containing the different care settings available based on needs and wants such as price range, health status, insurance and personal requirements Facility Finder Provides information on facilities that match the individual’s needs and wants: Website information with 360° virtual tours Toll-free phone numbers Schedule visit/tour Home Care Finder Provides access to medical and non-medical home health services and products: Medical: Licensed home health, home care and hospice providers Non-medical: Housecleaning, meal preparation, companionship, shopping TLC Confidential & Proprietary
10. Provider Portal Allows any facility to receive referrals, view clinical documents, and respond Available anywhere you can access the internet No cost for participation or portal use Complimentary training and support Providence Everett has sent you a referral for patient #16331956. Please log onto the Provider Portal and respond by 4:35 PM today. Thank you.
11. The Discharge Process Hospital Case Manager (CM) searches for and locates facilities online CM uploads clinical documents needed by facilities Facilities view documents online and decide if they can accept patient Facilities respond yes or no or need to discuss with CM (in 30 minutes or less) CM discusses facilities with patient/family; patient decides Forms completed and submitted by CM for selected facility and other agencies Reports completed for Hospital and Facility Management to measure and improve performance TLC Confidential & Proprietary
12. CareFinder Pro Value Statement Total Living Choices: Existing Success Referral Accepted Referral Sent Discharged Before TLC After TLC Engage and educate the patient and their family TLC has built a strong acute and post-acute care network of more than 70,000 providers Coordinate the transition of care through innovative technology 90% provider engagement Median Response Time of 30 min. TLC Confidential & Proprietary
13. Benefits for Hospitals Clinical performance impact: Accelerated post-acute placement Post-acute care coordination Reduced time to discharge Improved throughput Increased patient satisfaction Financial performance impact: Reduced operating costs associated with avoidable days Decreased length of stay Minimized readmissions Revenue enhancement associated with increased or virtual capacity Ability to establish a Continuing Care Network (CCN) with post-acute care providers TLC Confidential & Proprietary
14. Benefits for Post-Acute Providers Better Care Transitions: Finds a better patient “fit” by matching facility profile with patient’s clinical needs and lifestyle desires Facilitates information sharing and enables quick collaboration No Cost Engagement: Every facility is (or can be) included in the provider network Access to the provider portal with training and support have no cost Increased Referral Traffic: Facilities are automatically available for hospitals based on patient needs Referral traffic and volumes can be managed through unique analytics TLC Confidential & Proprietary
15. Some of Our Clients 15 TLC Confidential & Proprietary
16. National Reach TLC Confidential & Proprietary
17. Channel Partnership Total Living Choices introduced partnership with Cerner in 2011 Cerner Corp. provides complete systems for hospitals and other medical organizations to manage and integrate all electronic medical records (EMR), computerized physician order entry (CPOE) and financial information. Cerner integrated and now sells Care Finder-Pro within Cerner’s Care Management solution TLC Confidential & Proprietary
18. Veterans Administration Pilot Program 2011 – Information Technology Discharge Solution (ITDS) Pilot through VISN 1 & White River Junction VAMC 3 companies selected to participate 9 reviewers TLC Confidential & Proprietary
19. VA and Military Health Opportunities RECOMMENDATION: “Total Living Choices should be offered the opportunity to further pursue discussions with VA to potentially transition their (Care Finder-Pro®) Discharge Planning software from Class lll to Class I to be incorporated with the VA Enterprise (CPRS-GUI/ViSTA).” SUMMARIZATION: “The test period was effective in identifying a unanimous decision that the Total Living Choices software program best fits the VA mission and philosophy and should be recommended for implementation as the VA‘s lnformation Technology Discharge Solution.” The decision to support TLC was unanimous from all reviewers Currently there is language on Capitol Hill to implement a Military Health Service follow-on project The Coast Guard is also exploring a project to look at ITDS following the VA’s lead All contingent on individual VA/VISN decisions or national funding TLC Confidential & Proprietary
20. Making the Transition from Volume to Value TLCs’ track record of success in: Coordinating Care Building strong networks Engaging patients Finding the right community partners TLC Confidential & Proprietary
21. Care Coordination Care coordination has been a Top 10 (now Top 5) priority for hospital leaders the last few years Stakeholders know transitions of care provide opportunities for improvement Provider-risk or bundled payment financially links different settings of care Hospitals are likely in one of the best positions from which to manage a coordinated care enterprise In the real world, hospitals have started programs that: Assign case managers/care coordinators to a significant percentage of all discharges Send hospital employees physically into other providers Are time and resource intensive Need for a Mentality Shift“Practitioners need to shift their mind-set from the concept of a patient discharge toward that of a patient transfer to continuous care management.”Caretransitions.org TLC Confidential & Proprietary
22. How Do We Approach The Transition? Many health systems (and some of our clients) are faced with deploying a high cost, personnel-heavy solution to tackle coordination and avoid readmissions penalties We believe there needs to be more than one solution based on risk stratification: High-Risk Patients: More frequent monitoring, greater access to personnel and resources Moderate-Risk: Remote Monitoring to focus limited resources and recognized complications early Low-Risk Population: Provide the patients with a set of resources to motivate and self-manage/report The best solution is a combination of: Evidence-based medicine - Lean process - Enabling technology Your Risk: $18.7M to $30.7M TLC Confidential & Proprietary
23. TLC’s Enabling Technology Discharged Patient has no primary care physician Ongoing Care Coordination Avoidable Readmissions Post-acute provider Incapability Medication confusion Family members lack proper knowledge Lack of transportation for physician follow-up OutcomesMeasurement Lack of proper home health resources Patient Engagement Poor communication between hospital and post care TLC Confidential & Proprietary
24. TLC’s Enabling Technology Discharged TLC Confidential & Proprietary
25. TLC’s Ensocare: Targeted Focus Engage and activate patients Connect patients to proper post-discharge providers Provide rapid communication among disparate providers and hospital Focus limited hospital personnel on the right patients for follow-up Understand the “why” and the “how” of readmissions Measure outcomes for all patients Why is TLC uniquely positioned to achieve these goals? 1) The process starts with discharge and provider engagement 2) TLC‘sno-cost network model encourages participation 3) TLC’s call center and service focus drives results 4) Innovative insight is provided throughmeasurement, reporting and analytics TLC Confidential & Proprietary
26. Use Case #1: Tracking Patient Flow Outside Your Hospital A high-risk patient is discharged from hospital to a post-acute facility outside of the hospital system: The post-acute facility has a free electronic system to communicate any changes in the patient’s condition The post-acute facility can access and see instructions, care plans, or other relevant information from hospital personnel Predictive analytics, built on network data, estimates readmission risk Care plan steps can be monitored with a regular frequency, automating the hospital’s watch on high-risk patients If the patient is discharged from the post-acute facility or readmitted to another hospital, hospital is notified Audit trails and outcomes reporting allows hospital to “manage their network” by tracking and monitoring the quality of clinical partners Hospital A 3 Post-Acute Facility 1 2 Patient Home Hospital B TLC Confidential & Proprietary
27. Use Case #2: Engaging Patients When They Go Home CHF patient is discharged home from a system facility: All discharge instructions and the patient’s care plan are available online for 4 weeks (set by care plan) Patients can log in from home and answer condition-specific questions to monitor their progress (i.e. Are your rings or clothes fitting more tightly?) “Yes” answers alert a Care Coordinator who intervenes and gets resources to the patient “No” answers are tracked for use at the next care opportunity If questions are not answered within a period of time, a Care Coordinator or the TLC call center reaches out to the patient to ensure the data is collected Hospital/system can set thresholds through the Care Plan to alert all relevant ACO entities of patient risk Hospital Home PCP Family Specialist Payor Pharmacy TLC Confidential & Proprietary
28. Data Analytics to Drive Outcomes To properly manage coordination networks and readmissions patterns, data analytics will be key Focus on data mining, analysis, operationalizing the results Understanding the trends of “how” and “why” readmissions or care breakdowns occur Enable comparative effectiveness studies of coordination best practices Put relevant data at the point of care to drive proven results Enabling predictive analytics Risk profiling and stratification Anticipating clinical outcomes Predicting clinical “cliffs” University of Iowa’s Computational Epidemiology Group is great example for collaboration crossing the School of Medicine with Computer Science TLC Confidential & Proprietary
29. Clinical Partnership – Adventist Health Highlighted by The Advisory Board, Adventist Health Portland is one of three “Phase 1” beta sites for TLC Part of the clinical focus Adventist brings to the partnership is how they implement risk stratification Adventist has primarily impacted inpatient care plans – working with TLC to drive post-acute planning Working with Adventist on system-wide issues around implementation of processes and building expertise into the Ensocare system TLC Confidential & Proprietary
30. Your Role Most Important - Fill out online survey www.TLChoices.com/hhsurvey Tell your medical community to use “electronic discharge” – including the VA/VISN Sign-up for TLC’s Provider Portal (Paperless Provider Feature) Respond to referral requests in 30 minutes or less Refuse to “Pay to Play” TLC Confidential & Proprietary
31. Key Outcomes TLC Confidential & Proprietary