Extending Case Management Using Telehealth Josi DeHaven, MPH, BSN, RN, CCM Manager, Ambulatory Care Coordination and Diabetes Education Goshen Health System, Goshen, Indiana

Care Coordination across the Continuum Hospital Providers, Acute Care Coordinator and Social workers Outpatient Educators, Therapists, Health Coaches Nurse On Call Community Resources Real Services, APS, Council on Aging SNF Nurse Liaison and care conference planning ER Providers, Nurses, and Acute Care Coordinators Health Care Partners Home Home Care nurses and Social Workers Ambulatory Care Coordinators Informed, Engaged Patient/ Caregiver Prepared, Proactive PMCH Team Productive Interactions Patient-Centered Medical Home

Goshen Health Ambulatory Care Coordination Model Self-management Support Care Coordination Resources

Goshen Health Ambulatory Care Coordination Model Self-Management Care Coordination Resources Patient demonstrates appropriate response to s/s which require additional follow-up Engaged caregiver/support system Medication management plan Utilize resources independently (appointments, transportation) Patient demonstrates knowledge of their plan and coordinates and communicates their own plan/care. No recent hospital utilization Defined medical treatment plan in place PCP and patients agree on goals of care Patient not expected to die in the next 12 months Health-related needs are met currently, with plan in place for future needs Connection to community resources to assist with future needs. Resources in place which support self-management plan Patient demonstrates engagement with care coordination program. Success Telehealth is part of all 3.

Telehealth Program

Telehealth Video

Telehealth Disease Management COPD 8 week video education Action Plan and Activity Hypertension 4 week video education Meds and Monitoring Heart Failure Daily weights and Action Plans Diabetes 12 month program Glucose Monitoring and quarterly engagement activities

Used with permission: http://www.livingwellwithcopd.com/ Curriculum Used with permission: http://www.livingwellwithcopd.com/

Why Telehealth? Video telehealth improves relationship based care. Patient-reported data supports disease self-management. Telehealth in context of care coordination supports appropriate utilization of resources.

Telehealth Next Steps Population-specific programs Scalable and Sustainable Models Cross-continuum Implementation Population-specific programs