The National Implementation of Care Coordination in VA SPRY Conference Washington DC 3 rd October 2003 Adam Darkins MD, MPH, Chief Consultant for Care Coordination Department of Veterans Affairs

Mortality rates decreasing by 1% p.a. Nursing home utilization 0.7% lower p.a. Disability rates decreasing by 2.2% p.a. Over 65’s increasing by 1.5% p.a Over 85’s increasing by 2.2% p.a 2% of patients 20-30% of costs Complex needs unmatched to service delivery Patients falling through the cracks in system Changing National Trends in Long- term Care

Centers or Outpatient Home Doctor’s Office Health Clinics Rural and Regional Hospitals Referral Hospitals Primary Secondary Tertiary A: The Existing Health Care System

Smart Home Doctor’s Office B: The New Care Coordinated Health Care System Primary Web Info Telehealth Community Tertiary Regional Rural and Hospitals Referral Outpatient Health Clinics Secondary Centers or

Let technology lead services? Create financial incentives? Let a 1000 seeds bloom? Find a way to coordinate development? Getting from A to B?:

“The ongoing monitoring and assessment of selected patients using telehealth technologies to proactively enable prevention, investigation, and treatment that enhances the health of patients and prevents unnecessary and inappropriate utilization of resources. Care Coordination uses best practices derived from scientific evidence to bring together health care resources from across the continuum of care in the most appropriate and effective manner to care for the patient” Care Coordination: definition

Patient and not provider centric Designed to fill a gap in the system. Contingent on collaboration with providers. Manages chronic disease (DM, CCF, SCI, PTSD, DP WC) Expands patient and provider relationship into the home (home-telehealth technologies) Expandable from current chronic disease Model of Care Coordination

Care Coordination: outcomes Quality of life Quality of life Patient satisfaction Patient satisfaction Utilization: Utilization:

Define Model Evaluate Implement Critically Review

Care Coordination Telecom server Databases Health data repository Data is linked to Intranet and sent to VistA HOME Vital sign data Disease management data E-health information Ethernet 56k DSL Cable Intranet Patient Caregiver or Care Provider takes measurements VSB HospitalInternet Firewall Encryption PKI National VHA Care Coordination Infrastructure National VHA Care Coordination Infrastructure

Phase 1 (1999) 1,500 Patients Phase 2 (2003) 2,500 Patients Phase 3 (2004) 10-25,000 Patients Phase 4 (2005) 50,000 Patients Model of Care Coordination Program Office Technology Specifications Performance Measures Licensing and Quality Management Care Coordination Implementation

Reimbursement model Programs self-sustaining Interface care coordination and case management From management chronic diseases to ADL’s Expansion Post October 2004

Clinical Settings Clinical services Care Coordination: Making the Connection Provider Patient at Home Technology

NormalMildHigh Percent Patients 3,133 6,5078,3579,41810,745 P <.0001 Improving Hypertensives

Multi-media record including data from home Outcomes measurement R&D Shared-decision making Care Coordination

Program office for care coordination roll out Clinical input into e-health to patients Clinical input into MyHealth-e-Vet R&D Office of Care Coordination