10/22/2015 Provider Educational Seminar Care Management: Part II 10/22/2015

Automated, telephone-based telemonitoring system Patients self-report physiologic parameters (using durable medical equipment) and answers pre-recorded disease-specific questions Algorithms designed to detect worrisome trends or responses which automatically alert the nurse 10/22/2015 Presented by: Johns Hopkins HealthCare Care Management: TeleWatch-Telemedicine System

Medication use and adherence Exacerbations Urgent care/Inpatient utilization Appointment follow-up Overall action plan and goals Immunization history Test requirements and results 10/22/2015 Presented by: Johns Hopkins HealthCare Care Management: Monitoring Members

TeleWatch Version 1.0: 10/22/2015 Presented by: Johns Hopkins HealthCare Care Management: Automating Disease Management

Identification of members  Population analysis Clinical outcomes  Lab value  Medication usage  Biometrics (BP, HR)  Program specific (birth weight, NICU admits, A1c, Influenza vaccine, CD4/viral load Utilization Outcomes  Hospital admissions, length of stay  ER admissions Satisfaction  Patient/caregiver  Provider 10/22/2015 Presented by: Johns Hopkins HealthCare Care Management: Uses of Data

Units within: Inpatient team Intake services Medical review Transitional care Behavioral health 10/22/2015 Presented by: Johns Hopkins HealthCare Care Management: Utilization Management

Overview: Coordinator acts as liaison between the member, Priority Partners, health providers, and government agencies Provides interpreter services 10/22/2015 Presented by: Johns Hopkins HealthCare Care Management: Special Needs Coordination

Members with chronic illness often have non-health related issues that may impact their ability to focus on their health Social workers support clinical staff on a variety of issues such as:  Housing  Non-covered benefits  Food  Domestic violence  Transportation  Community resources 10/22/2015 Presented by: Johns Hopkins HealthCare Care Management: Social Work