1. Chronic Disease Management
In-Home Monitoring Tools
DATE: March 16, 2017
PRESENTED BY: Amber Hoffman, MSN RN, OHSU Telemedicine Nurse Educator

2. Current Tools Health Harmony Glooko for diabetes Health Harmony

4. Session Design Questions Y/N Response Surveys
This data is captured back in the cloud for care coordination and violations

8. Health Harmony Program online for two months
1 current service line – heart failure
1 service line coming soon – comprehensive joint replacement 8

9. Outcome Measures
What is the current data or problem trying to solve – example picking lines with high readmission rates or high mortality/infection rates. High visits or system utilization. Pick a parameter for outcomes trying to improve. Have clear outcomes. Know how long to keep patients on program – what triggers program conclusion? Transitioning off the program. 9

10. Choosing your patients
Picking Inclusion and Exclusion criteria: Able to use the technology, willing to get frequent phone calls from clinical staff, willing to submit daily assessments, have a house,
* Photo: Tori Cat at Flickr 10

11. Outsourcing options Logistics Call Center Device maintenance
Logistics – we have outsourced managing the equipment and loading the program. Various levels of logistical support available. Some programs do all logistics internally.
Call Center – First level of triage. Make sure patient is using equipment. Call when there is a red flag. Provide educational support.
Have to have clear workflows for when the calls are triaged to the provider and who the provider is. Method of contact. 11

12. Glooko for diabetes
Current Uses
Future potential

13. Call Fatigue
Need to set expectation that patient will get called with red flags – could be daily. Will be called the first few days as well. To reduce call fatigue, wait until second missed assessment to call. Need a clear communication when to call and when not to – if patient goes out of town or has a family emergency, need to be able to not get calls for afew days.

14. Provider Considerations
For chronic conditions – may not save time for the provider because they will have more contact points with the patient. For surgical, has potential to pre-triage calls to providers such as constipation complaints.
Having a call center and outsourcing distribution – Saves time on provisioning, distribution, tracking devices. Call center – Can do the first triage follow-up call and provide a targeted
We’ve just sucked one hour of your life away.
Tell me…how do you feel?
-Princess Bride

15. Future Vision
Increase the heart failure to all services. Add in additional chronic illnesses – DM, COPD. Add pediatric services – diabetes, single ventricle interstage. Add in partners through Propel. With logistics and call center support have potential to serve hundreds of patients.

16. Thank You