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

3. 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

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

5. 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.

6. Telehealth Program

7. Telehealth Video

8. 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

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

11. 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.

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