2.  Discussing Vidant Health’s Telehealth & Care Transitions Program  Discussing VH’s Telehealth Outcomes

4. 4 ◦ Shift focus from hospital to coordinating patient care transitions ◦ Define & implement standardized risk stratification tools ◦ Standardize post acute care services  Remote patient monitoring services  Transitions in care  Chronic Disease Management  Care Transitions  Health Coaches  Telephonic follow-up

5. Patient Risk Assessment Completed by Hospital Case Managers Hi Risk Social Issues/ Frailty Telehealth & Transitions in Care Program Medium Risk VMG patient Daily biometric data Low Risk Telephonic Services TIC services Consider Telephonic Service TH Transitions in Care TIC Services Non VMG patient Health Coach Consider TIC services

6. 6 ◦ PAMI & II ◦ DxAny chronic disease ◦ Readmissions< 30 day ◦ ED visits4 + ◦ Medications6+ ◦ Social issuesHomelessNo Transportation No PCPUn/underinsured

7. 7 ◦ Remote Patient Monitoring  Referred from hospital or clinic  Enrolled in hospital or home  Home Visit- Med. Rec. & train/competency validate patient/home safety assessment  Daily biometric data monitoring / Daily phone calls for abnl parameters  Weekly telephonic assessment, education, coaching  Staff ratio: 1 -85 – 100 patients ◦ Care Transition Services  Enrolled in hospital  Hospital visit  Home Visit(s)- med. Rec. and patient education  Phone Calls  Attend MD Visits  Staff ratio: 1- 18 – 30 patients

8. ◦ Clinical Data  LDL, BP, Pulse, Height, Weight, HgA1c, oxygen saturation ◦ Patient Satisfaction ◦ Financial Outcomes- 90 days pre TH, during TH, 30 days post TH  Hospitalizations  Bed Days

9. Demographics N=926

12. N= 926

14. 14

15. 15 Decreased by 69% Prior to During Decreased by 76% Prior to Post

16. 16 Decreased by 67% Prior to During Decreased by 81% Prior to Post

18. 18  PAMIII  DxDementia, Mental Illness, Substance Abuse, new chronic disease  Readmissions<30 day with Obs. Within 60 days  ED visits2 +  MedicationsAnticog./insulin/glycemic, Dig., Phenobarbital, Lithium  Social IssuesUnstable housingRelay on others Multiple PCPsInability to pay

19. 19  Remote Patient Monitoring- Transitions in Care  Care Transitions services ◦ Enrolled in hospital ◦ Hospital visit ◦ Home Visit(s)- med. Rec. and patient education ◦ Phone Calls ◦ Attend MD Visits ◦ Staff ratio: 1- 18 – 30 patients  Health Coaches ◦ Enrolled in PCP Clinic ◦ Phone Calls ◦ Coaching- telephonic and in-clinic ◦ Coordination of services

20. 20  PAMIII or IV  DxTBD  Readmissions0  ED visits 0-1  Medications< 6  Social IssuesStable housingPCP Insurance

21. 21  Telephonic follow-up/education  Patient identified in-hospital & clinic