1. 1 Care Coordination Through the Use of Home TeleHealth Technologies VHA Care Coordination Program VHA Care Coordination Program VA Healthcare Network of Upstate NY Pamela Page, APRN, BC Pamela Page, APRN, BC Behavioral Health Clinical Nurse Specialist

2. 2 VHA’s Domains of Value QualityAccessSatisfaction Functional Status Cost Efficiency Building Healthy Communities

3. 3 Mission: Mission: Coordinating the Right Care at the Right Place at the Right Place at the Right Time at the Right Time Vision: Vision: The place of residence is the place of care The place of residence is the place of care

4. 4 Lifelong Health Record Intake - Baseline Training Assignments Deployment Demobilization Discharge Retiree / Veteran Past Events Inform Future Care Risks Injury Exposure Illness Late Illness

5. Care Coordination: Definition “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”

6. 6 The Essence of Care Coordination Patient Focused Assessment: Clinical needs,functional status,social & environmental issues Assessment: Clinical needs,functional status,social & environmental issues Matching: Clinical care from across the VHA continuum and Matching: Clinical care from across the VHA continuum and Monitoring: Patient use, outcomes and quality of life. Monitoring: Patient use, outcomes and quality of life.

7. 7 Care Coordination Components Disease Management Disease Management –Knowledge / Patient Education –Symptom –Behavior Case Management Case Management –High users ( ER), high risk, frequent admissions Self Management of Chronic Disease Self Management of Chronic Disease Quality,Access, Satisfaction, Value Quality,Access, Satisfaction, Value

8. 8 Goals of Case Management Quality of Care Quality of Care Collaboration Collaboration Fiscal Responsibilities Fiscal Responsibilities Patient Advocacy Patient Advocacy Outpatient Management Outpatient Management Professional Nursing Practice Professional Nursing Practice

9. 9 Sense of Uncertainty Reading the organizational thermostat Reading the organizational thermostat Nurturing the system to embrace innovation Nurturing the system to embrace innovation Doing business differently Doing business differently Establishing credibility through quality Establishing credibility through quality –Evidence-based approach Building a bridge of trust Building a bridge of trust Educating staff to acceptance Educating staff to acceptance “Quality and Trust are first cousins.” Dr. Donald Berwick

10. 10 Targeted Populations Congestive Heart Failure ( CHF) Congestive Heart Failure ( CHF) Chronic obstructive pulmonary disease (COPD) Chronic obstructive pulmonary disease (COPD) Diabetes and Hypertension Diabetes and Hypertension Major Depression Major Depression Advanced Illness/ Palliative Care Advanced Illness/ Palliative Care PTSD PTSD Caregiver Support – Alzheimer’s, Dementia Caregiver Support – Alzheimer’s, Dementia

11. 11 Patient Selection Criteria For CHF, COPD, DM/HTN Diagnosis: COPD, CHF, or DM/HTN (with or without dementia) Diagnosis: COPD, CHF, or DM/HTN (with or without dementia) Greater than or equal to 2 hospital admissions or ER visits (VA and nonVA) in 1 year for the selected diagnosis Greater than or equal to 2 hospital admissions or ER visits (VA and nonVA) in 1 year for the selected diagnosis Greater than or equal to 6 OPT visits for CHF, COPD, or DM/HTN in the last year Greater than or equal to 6 OPT visits for CHF, COPD, or DM/HTN in the last year

12. 12 Patient Selection Criteria (cont.) Patient/caregiver able to provide signed consent and adhere to responsibilities Patient/caregiver able to provide signed consent and adhere to responsibilities Patient/caregiver has the ability to operate technology Patient/caregiver has the ability to operate technology Safe home environment (adequate electrical/phone services, scales, BP cuffs, batteries). Safe home environment (adequate electrical/phone services, scales, BP cuffs, batteries).

13. 13 Patient Selection Criteria For Depression More than 2 ER visits for depression or more than 2 off-hours calls to address depressive symptoms More than 2 ER visits for depression or more than 2 off-hours calls to address depressive symptoms 1 admission to Inpatient Psychiatry within 12 months 1 admission to Inpatient Psychiatry within 12 months GAF = 35-50 GAF = 35-50 Depression a problem for more than 6 months Depression a problem for more than 6 months Decreased behavioral control in clinic settings Decreased behavioral control in clinic settings ECT within the past year ECT within the past year

14. 14 Exclusion Criteria History of behavior that would impact the safety of staff or equipment History of behavior that would impact the safety of staff or equipment Unable to read or operate equipment Unable to read or operate equipment No phone access No phone access Depression with Psychotic features (specific to depression module) Depression with Psychotic features (specific to depression module)

15. 15 Health Buddy System Components: Match Standard Practice Guidelines

16. 16 Data Center Store & Send Technology In-home Messaging

17. 17

18. 18 Technology Solutions for Health Monitoring Health Hero ® Network Confidential

19. 19 The system includes monitoring technologies, clinical information databases, Internet-enabled decision support tools, health management programs, and content development tools. Health Buddy® System

20. Congestive Heart Failure COPD Coronary Artery Disease Hypertension Co-Morbid Hypertension/Chronic Obstructive Pulmonary Co-Morbid Congestive Heart Failure/Diabetes Diabetes Co-Morbid Diabetes/ Hypertension Co-Morbid CAD/Angina Adult Asthma Depression Bi-polar Disorder Senior Wellness Disease Management Programs

21. 21 Device Integration Opportunities Blood Pressure Monitors* Blood Glucose Monitors Coagulation Meters* Peak Flow Meters* Digital Weight Scale Open architecture can be developed to interface to a variety of home medical devices from multiple manufacturers. Multiple licensing, marketing, and distribution opportunities with medical device manufacturers

22. 22 Simple  4 button self-explanatory action  No computer skills required & easy to set up Flexible  Patients respond at their convenience  No missed phone calls/appointments  Port for connection to medical devices Timely  Immediate call-back or;  Escalations based on patient responses Monitoring Technologies: Health Buddy ® Appliance

23. 23 Daily Risk Stratified View of Patient Caseload iCare Desktop ™ Work List

24. 24 Daily Risk Stratified View of Patient Caseload Decision Support Tools: iCare Desktop™ Application Work List

25. 25 Detailed View of Patient Results Decision Support Tools: iCare Desktop™ Application Results

26. 26 View of Key Clinical Indicators Over Time iCare Desktop ™ Trends

27. 27 Choose your own graphs and view multiple sets of data in chart format Choose your own graphs and view multiple sets of data in chart format Decision Support Tools: iCare Desktop™ Application Trends

28. 28 Health Buddy System Components: Health Management Programs Health Management Programs: Interactive scripted content based on standard practice guidelines for over 45+ disease states is delivered via our monitoring technologies to educate patients, enhance medication compliance, and improve patient behavior. Health Management Programs: Interactive scripted content based on standard practice guidelines for over 45+ disease states is delivered via our monitoring technologies to educate patients, enhance medication compliance, and improve patient behavior. Heart Failure * Hypertension* COPD* Diabetes* Major Depressive Disorder* * Included in VA contract, matches VHA Practice Guidelines

29. 29 Content Development Tools Content Development Tools: Robust software tools enable health management program development, with dynamic branching logic, flexible question taxonomy, and the ability to collect variable patient responses. Content Development Tools: Robust software tools enable health management program development, with dynamic branching logic, flexible question taxonomy, and the ability to collect variable patient responses.

30. 30 Health management programs built using standard practice guidelines with focus on key aspects of care including signs and symptoms, behavior, and knowledge Health management programs built using standard practice guidelines with focus on key aspects of care including signs and symptoms, behavior, and knowledge Rich variety of question types Rich variety of question types Question taxonomy is dynamically branching to varied responses with associated risk tags Question taxonomy is dynamically branching to varied responses with associated risk tags Built-in outcomes measures including utilization and patient satisfaction, quality of life, medication compliance and individual patient population reporting (SF36v, SF12, Minnesota Living with Heart Failure Assessment) Built-in outcomes measures including utilization and patient satisfaction, quality of life, medication compliance and individual patient population reporting (SF36v, SF12, Minnesota Living with Heart Failure Assessment) Customization and personalization of health management programs to fit policies and procedures for any disease Customization and personalization of health management programs to fit policies and procedures for any disease Online review of health management programs Online review of health management programs Content Development Tools: Care Composer™ Software

31. 31 Question and Response Types Multiple Choice Extended Multiple Choice

32. 32 Question and Response Types Numeric Range/Scale

33. 33 Question and Response Types Binary

34. 34 Question and Response Types Prompt / Education / Information

35. 35 Provider StationPatient Station Audio/Visual/Real-time

36. 36 AVIVA Pilot Projects Specialty services to include Specialty services to include –Consultation from Tertiary site to CBOC ex: Cardiology VA Bath/Buffalo ex: Cardiology VA Bath/Buffalo –Increase access to care by extending services to remote areas –Increased patient satisfaction by reducing travel requirements –Potential reduction in fee costs

37. 37 Outcome Measurement System Utilization Measures - Pre and Post technology Utilization Measures - Pre and Post technology Clinical Measures Clinical Measures Business and Efficiency Measures Business and Efficiency Measures Patient, Caregiver, Provider and Staff satisfaction Patient, Caregiver, Provider and Staff satisfaction

38. 38 Utilization Pre and Post Program Enrollment  ER Visits  Admissions to Acute Care  Number of Clinic Visits Clinical Pre and Post Program Enrollment CPG’s for:  CHF  COPD  DM/HTN  Major Depression  Palliative Care Care Coordination Performance and Quality Plan Satisfaction  Patient Survey / May ’04  Provider Survey  Care Giver Survey  Staff Survey Business  Total # of CCHT encounters  Panel Size  % patient using technology(P)

39. 39 OUR PROMISE TO OUR VETERANS To empower our patients and the people who care for them To empower our patients and the people who care for them Focus on prevention not rescue Focus on prevention not rescue Respond with the Right Care, Right Place, Right Time Respond with the Right Care, Right Place, Right Time

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