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Care%20Coordination

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Congestive Heart Failure ( CHF) Chronic obstructive pulmonary disease (COPD) ... on key aspects of care including signs and symptoms, behavior, and knowledge ... – PowerPoint PPT presentation

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Title: Care%20Coordination


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

2
VHAs Domains of Value
  • Quality
  • Access
  • Satisfaction
  • Functional Status
  • Cost Efficiency
  • Building Healthy Communities

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

4
Lifelong Health Record
Risks
Injury
Exposure
Late Illness
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
The Essence of Care Coordination
  • Patient Focused
  • Assessment Clinical needs,functional
    status,social environmental
    issues
  • Matching Clinical care from across the
    VHA continuum and
  • Monitoring Patient use, outcomes and
    quality of life.

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

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

9
Sense of Uncertainty
  • Reading the organizational thermostat
  • Nurturing the system to embrace innovation
  • Doing business differently
  • Establishing credibility through quality
  • Evidence-based approach
  • Building a bridge of trust
  • Educating staff to acceptance

Quality and Trust are first cousins. Dr. Donald
Berwick
10
Targeted Populations
  • Congestive Heart Failure ( CHF)
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes and Hypertension
  • Major Depression
  • Advanced Illness/ Palliative Care
  • PTSD
  • Caregiver Support Alzheimers, Dementia

11
Patient Selection Criteria For CHF, COPD, DM/HTN
  • 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 6 OPT visits for CHF,
    COPD, or DM/HTN in the last year

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

13
Patient Selection Criteria For Depression
  • 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 
  • GAF 35-50
  • Depression a problem for more than 6 months
  • Decreased behavioral control in clinic settings
  • ECT within the past year

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

15
Health Buddy System Components Match Standard
Practice Guidelines
16
In-home Messaging
Store Send Technology
Data
Center
17
(No Transcript)
18
Technology Solutions for Health Monitoring
Health Hero Network
Confidential
19
Health Buddy System
The system includes monitoring technologies,
clinical information databases, Internet-enabled
decision support tools, health management
programs, and content development tools.
20
Disease Management Programs
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
21
Device Integration Opportunities
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
Blood Pressure Monitors
Blood Glucose Monitors
Coagulation Meters
Peak Flow Meters
Digital Weight Scale
22
Monitoring Technologies Health Buddy Appliance
  • 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

23
iCare Desktop Work List
Daily Risk StratifiedView of Patient Caseload
24
Decision Support ToolsiCare Desktop
Application Work List
Daily Risk StratifiedView of Patient Caseload
25
Decision Support ToolsiCare Desktop
Application Results
Detailed View of Patient Results
26
iCare Desktop Trends
27
Decision Support ToolsiCare Desktop
Application Trends
Choose your own graphs and view multiple sets of
data in chart format
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.

Heart Failure Hypertension COPD
Diabetes Major Depressive Disorder
Included in VA contract, matches VHA Practice
Guidelines
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.

30
Content Development ToolsCare Composer Software
  • 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
  • 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)
  • Customization and personalization of health
    management programs to fit policies and
    procedures for any disease
  • Online review of health management programs

31
Question and Response Types
Multiple Choice
Extended Multiple Choice
32
Question and Response Types
Numeric
Range/Scale
33
Question and Response Types
Binary
34
Question and Response Types
Prompt / Education / Information
35
Audio/Visual/Real-time
Provider Station
Patient Station
36
AVIVA Pilot Projects
  • Specialty services to include
  • Consultation from Tertiary site to CBOC
  • 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
Outcome Measurement System
  • Utilization Measures - Pre and Post technology
  • Clinical Measures
  • Business and Efficiency Measures
  • Patient, Caregiver, Provider and Staff
    satisfaction

38
  • Clinical
  • Pre and Post Program Enrollment
  • CPGs for
  • CHF
  • COPD
  • DM/HTN
  • Major Depression
  • Palliative Care
  • Utilization
  • Pre and Post Program Enrollment
  • ER Visits
  • Admissions to Acute Care
  • Number of Clinic Visits
  • Satisfaction
  • Patient Survey / May 04
  • Provider Survey
  • Care Giver Survey
  • Staff Survey
  • Business
  • Total of CCHT encounters
  • Panel Size
  • patient using technology(P)

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

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