Innovation Panel - Vidant Health

Innovation Panel - Vidant Health

• 1.
  Innovation Panel MATRC March 16,2012
• 2.
  Vidant Health 1
• 3.
  Vidant Health’s Approach VH-hospitalCare Coordination VH- In-home Care Coordination VMG In-clinic Care Coordination PCP Telehealth CM Telehealth Daily care coord. Med. Rec Equip. Install 2
• 4.
  Phase Sites Vidant Chowan ECUFamily Practice Vidant Edgecombe Vidant RoanokeChowan ECHI at VMC Cardiovascular / Pulmonary Homebound Patients Cardiovascular / Pulmonary Cardiovascular / Pulmonary Heart Failure 45 25 50 30 50 3
• 5.
  Telehealth and CareCoordination Goals • Access to enhanced care coordination and post d/c remote monitoring for high-risk high-cost CVD and pulmonary patients • Expand and improve the quality of health information available to health care providers, patients and their families • Reduce health care expenditures by reducing 30-day readmissions, bed days and ER visits • Improve clinical outcomes • Improve the patient’s perception of care and patient’s quality of life. 4
• 6.
  Inclusion Guidelines • CVDand Pulmonary Disease patients who experience frequent: – hospitalizations – ER visits – less than 30 day readmissions and – require daily monitoring, health assessment and education. • Patient Activation Measurement score of Level 1 or 2 5
• 7.
  Exclusion Criteria Insufficient homeelectrical service to operate the system 6
• 8.
  The Model In-hospital Care Coordination •Hi-risk pt. Identification • Patient referral • Pt enrollment/ education • Schedules PCP visit • Medication Rec. • Schedules inhome visit In-home Care Coordination In-clinic Care Coordination Telehealth Daily care coord. • PCMH • Health Coaches Med. Rec Equip. Install • • • • • Sets parameters Daily remote monitoring Sets Weekly goals Pt. Assessment/Education PCP notification via EHR • Med. Rec • post d/c • post 1st PCP visit • Reinforces equipment instruction • Equipment install • Competency Validation 7
• 9.
  Evaluation • Demographics • Objectiveclinical data – Height – Weight – Blood Pressure – Pulse – Pulse Oximeter – LDL (every 6 months if elevated, or otherwise indicated) • A1C for uncontrolled diabetes 8
• 10.
  Evaluation • Subjective clinicaldata – Medication compliance – Nutrition compliance – Patient’s knowledge of red flags 9
• 11.
  Evaluation • Financial data •Hospitalizations – Number of hospitalizations – Patient bed days – Total charges for Hospitalization • Emergency Department – Number ED visits – Total charges for ED 10
• 12.
  Contact Information Bonnie Britton,MSN, ATAF [email protected] 252-847-6419 11