Transcript CARE COORDINATION HOME TELEHEALTH

CARE COORDINATION
HOME TELEHEALTH (CCHT)
VHSO Nurses
Proud to Serve, Proud to Care
Veterans Health Care System of the Ozarks
Fayetteville, AR
Presentation by:
Patricia Bennett, RN
DEFINED AS:
• Ongoing monitoring using telehealth
technology for prevention and treatment that
enhances health of patients and prevents
unnecessary utilization of resources
• Uses best practices derived from scientific
evidence to bring together health care
resources from across the continuum of care
VISION
Patients will experience:
• Improved clinical outcomes
• Improved quality of life
Utilize CCHT programs to
promote:
• Right care
• Right place
• Right time
MISSION
• Coordinate the delivery of compassionate,
patient-centered care that anticipates patient
needs and is seamless across environments
and conditions.
• To improve and expand access to Veteran-centric,
quality distance health by leveraging internal and
external resources to improve and develop methods to
meet the needs of our veterans.
Veteran's Health Care Model Focus:
• Pts with chronic diseases
DM, HTN, CHF, COPD, PTSD,
and Depression
• Making home the preferred place of care
• Focusing on the 2-3% of pts whose treatment incurs 2030% of health care costs
• Providing non-institutional support for veteran pts
• Additional access to care
• Assisting Veteran self-management of disease
(VA ,2010)
CCHT DEMOGRAPHICS
Veteran demographics parallel the
relative burden of disease noted in
the general public sector.
• Over 65’s increasing by 1.5% per year
(Baby Boomers)
• Over 85’s increasing by 2.2% per year
(Traditionalists/Veteran)
• Multiple diseases with needs/care
mismatch
GENERATIONAL CHARACTERISTICS
Traditionalist or Veterans
Baby Boomers
Born between 1922 and 1943
Born between 1943 and 1960
 Independent
 Optimistic
 Strong family values
 Value youth
 Value health
 Respect for
authority
 Personal gratification
 Material wealth
 Loyalty
 Hard work
All are soldiers
 Hard work
8th MP Soldiers – Father & Son
(Zemke, Rains, & Filipczak, 2000)
(Gerke, 2001)
Unacceptable for our Veterans
CCHT GOALS
•
•
•
•
Improve clinical outcomes
Reduce emergency room visits
Reduce hospital admissions
Reduce clinic visits
Marketing
Getting the Word Out
• Educate PC and our new PACT (pt aligned care
teams) regarding CCHT as a benefit to the
team
Allows smooth clinic flow
Reduces walk in traffic
• Improvement in patient outcomes
• Educate on ease of consultation process
PROCESS OF CARE
Needs assessment
Finding pts that may benefit from CCHT
Inclusion Criteria
POTS (plain old telephone service) or other approved connectivity
Electric service
 PC team
 Good cognitive function or caregiver willing to utilize equipment
 Meets high utilization, high cost, or high risk for increased utilization due to
disease severity
High Risk/High Cost/ High Utilization
HgA1c 9 or above
Newly insulin dependent
BP 160/100 on more than one occasion
 In the ED 2 times in the past year
 Inpatient 2 times in the past year
 Compliance issues with medication
10 clinic visits in one yr or 2 specialty
providers
EXCLUSION CRITERIA
• Patient does not have a plain old telephone or
ability to connect to internet
• HgA1c or BP not really out of range
• Patients that decline participation
• Documented violence or aggression
Consultation form
QUESTIONS FROM PATIENTS
•
•
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How much does it cost?
Will my Dr. still know what is going on?
Who adjusts my medications?
Does the Telehealth Equipment interrupt my phone service?
• How does it send you the information?
• Do I have to do my sessions at the same time everyday?
• What about vacation?
• Can I take my spouse’s BP?
• Do I have to pay for broken equipment or lightning strikes?
• Can anyone see in my house?
The Journey
CCHT started – DM
HTN
COPD, CHF, MH
Monitor & Adjust
PTSD Palliative Care
Looking ahead
2011-2012 More emphasis on managing CHF and
more mental health patients
CCHT MEASURES
Care Outcome Measures
• Lower HgA1c (7 or below)
• Lower BP (140/90 or 130/80)
Process Measures
• Lower utilization/Inpatient stays
30% decrease meets target
40% exceeds target
• Increase participation
Fayetteville exceeds each enrollment target
Fayetteville
VISN 16 Bed Days of Care (BDOC) % CHANGE QUARTERLY
REPORT FY10 Performance Monitor Scoring:
 30% Reduction meets target
 40% Reduction exceeds target
VHSO continues to exceed the target in reducing BDOC
BDOC % Change FY 10
B
E
S
TB
E
T
T
E
R
0.0
-10.0
% Change
-20.0
-30.0
-40.0
-50.0
-47.0
-54.0
-60.0
-70.0
-48.0
-58.0
-67.0
FAY
-66.0
-68.0
-80.0
-90.0
-100.0
-93.0
3rd Qtr
1st Qtr
2nd Qtr
4th Qtr
FAY
-67.0
-58.0
-93.0
-68.0
V16
-66.0
-47.0
-54.0
-48.0
V16
B
E
T
T
E
R
B
E
T
T
E
R
WHAT NEXT?
• Increased CHF focus
• Increased Mental Health focus
• Technology changes
Questions ?
References:
Gerke, M.L. (2001, September). "Understanding and leading the quad matrix:
Four generations in the workplace: The traditional generation, boomers,
gen-x, nexters,“ Seminars for Nurse Managers 9 173-181.
VA, (2010). VISN 16 Distance Health Program Care Coordination Home
Telehealth , Operations Manual. Author. Retrieved March 23, 2011 from
http://vaww.visn16portal.va.gov/SiteDirectory/diag/cccht/
Zemke,R., Raines, C., Filipczak, B. (2000). Generations at Work: Managing the
Clash of Veterans, Boomers, Xers and Nexters in Your Workplace . New
York: Amacom.