Transcript PowerPoint - GRECC Audio Conferences

Technology-Assisted Care
Coordination for Chronic Disease
Management in the Elderly
Stuti Dang, MD, MPH
Clinical Director, T-Care and TLC for Dementia
Miami VA GRECC & Medical Center
University of Miami Miller School of Medicine
GRECC Audio Conference, May 26th, 2011
1
Objectives
 Understand definitions of care
coordination and home telehealth
 Discuss examples of technology assisted
care coordination for chronic diseases
 Review proposed reasons for technologyassisted care coordination to work
 Recognize work ahead
2
Problems With Current System
 Increasing number of complex older
patients with chronic diseases
 Disproportionate health care resources
 Fee for service payment structure
 Fragmentation and duplication
 Rapidly escalating health care costs
 Health care delivery system is under
stress with shrinking resources
3
Average Annual Per Capita Spending for Patients
with Different Numbers of Chronic Conditions
Bodenheimer T, et al., N Engl J Med, 2009; 361:1521-1523.
4
Institute of Medicine
Priorities for national action (2003):
Transforming Health
Care Quality
-Increased demands
-Poorly coordinated care
-Inadequate implementation
of information technology
in health care
5
Care Coordination Definition
 “Care coordination” is a client-centered,
assessment-based interdisciplinary approach
to integrating health care and social support
services in which an individual’s needs and
preferences are assessed, a comprehensive
care plan is developed, and services are
managed and monitored by an identified care
coordinator following evidence-based
standards of care.
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Brown R, in a report commissioned by the National Coalition on Care Coordination,
in 2009, at http://www.socialworkleadership.org/nsw/Brown_Full_Report.pdf
Impact of Care Coordination
Interventions
Nurse/SW directed, multidisciplinary
interventions in high risk patients
 Reduced hospital admissions
 Significantly reduced cost
 Improved quality of life for patients and
caregivers
 Improved satisfaction of care
Rich MW, et al., N Engl J Med, 1995;333(18):1213-4.
Naylor MD, et al., JAMA, 1999;282(12):1129 – 36.
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Care Coordination Interventions
 Transitional care
 Self-management education: short
community-based programs to “activate”
patients in disease self management
 Coordinated care: patients with chronic
conditions at high risk of hospitalization,
provide care planning, monitoring of
patients’ symptoms and self-care, working
with the patient, PCP and caregivers
Coleman EA, et al.,Arch Intern Med. 2006 Sep 25;166(17):1822-8.
Lorig KR et al. Eff Clin Pract. 2001 Nov-Dec;4(6):256-62.
Peikes D, et al. JAMA. 2009 Feb 11;301(6):603-18.
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Medicare Coordinated Care
Demonstration (MCCD)
 Only 3 of the 15 programs effective
 Six key components
Targeting
In-person contact with patients
Timely information on admissions
Close interaction between care
coordinators and PCP: face-to-face and
same care coordinator
 Services provided
 Staffing: nurses, social workers
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Peikes D, et al. JAMA. 2009 Feb 11;301(6):603-18.
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Would Adding Technology
Enhance the Model??……..
 Technology assisted care coordination
may provide an effective and efficient
alternative to providing care
coordination the traditional way
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Telemedicine Definition
 “...the use of electronic information
and communications technologies to
provide and support health care when
distance separates the participants...”
Field MJ, et al., Institute of Medicine: Telemedicine: A Guide to Assessing
Telecommunications in Health Care, 1996.
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Telehealth Definition
 Telehealth (or Telemonitoring) is the use of
telecommunications and information
technology to provide access to health
assessment, diagnosis, intervention,
consultation, supervision and information
across distance.
 Includes use for clinical and non-clinical
services such as medical education,
administration, and research.
Center for Medicare and Medicaid Services, 2010, at https://www.cms.gov/Telehealth/12
Care Coordination
 The Veterans Health Administration
defines care-coordination as the
“wider application of care and case
management principles to the delivery of
health-care services using health informatics,
disease management, and telehealth
technologies to facilitate access to care and
improve the health of designated individuals
and populations with the intent of providing
the right care in the right place at the
right time.”
http://vaww.telehealth.va.gov/telehealth/ccht/index.asp#info
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Technology-Assisted Care Coordination
Model for Chronic Disease
Better Health
Outcomes
Decreased
Cost
Increased
quality
Monitoring
Education
Feedback
Peer Leaders
Caregivers
Pharmacy
Patients at home
HTN, DM, COPD, CHF,
Asthma, depression,
PTSD
Specialists
Primary Care
Providers
Education
Non VA
Providers
Support
Feedback
Care coordination
team
Support
Technologies
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15
Blood Pressure Graph For a Patient
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Technology Assisted
Care-Coordination
Some Examples
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Telephone-based Management
Telephone calls with RN follow-up
 Biweekly automated telephone calls
 Maximum benefit when A1c>8% (net effect
- 0.5 – 1.1%)
Mobile phone and SMS messaging
 Patients sent glucose result via phone,
received message from nurse
 Decrease in A1c by 1.1% over 12 weeks
Piette JD, et al., Diabetes Care, 2001;24(2):202-8.
Kim HS, et al., Int J Nurs Stud, 2007;44(5):687-92.
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Web-based Management
 104 Veterans with diabetes, HbA1c 9.0%
 Web-based care management: notebook
computer, glucose and blood pressure
monitoring devices, and access to a care
management website, messaging system
 At 12 m, lower A1C, BP, HDL (P < 0.05)
 More improvement in persistent users and
with larger number of website data uploads
McMahon G, et al., Diabetes Care, 28:1624–1629, 2005
19
IDEATel - Informatics for Diabetes
Education and Telemedicine
METHODS
 Telemedicine home unit with
videoconferencing and case management
 Randomized trial with a usual care group
 Five year follow up
 Medicare beneficiaries (n= 1665)
 Diabetes, >55 years, medically under-served
areas in NY (upstate and NYC)
Shea S, et al., JAMIA, 2006;13(1):40-51.
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IDEATel Results
 Modest clinical effects
 Small but significant changes
 A1c (0.29%), SBP (4.3 mm Hg), Lipids (3.8 mg/dl)
 Reduced waist circumference and BMI
 Increased diet and exercise knowledge
 No mortality benefit
 Costs
(Likely under-powered)
 $622 per person per month
 Mean Medicare payment in UC $9040
versus IDEATel $9669 per person per yr
Moreno L, et al., Diabetes Care, 2009;32(7):1202-4.
Palmas W, et al., J Am Med Inform Assoc, 2010;17(2):196-202.
Izquierdo R, et al., Diabetes Therapeutics and Technology, 2010;12(3):213-20.
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The Diatel Study
 Active Care Management + Home
Telemonitoring (ACM+HT=73) Vs. Monthly Care
Coordination Telephone Call (CC = 77)
 Blood glucose, BP, and weight daily in ACM+HT
 ACM+HT had larger decrease in A1c at 3
months (1.7 vs. 0.7%) and 6 months (1.7 vs.
0.8%; P<0.001 for each)
 Frequency of self monitored blood glucose did
not correlate significantly with reduction in A1c
Stone RA, et al., Diabetes Care, 2010;33(3):478-84
22
Multicenter Randomized Trial on
Home-based Telemanagement
 460 patients with heart failure – 230 each
 HBT received a portable device to transfer a onelead trace to a nurse by telephone
 HBT group had
 lower risk of readmission compared with the
Usual Care group (RR = 0.56; 95% CI: 0.38–
0.82; p = 0.01)
 lower risk of heart failure-related readmission
(RR = 0.49, 95% CI: 0.31–0.76; p = 0.0001)
 No significant difference in cardiovascular
mortality
Giordana A, et al., Int J Cardiology, 2009;131(2):192-9
23
Telemonitoring to Improve Heart
Failure Outcomes (Tele-HF)
 1,653 recently hospitalized patients at 33 centers
 Telephone-based interactive voice-response system,
daily information on symptoms and weight
 No difference in all-cause mortality (11% both
groups) or hospital readmission for any reason
(49.3% vs. 47.4%; P=0.45) at six months
 14% did not use system; 55% used at 6 months
 Increase contact, formal education, medication
management, or peer support to enhance
 Caution about investment in unevaluated disease
management protocols and processes
Chaudhry S, et al., NEJM, 2010;363(24):2301-9
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Effectiveness of Home Blood Pressure
Monitoring on Hypertension Control
 Three-arm randomized controlled trial for 12 m
 778 pts, age 25–75, with Internet access
 Interventions—(1) BP monitoring and secure patient
website training (BPM-Web); (2) BPM-Web plus
pharmacist care management via web
 Results:
 BPM-Web: nonsignificant increase in % with controlled
BP compared to UC (36% vs 31%; P = .21)
 BPM-Web-Pharm: significant increase in % with
controlled BP (56%) vs. UC and BPM-Web (P <.001)
 No difference in PCP, ER or inpatient use
 Increased web and phone contact in BPM-Web-Pharm
Green B, et al., JAMA, 2008; 299(24): 2857–2867.
25
Telemonitoring for COPD –
a Systematic Review
 9 original studies with 858 patients
 Home telehealth
Reduced rates of hospitalizations
Reduced emergency department visits
Bed days of care varied
Increased mortality based on 3 studies
(Risk Ratio 1.21; 95% CI 0.84-1.75)
 Improved quality of life
 Improved patient satisfaction
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Polisena J, et al., J Telemed Telecare,2010;16:120-127.
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Other Chronic Diseases
 Interactive asthma education
 Access to a website:
 Increased asthma knowledge, reduced symptom
days, fewer ER visits, lower steroid doses
 Weight management using ecounseling
 Greater weight loss with website access and
e-counseling
Krishna S ,et al., Pediatrics 2003; 111: 503-510
Tate DF,et al., JAMA 2003; 289: 1833-1836
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Improvement in Cardiovascular
Risk Despite Clinical Inertia
Dang S, et al., Diabetes Therapeutics and Technology, 2010;12:995-1001. 28
Veterans Health Administration’s
Telehealth Interventions
 Care Coodination Home Telehealth
(CCHT) with over 40,000 Veterans


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diabetes mellitus (48.4%)
hypertension (40.3%)
congestive heart failure (24.8%)
chronic obstructive lung disease (11.4%)
depression (2.3%) and PTSD (1.1%).
 Reductions in admissions (19.7%)
and bed days of care (25.3%)
Darkins A, et al., Telemed J E Health, 2008 Dec;14(10):1118-26.
Hill RD, et al., Am J Manag Care, 2010;16, e302-e310.
http://www.carecoordination.va.gov/telehealth/ccht/index.asp
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Reduction in Utilization by
Condition Monitored in the VHA
Condition
# of Patients
% Decrease
Diabetes
8954
20.4
Hypertension
7447
30.3
Chronic Heart Failure
4089
25.9
Chronic Obstructive
Pulmonary Disease
1963
20.7
Post Traumatic Stress
Disorder
129
45.1
Depression
337
56.4
Other Mental Health Condition
653
40.9
Single Condition
10885
24.8
Multiple Conditions
6140
26.0
Darkins A, et al., Telemed J E Health, 2008 Dec;14(10):1118-26.
Hill RD, et al., Am J Manag Care, 2010;16, e302-e310.
http://www.carecoordination.va.gov/telehealth/ccht/index.asp
Key Contributions of VHA to
Teleheath Care Coordination
 Broadest spectrum of veteran patients
 Targeting the non institutional care (NIC) patients
 Standardized procedures for ensuring the security
of patient data
 Highlighted the role of the computerized patient
record as a fundamental prerequisite
 National training program focused on rapidly
training staff in care coordination
 Standardization of the clinical, educational,
technical, business, and organizational elements
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Why Might TechnologyAssisted Care Coordination
for Chronic Disease
Management Work?
32
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Chronic Care Model ~
Care Coordination + Technology
Benefits stem from re-engineering care, not
from addition of technology
 Patients self-manage
 Just-in-time versus just-in-case care
 Proactive not reactive
 Continuous not episodic
 Integrate technology into care system
 Integrate available resources
 Redesign the system
34
Interactive Behavior Change
Technology (IBCT)
 Any hardware and software to promote
and sustain behavior change
 Assists patients and clinicians in monitoring
 Assists enhanced frequent communication b/w
patients and providers and caregivers
 Provides ongoing self-management education
and support
 Enables patients’ efforts to change behavior
 Feedback to providers enables changes in
treatment regimens and without office visits
Piette JD,et al., Diabetes Care, 2007;30(10):2425-32.
35
Other Potential Benefits of
Technology in Care Coordination
 Case management by exception
 Enhanced efficiency of care provision
 Cost effective approach to manage large
populations
 Centralized data management
 Potential cost savings
 Access to care
 Decrease travel time
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Technology-Assisted Care
Coordination –Where does it stand?
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Establishing programs is feasible
Can complement the ability to assess,
monitor, educate, and support patients
Technology has limitations
Some clinical benefits demonstrated
Limitations in study design
Questions regarding impact on health care
utilization, mortality, and cost
Questions regarding design
Technology is a tool
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Technology is a tool –
Circle of Management
 Reliable measure of the correct
physiological variable(s)
 Efficient transmission of information
 Information received by personnel
qualified to recommend an appropriate
and effective intervention
 Patient must correctly implement the
intervention
 Reassessment
Desai A and Stevenson LW. NEJM, 2010; 363:2364-2367
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Current and Perceived Challenges
People: politics, relationships, provider, patients
Cost: capitalization, operations, sustainability
Difficult outside an integrated delivery model
Reimbursement: unaligned incentives/payments
Regulatory: licensure, credentialing, malpractice
liability and jurisdiction, protected health
information
 Limitations of technology
 Systematic protocols, best practices, and
standards
 Lack of adequate outcome data
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Kang ,et al., J Am Geriatr Soc, 2010; 58:1579–1586.
Dang, et al., Telemedicine and e-Health, 2006; 12(1):14–23.
39
Work Ahead…
 Evidence on cost, effectiveness, and best
practices, and guidelines
 Collaboration between clinicians, patients,
academia, industry, and health policy-makers
 Healthcare system reform
 Integrated delivery models
 Payment reform and aligned incentives
 Regulatory and licensure changes
 Interoperability of systems and devices
 Robust, fail-safe systems and operating procedures
 Interoperability of systems and devices with the
creation of a single end user interface interoperable
with multiple applications and providers
Kang, et al., J Am Geriatr Soc,2010; 58:1579–1586.
http://www.ntia. doc.gov/reports/telemed/privacy.htm
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Interoperability of Systems
and Devices
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Work Ahead…
Issues for Ongoing Research
 Ideal design: technology, professional, patients, protocols
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Ideal parameter(s) to monitor
Episodic vs. continuous enrollment/eligibility
For what purpose: prevention, disease management
Frequency of monitoring
Frequency of communication
 How to assess technology’s contribution as distinct
from other components of care
 Impact on health care utilization, mortality, and cost
Dang, S., et al., (2009). Telemedicine and e-Health. 15 (10),1-14.
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Health Care Costs are Rising
43
Source: CBO
The Health Care Imperative
Decrease
Cost
Improve
Outcomes
/Quality
44
Patient Protection and Affordable
Care Act – Public Law 111-148
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Accountable Care Organizations
Patient Centered Medical Home
Partially Capitated
Fully Capitated
 Independence at Home Project
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“I don’t want to talk to the doctor, I want my
symptoms to go straight through to your computer!”
46
Special Thanks to:
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Office of Telehealth, VISN 8, and Sunshine Training Center
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Office of Geriatrics and Extended Care and GRECC
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Tom Edes, MD
Ken Shay, DMD
Miami VAHS
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Adam Darkins, MD
Pat Ryan, MSN
Rita Kobb, MSN
Bernie Roos, MD
Adam Golden, MD, MBA
Hermes Florez, MD, MPH, PhD
Jorge Ruiz, MD
Enrique Aguilar, MD
Herman Cheung, PhD
Past and present care coordinators, fellows, and students
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Technology-Assisted Care
Coordination: Design Questions
 Ideal intervention
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Technology
Professional
Patients
Protocols
Ideal parameter(s) to monitor
Duration
Frequency of monitoring
Frequency of communication
Relative contribution of technology vs. coordination
Dang, S., et al., (2009). Telemedicine and e-Health. 15 (10),1-14.
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It's Not About The Technology

Most patients are comfortable and
adapt to technology

Technology has its limitations
 Patients’ willingness ability to use
 Providers willingness to be part of it
 Health informatics and sufficiently
robust
 IT infrastructure can be implemented
50
Issues Plaguing
TeleCare Coordination
Evaluation Issues
Lack of adequate outcome
data
Few systematic comparative
studies that assess effect on
quality, accessibility, or cost of
health care
 Unmatched retrospective analyses
using a single-group study design
 regression to the mean
Essential Transformational Elements:
Patient (Veteran) Centered Care
 Delivering “health” in addition to “disease
care”
 Veteran as a partner in the team
 Empowered with education
 Focus on health promotion and disease
prevention
 Self-management skills
 Efficient Access
 Visits
 Non face-to-face
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Telephone
Secure messaging
Telemedicine
Others?
ACP Medical Home Builder
Modules
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Patient-Centered Care & Communication
Access & Scheduling
Organization of Practice
Care Coordination & Transitions of Care
Use of Technology
Population Management
Quality Improvement & Performance
Improvement
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Technology-Assisted Care:
Research Questions
 Who benefits most? And from which
technologies?
 How long? In which setting? For what
purpose, e.g., prevention, disease
management?
 How to assess technology’s contribution as
distinct from other components of care
 Chronic disease management (T-Care and TLC)
 Health promotion and disease prevention (MOVE)
 Patient safety and medication reconciliation for
community-based dependent elderly
U.S. Health Care Spending
In 2009, the U.S. spent
$2.53
TRILLION
on Health Care
56
Home Telemonitoring for Heart
Failure: Systematic Review
 Twenty-five original studies (3062 patients)
 A random effects model was used to compute
average treatment efficacy
 Reduced mortality (RR 0.66, 95% CI 0.54 to 0.81,
P < 0.0001) compared with usual care and CHFrelated hospitalizations (RR 0.79, 95% CI 0.67 to
0.94, P = 0.008)
 Several studies suggested lower the number of
hospitalizations, improved quality of life and
satisfaction
Polisena J, et al., J Telemed Telecare, 2010;16(2):68-76.
57
Patient Protection and
Affordable Care Act –
Public Law 111-148




Accountable Care Organizations
Patient Centered Medical Home
Partially Capitated
Fully Capitated
 Independence at Home Project
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Communication Links that could be
Targeted by Interactive Behavior
Change Technology
Piette JD, Diabetes Care, 2007;30(10):2425-32.
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Care Coordinator Role
 Licensed health care professionals who
assess and monitor patients using home
telehealth
 Detect changes in chronic diseases and
conditions
 Identify and coordinate services across a
continuum of care
 Provide education and emotional support
for frail patients with complex clinical
needs
60
Care Coordination Definition
Veterans Health Administration definition:
“process of assessment and on–going
monitoring of selected patients using
telehealth to proactively enable prevention,
investigation, and treatment that enhances
the health of patients and prevents
unnecessary and inappropriate use of
resources. This process allows for the
appropriate information to be
communicated to providers and the
healthcare system to assure the right care,
at the right place, and at the right time. ”
61
http://vaww.telehealth.va.gov/telehealth/ccht/index.asp#info
Types of Applications
 Store and Forward
 Remote Monitoring
 Interactive Services
http://www.answers.com/topic/telemedicine#Types_of_telemedicine
62
Patient Centered Goals of
Care Coordination
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Medical, preventive and psychosocial needs
Ensure appropriate and comprehensive care
Make the patient a partner in his/her care
Promote communication
Guide through a maze of services
Match need with funding and resources
Maximum cost effective use of resources
Maintain function and independence to
enable person to remain in the most
independent environment
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REMOVE Care Coordination
Definition
“the deliberate organization of patient care
activities between two or more participants
(including the patient) involved in a patient's
care to facilitate the appropriate delivery of
health care services. Organizing care involves
the marshalling of personnel and other
resources needed to carry out all required
patient care activities, and is often managed
by the exchange of information among participants responsible for different aspects of care.
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies.
64
Agency for Healthcare Research and Quality (US); 2007
Current and Perceived Challenges
 Physician skepticism of new healthcare
models
 Coordination outside of an integrated delivery
model
 Reimbursement - Payment reform and
aligned incentives
 Interoperability of systems and devices
 Developing the evidence
 Caution about increased use and
investment in unevaluated technologies
 Integrate into existing practice and process
65
 Identify best practices
Challenges Ahead…Technology
 Robust, fail-safe systems and
operating procedures for lay people
 Hardware and software with the
creation of a single end user
interface interoperable with multiple
applications and providers
 Safe, reliable, and secure
 FDA approval
http://www.ntia. doc.gov/reports/telemed/privacy.htm
Mahoney DM, et al. Telemed J E Health 2008;14:224–234.
66
The Future…….
 Dialogue between clinicians and
patients and between academia,
industry, and health policy-makers
 regulatory and licensure needs
 Early real-world testing of technology
and collection of cost effectiveness data
 Guided by geriatrics providers, patients
and caregivers
Kang, et al., J Am Geriatr Soc,2010; 58:1579–1586.
67
Care Coordination
 The Veterans Health Administration
defines care-coordination as the
“wider application of care and case
management principles to the delivery of
health-care services using health informatics,
disease management, and telehealth
technologies to facilitate access to care and
improve the health of designated individuals
and populations with the intent of providing
the right care in the right place at the
right time.”
68
But Needs Caution…….
 Nurse care management
- 246 patients, A1c 9.3%
- Nurse care management using
algorithms; follow-up over 18 months
- No difference in A1c, BP, lipids
- Intervention resulted in greater
satisfaction with diabetes care
Gagnon AJ, et al., J Am Geriatr Soc, 1999;48(5):596-7.
Boult C, et al. J Am Geriatr Soc, 2000;48(8):996-1001.
69
70
IDEATEL – Change in A1c
Shea S, et al., JAMIA, 2009;16(4):446-56.
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Technology-Assisted Care:
Some Recent Answers
 Real Time Transmission of Data
 1 year controlled parallel group trial
 Intervention group assigned to teleassistance system using real
time transmission of FSBG with immediate reply when needed +
Telephone consultation
 Control Group
 328 T2D from 35 family practices in Spain
 At 12 months


Intervention group with in A1c (7.62 ±1.60 to 7.40 ±1.43; P=0.025)
and significant in blood pressure, total and LDL cholesterol, and BMI
Control Group with in A1c (7.44 ±1.31 to 7.35 ±1.38; P=0.303) and
only decrease in LDL cholesterol
 Feasible in primary care setting
Rodriguez-Idigoras MI, et al., Diabetes Therapeutics and Technology, 2009
;11(7):431-7.
72
Care Coordination Definition
Veterans Health Administration 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“
Case management is the foundation of care
coordination.
VHA Office of Care Coordination, 2003
73
Improvement in Cardiovascular
Risk Factors Despite Clinical Inertia
180
160
140
120
SBP
mmHg
100
80
p=0.03
p=0.09
60
40
20
0
No Clinical Inertia
Baseline
Clinical Inertia
T-Care 2 Years
n = 46; Clinical Inertia is the lack of dose adjustment or initiation of a new medication for BP or lipid
74
management when indicated according to practice guidelines. For BP medication: 10.8%; for lipid
medication: 15.5%. Dang S, et al., Diabetes Therapeutics and Technology, 2010
E-Health
 e-Health is broader than
either telemedicine or telehealth and can
be described as an emerging field in the
intersection of medical informatics,
public health and business, that enables
health services and information to be
delivered or enhanced through the
Internet and related technologies.
(http://www.biohealthmatics.com/healthinf
ormatics/ telemedicine/telemed.aspx )
75
Reduction in Utilization
by Condition Monitored
Condition
# of Patients
% Decrease
Diabetes
8954
20.4
Hypertension
7447
30.3
Chronic Heart Failure
4089
25.9
Chronic Obstructive
Pulmonary Disease
1963
20.7
Post Traumatic Stress
Disorder
129
45.1
Depression
337
56.4
Other Mental Health Condition
653
40.9
Single Condition
10885
24.8
Multiple Conditions
6140
26.0
76
Reimbursement
 Provider - same Common Procedural
Terminology (CPT) code, and add
Healthcare Common Procedure Coding
System (HCPCS) modifier code ‘‘GT’’
 Patient site:
 Telehealth Originating Site Facility Fee CPT/HCPCS code Q3014
 Appropriate clinical code for a separate face-toface visit to account for clinical activities
 Store and forward - CPT 99090
77
Reimbursement – Medicare
Limitations
 ‘‘Originating site’’ - non-Metropolitan or a
rural health professional shortage area
 Specific CPT codes - consultations, general
office visits, psychiatry, psychotherapy,
pharmacological management, end-stage
renal disease services, and nutrition
 Particular providers - physician, mid-level
practitioner, nurse–midwife or clinical nurse
specialist, psychologist, social worker, and
registered dietitian or nutritionist
78
List of Medicare Telehealth Services. Vol Pub 100-04 Medicate Claims Processing:
CMS Manual System; 2005
 Issues for Ongoing Research
 While much has been learned since
the earliest care coordination efforts
and the components
 of effective interventions can now be
specified with a substantial
probability of success, much
 remains to be learned. The key issues
for which greater clarity is required
are:
79
Major Forces Driving Health Care
into the Home
 Aging of the U.S. population
 Epidemics of chronic diseases
 Technological advances
 Health care consumerism
 Rapidly escalating health care costs
80
 . The LifeMasters Demonstration
program is a population-based
program targeting people dually
eligible for Medicare and Medicaid
with particular diagnoses and is also
at financial risk for program fees.
Enrollment through January 2006 was
50,654 (36,182 of whom were in the
treatment group). LifeMasters’ fees
are lower because it is not providing
prescription drug coverage. The
81
Improvement in Cardiovascular
Risk Factors Despite Clinical Inertia
180
160
140
120
SBP
mmHg
100
80
p=0.03
p=0.09
60
40
20
0
No Clinical Inertia
Baseline
Clinical Inertia
T-Care 2 Years
Clinical Inertia is the lack of dose adjustment or initiation of a new medication for BP or lipid
management when indicated according to practice guidelines. For BP medication: 10.8%; for lipid
medication: 15.5%.
TLC and Caregiver Burden
40
35
Zarit
Burden
Interview
Score
*
30
25
p<0.05
*
20
15
10
5
0
n=113
n=60
Overall
Black
Baseline
Hispanic
TLC
Dang et al. J Telemed Telecare 2008;14:443-447.
White
TLC and Caregiver Depression
25
20
15
CES-D
Score
10
5
0
n=113
n=60
Overall
Blacks
Baseline
Hispanics
Whites
TLC 1 Year
Dang et al. J Telemed Telecare 2008;14:443-447.