Presentation by Bonnie Britton, RN, MSN, ATAF, Vidant Health

1. Innovation Panel
MATRC
March 16, 2012

2. Vidant Health
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3. Vidant Health’s Approach
VH-hospital Care
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
ECU Family Practice
Vidant Edgecombe
Vidant RoanokeChowan
ECHI at VMC
Cardiovascular /
Pulmonary
Homebound Patients
Cardiovascular /
Pulmonary
Cardiovascular /
Pulmonary
Heart Failure
45
25
50
30
50
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5. Telehealth and Care Coordination 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.
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6. Inclusion Guidelines
• CVD and 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 home electrical service to operate
the system
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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
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9. Evaluation
• Demographics
• Objective clinical data
– Height
– Weight
– Blood Pressure
– Pulse
– Pulse Oximeter
– LDL (every 6 months if elevated, or otherwise
indicated)
• A1C for uncontrolled diabetes
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10. Evaluation
• Subjective clinical data
– Medication compliance
– Nutrition compliance
– Patient’s knowledge of red flags
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11. Evaluation
• Financial data
• Hospitalizations
– Number of hospitalizations
– Patient bed days
– Total charges for Hospitalization
• Emergency Department
– Number ED visits
– Total charges for ED
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12. Contact Information
Bonnie Britton, MSN, ATAF
Bonnie.britton@vidanthealth.com
252-847-6419
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