Combating the Rising Cost of Care
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Presentation by Bonnie Britton, MSN, RN, ATAF Telehealth Program Administrator, Vidant Health
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Combating the Rising Cost of Care
- 2. Discussing Vidant Health’s Telehealth & Care Transitions Program Discussing VH’s Telehealth Outcomes
- 4. ◦ Shift focus from hospital to coordinating patient care transitions ◦ Define & implement standardized risk stratification tools ◦ Standardize post acute care services Remote patient monitoring services Transitions in care Chronic Disease Management Care Transitions Health Coaches Telephonic follow-up 4
- 5. Patient Risk Assessment Completed by Hospital Case Managers Hi Risk Medium Low Risk Risk Telehealth & Transitions in Care Program Daily biometric data Social Issues/ Non VMG patient VMG patient TH Transitions in Care TIC Services TIC services Consider TIC services Frailty Health Coach Consider Telephonic Service Telephonic Services
- 6. ◦ PAM I & II ◦ Dx Any chronic disease ◦ Readmissions < 30 day ◦ ED visits 4+ ◦ Medications 6+ ◦ Social issues Homeless No PCP No Transportation Un/underinsured 6
- 7. ◦ Remote Patient Monitoring Referred from hospital or clinic Enrolled in hospital or home Home Visit- Med. Rec. & train/competency validate patient/home safety assessment Daily biometric data monitoring / Daily phone calls for abnl parameters Weekly telephonic assessment, education, coaching Staff ratio: 1 -85 – 100 patients ◦ Care Transition Services Enrolled in hospital Hospital visit Home Visit(s)- med. Rec. and patient education Phone Calls Attend MD Visits Staff ratio: 1- 18 – 30 patients 7
- 8. ◦ Clinical Data LDL, BP, Pulse, Height, Weight, HgA1c, oxygen saturation ◦ Patient Satisfaction ◦ Financial Outcomes- 90 days pre TH, during TH, 30 days post TH Hospitalizations Bed Days
- 11. Patient Diagnosis 2% 4% 3% 1% 3% HTN HF COPD 33% 54% CHF/HTN Asthma Asthma/ HTN HF/HTN
- 12. N= 926 Patient Age Range 3% 18% 13% 19% 23% 24% 18-49 50-59 60-69 70-79 80-89 90-99
- 13. N= 926 Average Time Patient Utilizing Monitor < 30 days 30 days 60 days 90 days current 2% 9% 9% 18% 34% 28% > 90 days
- 15. Discharge Patients N=544 900 800 772 700 600 90 Days Prior 500 400 300 200 During 257 143 30 Days Post 100 0 Reductions Of Hospitalizations Decreased by 69% Prior to During Decreased by 76% Prior to Post 15
- 16. Discharged Patients N=544 4,000 3,458 3,000 90 Days Prior 2,000 1,124 1,000 753 During 30 Days Post 0 Hospital Bed Days Decreased by 67% Prior to During Decreased by 81% Prior to Post 16
- 17. Discharge Patients N=544 8,000,000 7,000,000 8,000,000 6,761,227 7,000,000 6,000,000 5,000,000 90 Days Prior 4,000,000 During 1,504,206 3,000,000 90 Days Prior 4,000,000 30 Days Post 3,000,000 1,000,000 6,969,198 6,000,000 5,000,000 2,000,000 Discharge Patients N=544 2,000,000 During 2,257,620 1,722,502 875,895 1,000,000 Hospitalization Costs Reimbursement 30 Days Post
- 18. PAM III Dx Dementia, Mental Illness, Substance Abuse, new chronic disease Readmissions <30 day with Obs. Within 60 days ED visits 2+ Medications Anticog./insulin/glycemic, Dig., Phenobarbital, Lithium Social Issues Unstable housing Multiple PCPs Relay on others Inability to pay 18
- 19. Remote Patient Monitoring- Transitions in Care Care Transitions services ◦ ◦ ◦ ◦ ◦ ◦ Enrolled in hospital Hospital visit Home Visit(s)- med. Rec. and patient education Phone Calls Attend MD Visits Staff ratio: 1- 18 – 30 patients Health Coaches ◦ ◦ ◦ ◦ Enrolled in PCP Clinic Phone Calls Coaching- telephonic and in-clinic Coordination of services 19
- 20. PAM III or IV Dx TBD Readmissions 0 ED visits Medications <6 Social Issues Stable housing 0-1 PCP Insurance 20
- 21. Telephonic follow-up/education Patient identified in-hospital & clinic 21