Care%20Coordination

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Care Coordination

• Through the Use of Home TeleHealth Technologies
• VHA Care Coordination Program
• VA Healthcare Network of Upstate NY
• Pamela Page, APRN, BC
• Behavioral Health Clinical Nurse Specialist

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VHAs Domains of Value

• Quality
• Access
• Satisfaction
• Functional Status
• Cost Efficiency
• Building Healthy Communities

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• Mission
• Coordinating the Right Care
• at the Right Place
• at the Right Time
• Vision
• The place of residence is the place of care

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Lifelong Health Record
Risks
Injury
Exposure
Late Illness
Illness
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Care Coordination 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

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The Essence of Care Coordination

• Patient Focused
• Assessment Clinical needs,functional
  status,social environmental
  issues
• Matching Clinical care from across the
  VHA continuum and
• Monitoring Patient use, outcomes and
  quality of life.

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Care Coordination Components

• Disease Management
• Knowledge / Patient Education
• Symptom
• Behavior
• Case Management
• High users ( ER), high risk, frequent admissions
• Self Management of Chronic Disease
• Quality,Access, Satisfaction, Value

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Goals of Case Management

• Quality of Care
• Collaboration
• Fiscal Responsibilities
• Patient Advocacy
• Outpatient Management
• Professional Nursing Practice

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Sense of Uncertainty

• Reading the organizational thermostat
• Nurturing the system to embrace innovation
• Doing business differently
• Establishing credibility through quality
• Evidence-based approach
• Building a bridge of trust
• Educating staff to acceptance

Quality and Trust are first cousins. Dr. Donald
Berwick
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Targeted Populations

• Congestive Heart Failure ( CHF)
• Chronic obstructive pulmonary disease (COPD)
• Diabetes and Hypertension
• Major Depression
• Advanced Illness/ Palliative Care
• PTSD
• Caregiver Support Alzheimers, Dementia

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Patient Selection Criteria For CHF, COPD, DM/HTN

• Diagnosis COPD, CHF, or DM/HTN (with or without
  dementia)
• Greater than or equal to 2 hospital admissions or
  ER visits (VA and nonVA) in 1 year for the
  selected diagnosis
• Greater than or equal to 6 OPT visits for CHF,
  COPD, or DM/HTN in the last year

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Patient Selection Criteria (cont.)

• Patient/caregiver able to provide signed consent
  and adhere to responsibilities
• Patient/caregiver has the ability to operate
  technology
• Safe home environment (adequate electrical/phone
  services, scales, BP cuffs, batteries).

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Patient Selection Criteria For Depression

• More than 2 ER visits for depression or more than
  2 off-hours calls to address depressive symptoms
• 1 admission to Inpatient Psychiatry within 12
  months 
• GAF 35-50
• Depression a problem for more than 6 months
• Decreased behavioral control in clinic settings
• ECT within the past year

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Exclusion Criteria

• History of behavior that would impact the safety
  of staff or equipment
• Unable to read or operate equipment
• No phone access
• Depression with Psychotic features (specific to
  depression module)

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Health Buddy System Components Match Standard
Practice Guidelines
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In-home Messaging
Store Send Technology
Data
Center
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Technology Solutions for Health Monitoring
Health Hero Network
Confidential
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Health Buddy System
The system includes monitoring technologies,
clinical information databases, Internet-enabled
decision support tools, health management
programs, and content development tools.
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Disease Management Programs
Congestive Heart Failure COPD Coronary Artery
Disease Hypertension Co-Morbid
Hypertension/Chronic Obstructive
Pulmonary Co-Morbid Congestive Heart
Failure/Diabetes Diabetes
Co-Morbid Diabetes/ Hypertension Co-Morbid
CAD/Angina Adult Asthma Depression
Bi-polar Disorder Senior Wellness
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Device Integration Opportunities
Open architecture can be developed to interface
to a variety of home medical devices from
multiple manufacturers. Multiple licensing,
marketing, and distribution opportunities with
medical device manufacturers
Blood Pressure Monitors
Blood Glucose Monitors
Coagulation Meters
Peak Flow Meters
Digital Weight Scale
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Monitoring Technologies Health Buddy Appliance

• Simple
• 4 button self-explanatory action
• No computer skills required easy to set up
• Flexible
• Patients respond at their convenience
• No missed phone calls/appointments
• Port for connection to medical devices
• Timely
• Immediate call-back or
• Escalations based on patient responses

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iCare Desktop Work List
Daily Risk StratifiedView of Patient Caseload
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Decision Support ToolsiCare Desktop
Application Work List
Daily Risk StratifiedView of Patient Caseload
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Decision Support ToolsiCare Desktop
Application Results
Detailed View of Patient Results
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iCare Desktop Trends
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Decision Support ToolsiCare Desktop
Application Trends
Choose your own graphs and view multiple sets of
data in chart format
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Health Buddy System Components Health Management
Programs

• Health Management Programs Interactive scripted
  content based on standard practice guidelines for
  over 45 disease states is delivered via our
  monitoring technologies to educate patients,
  enhance medication compliance, and improve
  patient behavior.

Heart Failure Hypertension COPD
Diabetes Major Depressive Disorder
Included in VA contract, matches VHA Practice
Guidelines
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Content Development Tools

• Content Development Tools Robust software tools
  enable health management program development,
  with dynamic branching logic, flexible question
  taxonomy, and the ability to collect variable
  patient responses.

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Content Development ToolsCare Composer Software

• Health management programs built using standard
  practice guidelines with focus on key aspects of
  care including signs and symptoms, behavior, and
  knowledge
• Rich variety of question types
• Question taxonomy is dynamically branching to
  varied responses with associated risk tags
• Built-in outcomes measures including utilization
  and patient satisfaction, quality of life,
  medication compliance and individual patient
  population reporting (SF36v, SF12, Minnesota
  Living with Heart Failure Assessment)
• Customization and personalization of health
  management programs to fit policies and
  procedures for any disease
• Online review of health management programs

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Question and Response Types
Multiple Choice
Extended Multiple Choice
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Question and Response Types
Numeric
Range/Scale
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Question and Response Types
Binary
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Question and Response Types
Prompt / Education / Information
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Audio/Visual/Real-time
Provider Station
Patient Station
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AVIVA Pilot Projects

• Specialty services to include
• Consultation from Tertiary site to CBOC
• ex Cardiology VA Bath/Buffalo
• Increase access to care by extending services to
  remote areas
• Increased patient satisfaction by reducing travel
  requirements
• Potential reduction in fee costs

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Outcome Measurement System

• Utilization Measures - Pre and Post technology
• Clinical Measures
• Business and Efficiency Measures
• Patient, Caregiver, Provider and Staff
  satisfaction

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• Clinical
• Pre and Post Program Enrollment
• CPGs for
• CHF
• COPD
• DM/HTN
• Major Depression
• Palliative Care

• Utilization
• Pre and Post Program Enrollment
• ER Visits
• Admissions to Acute Care
• Number of Clinic Visits

• Satisfaction
• Patient Survey / May 04
• Provider Survey
• Care Giver Survey
• Staff Survey

• Business
• Total of CCHT encounters
• Panel Size
• patient using technology(P)

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OUR PROMISE TO OUR VETERANS

• To empower our patients and the people who care
  for them
• Focus on prevention not rescue
• Respond with the Right Care, Right Place, Right
  Time

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Care Coordination Making the Connection
Clinical services
Patient at Home
Clinical Settings
Provider
Technology