Extending Care from Hospital to Home

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Extending Care from Hospital to Home

CP338.01 5/3/13

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Agenda

• Changing trends in healthcare

• Identifying key pain points

• Partnering with home health

• Why telehealth

• Measuring outcomes

• Next steps

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The shift to a patient-centric model is creating a seismic change in Healthcare implementation

Source: Reflection on the Future of Disease Management by Sam Nussbaum, MD

A new definition of success in healthcare

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Drivers of patient-centric care

Patient population trends• Growth in chronic diseases • Increase in aging population

Increased patient engagement • Proactively involved with maintaining

health on a daily basis• Desire to live independently longer

CMS payment model• Penalties for readmission rates above the

national average• Value-Based Purchasing payments based on quality

of care vs. fee for service • Meaningful Use incentives for utilizing certified EHR’s

to capture and share health information with care providers and patients

Source: Center For Disease Control (CDC)

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Identifying industry pain points

Pain Points Top Initiatives

• Reduce readmissions to avoid reimbursement penalties

• Prepare for changing reimbursement models (value-based purchasing, bundled payments, shared savings)

• Maximize Value-based Purchasing incentives for meeting quality of care standards

Financial

Patient Satisfaction & Quality

• Improve satisfaction surveys results and patient engagement/loyalty to secure incentive payments

• Better patient oversight and care transitions to increase quality of care and improve patient acquisition costs

Operational & Clinical Efficiencies

• Utilize analytics to access patient care data to decrease staffing costs and length of stay


Partnering with Home Health

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About (Your Agency Name Here)

(PLACEHOLDER: Include information about your agency including history, services, awards, and unique value/how you are different from other agencies)

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Patient populations that we serve

Patient Self-Managed

Value:

Enables Care Manager to offer support to Elders when and how they

need it

Population:

Mobile/Healthy Elder

Our fit: PERS

Mobile Healthy

Event-based

Value:

Event-initiated oversight and patient/disease management tools

Population:

mPERS/Disease Management/ Care Transitions

Our fit: PERS/Telehealth monitoring

At Risk

Full Clinical Oversight

Value:

Daily monitoring using telehealth products and services

Population:

Fragile, Homebound, Chronically Ill

Our fit: Telehealth monitoring

Fragile

• Mobile Healthy and At Risk patients who do not have a skilled need or are not homebound• Frequent fliers who need a daily connection to health monitoring to prevent emergent care use• Chronic disease patients who need assistance managing their care• Post acute patients not transferred to a SNF• Patients needing skilled nursing, PT/OT/MSW and/or daily monitoring services• (PLACEHOLDER: Add your other agency services here (home making/CNA /Hospice, etc.)

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How Home Health can help address your pain points

Daily health status monitoring • Patients can remain in their homes, and maintain their independence, while being monitored for changes

in health status• Changes in condition will trigger an action to review and modify the patient’s care plan, if needed, before

a re-hospitalization occurs

Education• We teach patients and families about their conditions, including compliance with care plans and how to

make better choices to improve their health

Transparent access to patient data• Co-case manage our mutual patient(s) by accessing patient data in real time• Review your patients’ information at any time with our analytics tools • Allowing family members to review care through secure online access to patient information

Improve patient satisfaction • Daily clinical oversight with remote monitoring provides patients with a sense of security and greater

peace of mind through interaction or human interaction

Result = Cost containmentThe value of daily health status monitoring helps control costs for your hospital


Telehealth Solution Overview

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Demystifying “Tele-Confusion”

TelehealthTelemedicine Telecare

Health data transfer between care

providers & patient for diagnosis &

treatment via live connections

Description

Services & Devices

Use of telecom & IT to provide

remote access to care to chronic

populations

Services enabling elderly &

vulnerable to live independently

in home or facility

• Physician & Patient

teleconsulations

• Telesurgery, teleradiology, tele-

ICU

• Holter & CRM home monitor

• Video conferencing

• Full clinical oversight through full

vitals monitoring

• Data management platform

• Implementation services

• Decision support tools

• Disease management

• Video visits

• Activity & sensor monitoring

• Gas & smoke detection

• Medication management

• Personal Emergency Response

System (mPERS)

Remote Diagnostic & Treatment Remote Patient Monitoring Activity Monitoring & Sensing

Where does Telehealth fit?

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LifeStream Care Provider Software

Our Solution: LifeStream Health Management Platform

Patient Devices and Peripherals

Manager Connect

AnalyticsView

LifeStream MobileHelp mPERS

Genesis Touch Genesis DM

We utilize Honeywell HomMed’s LifeStream Health Management Platform, and our telehealth solutions are supported by their Clinical Consulting Services

Peripherals

Our Monitoring Services

Installation

Daily Monitoring Physician engagement

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Scheduled or unscheduled biometric collection: Walks patients through the process to assist with

compliance

Optimized for mobility: Honeywell HomMed devices can be used both inside or outside the home

Wired and wireless peripherals: Devices can be used in any room with or without

dedicated wired connectivity

Integrated video capabilities: Hold video visits and educational sessions with

patients, family members, and other care providers

Solution Overview: Patient Devices

Telehealth• Mobile & desktop• 3G/4G & WIFI• Range of peripherals

Telecare• Mobile wireless• Location services• Falls (Q313)

Applications• Video visits• Deliver educational materials

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We track and manage patient data through Honeywell HomMed’s software management

interface

• Single consolidated view of patient data: Review and manage patient data from

LifeStream’s clinical dashboard

• Flexible, efficient workflows: Schedule and customize patient biometric collection, ask

specific disease management questions, and deliver relevant education to the patient

• Integration with common HIT interfaces: Connect patient data with your health records

(EHR) and electronic medical records (EMR) with HL7, one-way, or two-way interfaces.

Solution Overview: Care Provider Software

LifeStream Care Provider Software

Manager Connect

AnalyticsView

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Daily Monitoring: Our clinicians review patient biometric data daily and respond to changes

directly with each patient

Physician Engagement: We will work with you to identify the reporting and communication

methods you prefer to stay informed about your patients.

Installation: We will install the telehealth monitor in the patient’s home

HomMed Clinical Consulting: We work closely with Honeywell HomMed to adopt rigorous

standards for our telehealth program and ensure our staff is properly trained

Solution Overview: Clinical and Monitoring Services

Our Monitoring ServicesInstallation

Daily Monitoring Physician engagement


Measuring Outcomes

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Measuring a successful telehealth program

We benchmark our agency against the following criteria:

Readmission rate: How often are our patients re-admitted to the hospital and were any of the incidents preventable?

Quality of care and patient satisfaction: Are our patients satisfied with their care?

Operational and clinical efficiencies: Are we able to care for more patients and reach them more often with telehealth?

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Outcome Data: Home Health Compare

(PLACEHOLDER: Enter your agency’s outcome and home health compare data here)

http://www.medicare.gov/HomeHealthCompare

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Outcome Data: Our patient data examples

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Hospital Compare

(PLACEHOLDER: List the Hospital Compare data for the hospital you are presenting to)

http://www.medicare.gov/hospitalcompare/


Telehealth Success Throughout the Industry

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“We believe that telehealth services are key building blocks required for the delivery of quality home healthcare.”

Wayne Bazzle, CEO of CareCycle Solutions, Dallas, TX

30-Day Rehospitalization Rates

Medicare Beneficiaries – US Average* 19.60%Texas Medicare Beneficiaries* 19.40%Louisiana Medicare Beneficiaries* 21.90%Home Healthcare Partner – Non-TeleHealth 14.89%CareCycle Solutions – TeleHealth 7.30%

In an ongoing look at 6,000+ patients, readmission rates for the first 30-days of care averaged 7.3% for monitored patients vs. 14.2% for patients that did not receive telehealth monitors.

Care Cycle Solutions Example

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Advanced Telehealth Solutions

Focusing on highest cost

members of a population

yields sustainable savings over time

ROI Example

=

=

$6,000 PM/PY Avg.$6,000,000

$3,300,000

Insurance Cost [PM/PM $500 x 12 Months]

1000 Lives x $6,0005% of People [50] generate 55% of total cost:

55% of cost [an opportunity for savings of] =

Karen Thomas, President, Advanced TeleHealth Solutions

50%Members

Preventative Risk Mitigation Telehealth

10% 10% 25% 30% 25%

20% 25% 4% 1%

Well Members

Prevention and Education

Low Risk Members

Optimize Resources in Acute Episodes

of Care, Population Care

Moderate Risk Members

DM and Education,Risk Avoidance

High Risk, Multiple Diseases

Episodic Care Mgmt Clinical Guidelines

High Risk DM

Complex and Intensive Care

Total Care Integration

Cost

Prevention and Early Identification Risk Avoidance


Next Steps: Post-discharge process

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The handoff to home health

Recommended process for hospital and home health agency prior to patient discharge

24 hours prior to discharge: • Review patient care plan • Identify communication frequency/reporting plan• Deliver monitor to patient and provide telehealth education at

bedside, or develop a plan for in-home assessment depending on your preference

During monitoring:• Regular communication between hospital and home health according

to pre-discharge plans• Alert physicians to changes in health and revise care plan if needed• Evaluate need for video visits to reinforce care plans or introduce

additional educational information


Testimonials

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What do patients and family members say about us?

(PLACEHOLDER: List 3 – 4 of your patient testimonials here)


Thank you – How do we get started?

Extending Care from Hospital to Home

Documents

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