Are Our RoadMaps Going in the Right

Direction?John P Williams, MD

Peter and Eva Safar ProfessorAssociate Scientific and Medical

DirectorUPMC and University of Pittsburgh

Rare opportunity to quote a film and TV star....

HistoryWith apologies to Santayana...

“If you don’t know where you’ve been, how do you know you haven’t been here before?”

JPW

HistoryThe first thing we need is an example...

How about Congestive Heart Failure (CHF)?

Big problem

Bad history

Great opportunity

The most recent example...“Currently the NHS spends up to £1 billion a year,

apparently on managing heart failure badly”Lancet 2010, 376: 2041

History

72%

7%9%

11%

Hospital/Nursing Home $15.4

billion

Physicians/Other Professionals$1.6

billionMedications/Other

Medical Durables$2.0 billion

Home Health Care$2.4 billion

Total Cost in 2005, 27.9 $Billion- US

HistorySo what drives those hospital/nursing home costs?

Rev Cardiovasc Med. 2002;3(suppl

4):S3-S9.

Can We Change?Skepticism, like chastity, should not be relinquished too readily”

What make us think we can change in general?

What make us think that eHealth in specific can change this?

Previous Studies

Kleinpell and Avital, 2005

Dansky 2008Alston 2009 Hoover 2009

“...it is evident that the use of

telemanagement for CHF has

demonstrated positive outcomes,

including substantial reductions in

hospital readmissions,

emergency department visits, costs of care, and improvements in

quality of life.”

“In order to be successful and

sustainable, telehealth requires

integration into existing health structures and

processes”

UPMC/Jefferson Regional Home Health, LP

Located in Seven Fields, PA (suburb of Pittsburgh)

Part of a large integrated health care system

Joint Venture, Limited Partnership

Medicare certified, JCAHO accredited

Total Employees >697

UPMC/Jefferson Regional Home Health, LP

Coverage area includes 10 Counties – PA; 3 - Ohio

FY09 admissions – >33,085

FY09 visits - >410,167

FY09 Medicare episodes – 9,635

FY09 net revenue - $57 million

Average daily census –3,250

Heart Failure Initiative

With adequate education, medication management, multi-disciplinary care and the implementation of a Telehealth program, Heart Failure patients that are provided appropriate and timely intervention will see a reduction in the exacerbation of disease process, costly readmissions to the hospital and frequent visits to the Emergency Department.

Heart Failure/Telehealth Program Goals

Reduce re-hospitalizations within 30 days at targeted hospitals

Reduce frequent unnecessary visits to the Emergency Department

Provide appropriate and timely interventions to prevent exacerbation of disease process

Use outcomes as marketing tool to partner with 3rd party payers.

Heart Failure/Telehealth Program Goals

Increase patient compliance

Improve patient quality of life

Allow patient to remain independent

Eliminate travel time for staff

Assists in addressing the nursing shortage in specific geographic areas

Telehealth Program Expansion

Partnership with Third Party Payers

UPMC Health Plan

Three year pilot

25 monitors with peripherals

Home Health –oversight and intervention

Reimbursement for set-up/tear-down-$209.00

Collaborative data collection/analysis based on high utilization of services

Heart Failure Statistics forRe-hospitalizationsSource FY 2009

UPMC/Jefferson Regional Home Health Heart Failure

Program9.4%

UPMC/Jefferson Regional Home Health Heart Failure

with Telehealth2.5%

eHealth Benefit

Minimum savings of $312.50 per episode

based on Cost Per Visit of $125.00

Based on the average of 45 days and 100 monitors; each monitor could

service approximately 8

patients/year freeing nursing staff

to provide an additional 2000 visits (800 x 2.5) which results in

$250,000/(2000 x $125.00) savings

Methods for SuccessMedication reconciliation

Patient education specific to condition and co-morbidities

Problem solving skills for changes in the patients condition post discharge

Assessment of patient understanding

Written discharge plan

Discharge plan reconciled with National Guidelines

Methods for SuccessDischarge summary made available to PCP immediately upon patient discharge

Post discharge telephone reinforcement and Get Abby survey

Follow up physician appointment scheduling

Outstanding testing and support scheduling

Post discharge in home services: Safe Landing visit and Home Health care

Palliative and Supportive Care Services

Discharge Plan24-48 hours: The DA follows up with the patient via phone call to reinforce understanding of the established discharge plan and provides any new care coordination or education

2-3 days: The patient also receives a Safe Landing home visit to ensure that equipment, medications and supplies are present. The patient's understanding of their care and current health status are assessed. Home Health care is also a part of the care plan

5-7 days: the patient is scheduled to visit the PCP for a post discharge appointment (partner with Central Scheduling)

10 days post discharge, the patient receives a Get Abby phone survey to assess their current state of health

TIMELINE: CHF Post-Discharge Follow-Up

Discharge AdvocateOngoing medication reconciliation

Medication education in conjunction with the unit based pharmacist

Educates the patient and caregivers on the discharge plan

Consults appropriate inpatient services to assist with management and education specific to patient’s needs

Schedules post discharge follow up appointments for the patient

Discharge AdvocateFacilitates a 30 day supply of medications prior to discharge in conjunction with the outpatient pharmacy

Compiles a written, personalized discharge plan

Contacts the patient 24-48 hours post-discharge to reinforce the established discharge plan and provide any needed care coordination or education.

Sends inpatient information to the patient’s PCP

CHF Pilot Data

Baseline Pilot

Patients (N) 411 134Average Length of Stay

(Days) 12.1 9.8Readmissions at 30 Days

(N) 94 17Readmission Rate (%) 22.9 12.7

Avg. time to readmission (Days) 14.9 12.3

Case Mix Index 2.8194 1.69Average Age 63 60

% Male 58 57% Female 42 43

Mortality (%) 6 0

Next StepsHardwire use of CHF Admission Order Sets

Create care modules for co-morbid conditions (DM)

Lessons learned from Safe Landing Visits

Intervention post discharge: Day 14-30

Medication adherence – pill station

TeleHealth/TeleMonitoring

Avatar: a usable and interactive patient education module

QUESTIONS?

Examples53 single male living alone

SOC/ROC DATE: 05/16/2009 -DIAGNOSIS: CHF NEW NIDDM

PT ADM WITH SOB DX CHF BNP 2200 ALSO AIC 8.9 UNDERWENT CARDIAC CATH 5/13/09 DILATED LV SEVERE LV DYSFUNCTION PT ALSO WITH SLEEP

APNEA TO HAVE OUTPT SLEEP STUDY DONE PT NEW DM PT VERY CONCERNED WITH NEW DX CHF AND DM MANY QUESTIONS

PAST MEDICAL HISTORY: CHF HTN THYROID NODULES CARDIOMEGALYHT: 5 FT. 7 IN.WT: 335 LBS.

FUNCTIONAL LIMITATIONS: CARDIAC RESTRICTIONS

AUG - ADMITTED WITH URINARY RETENTION,EDEMA LOWER LEGS, SHORTNESS OF BREATH, NAUSEA/VOMITING, ABDOMINAL DISTENTION. BNP-

2320. TROPONIN ELEVATED. RENAL CONSULT-DR POWELL FOR CKD/PROTEINURIA. DIURESED. HAS RECURRENT RIGHT NECK

WOUND/ABSCESS. EGD SHOWED ANTRAL EROSIONS, BARRETT–LIKE MUCOSA. BIOPSY DONE. SHOULD HAVE EP STUDIES AS OUTPATIENT- ?

NEED FOR AICD.

Examples

Examples78 female with CHF, COPD, HTN,

HYSTERECTOMY, OBSTRUCTIVE SLEEP APNEA, AFIB, CHF, DIABETES, HYPOTHYROIDISM

- living in large suburban home with handicapped son until son married 1.5 years ago

- first monitor in Aug 2005 then 5 additional times post hospital discharge

-- no hospitalization while using monitor --Started with wt over 330 lbs and after removing

monitor wt was 230

Examples

ExamplesLive audio/video interaction with patient

Dedicated, secure telehealth database

Color-coded data for ease of review

Intuitive platform

HL7 interface to EMR

ExamplesDesigned to provide:

Real-time, two-way audio/video

Use of standard phone line

Easy to use

Integrated, patented Careton™ stethoscope

ExamplesOffers Face-to-face, personal interaction with accurate visual observation

Provides Peace-of-mind

Opportunity for immediate action for Alert conditions

Visits can be documented with photographs.

Ability to assess mental & physical acuity and behavioral changes

Medications can be managed and problems caught BEFORE they reach crisis levels!