An Essentia Health Story Keep Out! Avoiding Readmissions with Heart - - PowerPoint PPT Presentation

An Essentia Health Story

“Keep Out!” Avoiding Readmissions with Heart Failure.

gpTRAC Annual Conference, Bloomington, MN April 3, 2017 Maureen Ideker, RN, BSN, MBA System Director of Telehealth

Essentia Health as an ACO

 One of six health care systems in Country to achieve:

NCQA Accreditation as an Accountable Care Organization

Definition

A provider-based organization that take responsibility for meeting the health care needs of a defined population with the goal of simultaneously improving health, improving patient experience and reducing per capita costs. (Triple Aim)

Why Heart Failure?

Prevalence

– Affects 5.8 million in the U.S. – Over 650,000 new patients annually – The lifetime risk of developing HF is 20% for Americans ≥40 years of age. – HF is the most frequent cause of hospitalization in elderly (> 65 y/o)

Prognosis

– 1/2 of people who develop HF die within 5 years of their diagnosis – Less than 25% are alive at 10 years

• HF is not always treated correctly
• Patients do not adhere to diet and medication regime
• Projections show the prevalence of HF will increase 46%

from 2012 to 2030, resulting in >8 million people ≥18 years of age with HF

Heart Failure Progression is Inevitable

AHA Heart Disease & Stroke Statistics 2014 Update

What will it Cost?

• Estimated lifetime cost per each

individual HF patient is $110,000/year

• In 2012, total cost for HF was

estimated to be $30.7 million

• Projections show that by 2030, the

total cost of HF will increase almost 127% to $69.7 billion from 2012

Summary % Readmissions for Heart Failure Within 30 Days

• National – 24%
• Essentia Health – Duluth – 9%
• Essentia Health with Tele-Home Monitoring

Scales – 2%

Essentia’ s Tele-Home Monitoring Results Support Findings from Original Research

• Kaiser – Permanente (2000)
• University of Minnesota (2006)
• (References attached)

Essentia’s HF Program Model

• Consult 5-7 days after hospital discharge
• Patients managed by APP in ambulatory setting
• Seen by cardiologist initially, annually and as needed
• Registered nurses provide continuous case

management: – Phone triage – Follow-up on labs/ test results – Utilize protocols – Manage telescale data – ONGOING PATIENT EDUCATION

Monitoring and Exception Review

• Patient alerts in Cardiocom

– Nurse reviews data in both Cardiocom and EPIC – Makes decision if patient needs to be contacted

• If assessment is needed the nurse considers the

following:

– Nursing assessment and education needs – Review medication list – Dietary compliance – Follows diuretic protocol as indicated/or talks with provider – Initiate office visits or primary care referrals as needed – Care plan monitoring; hospitalization initiation – Communication with team members (other specialties)

HF Program Outcomes Data: 12 Months

East HF Program Patients (Inpt. & Outpt.) 2016 1,952 HF Admissions (185) Initial Diag. 9.5% All Cause 30 Day Readmissions (17) 9.25 HF 30 Day Readmissions (6) 3.2% East HF Programs Pts. (Inpts. & Outpts.) 2014 2,288 Tele-Home Monitored

• Pts. (296)

13% HF Tele-Home Pts. – 30 Day Readmissions (0) 0% HF 365 Day Tele-Home

• Pts. Readmissions (6)

2%

Appropriate use of telescales

Consider for:

• Patients with 2 or more

hospitalizations for HF during the past year

• Patients unable to self-report

weights within given parameters and/or inadequate social support

• Patients who live great distances

from clinic and have difficulty getting to office visits

Not recommended for:

• Dialysis patients
• Weight loss program
• Patients residing in skilled nursing

facility with 24 hour care

• Unsteady patients

Advantages to Tele-monitoring

• Facilitates early intervention and prevents ER

visits and hospitalizations

• Improved patient adherence with care plan
• Patients get immediate feedback on life style

choices

• High patient satisfaction
• Family reassured
• Provides additional opportunity to educate patients
• Builds trust between patient and provider

HF Program THEN NOW

Fee for Service Model

• Expense Center
• Little if any payment for

services

• Reimbursement reducer
• Prevents admissions,

readmissions and ED visits

ACO model

• Greatly improves the quality of

care for HF patients

• Reduces the cost of medical

care by reducing admissions, readmissions and ED visits

• Improved service and

experience for patients with close monitoring and coordination of care

• ACOs rewarded for improving

quality of care and controlling costs.

Re Refer erences ences

• American Hospital Association. Telehealth: Helping Hospitals

Deliver Cost-Effective Care, pgs1-7, 4/22/16. www.aha.org

• Erickson C, Ideker M, Fauchald S. Integrating Telehealth Into the

Graduate Nursing Curriculum. The Journal for Nurse Practitioners 2015; e1-5.

• Finkelstein S, Speedie S, Potthoff, . Home telehealth Improves

Clinical Outcomes at Lower Cost for Home Healthcare. Telemedicine and e-Health Vol 12, N0 2, 2006: 128-136.

• Johns Hopkins Medicine. A Typical Hospital at Home

Program Follows these Steps. http://www.hospitalathome.org/about-us/how-it-works.php.

• Johnston B, Wheeler L, Deuser J, Sousa KH. Outcomes of the

Kaiser-Permanente Tele-Home health research project. Arch Fam Med 2000;9:40-45.

Questions?? Thank you!!

Maureen Ideker, RN BSN MBA System Director of Telehealth Maureen.Ideker@essentiahealth.org