Northwest Regional Telehealth Resource Center Conference 2014 Jayne Mitchell, ANP,-BC Jean McCormick, RN, MSN Kristi Horne, MS February 12, 2014
Practice Gap/ Objectives / Disclosures • Practice Gap: Lack of information available regarding utilizing telemedicine in heart failure patients post discharge • Desired Outcome: – Providers will understand the effect of utilizing technology to manage a specific population from discharge to home. – Providers will recognize how internal/external workflows are vital to effectively manage the patients. – Providers will recognize that in home monitoring can be a valuable tool for this population. Disclosure of relevant financial relationships in the past 12 • months: The three presenters have no relevant financial relationships with commercial interests that may have a direct bearing on the subject matter of this CME activity
OHSU Telemedicine Commitment to improving access to care Keeping patients as close to home as safely possible Meeting the Triple Aim
Acute Care Telemedicine • Program began 2007 – PICU to Sacred Heart, Eugene • Expansion in 2010 Service lines – Stroke, PICU, NICU – Genetics, Trauma – Neurosx, Psychiatry 17 sites – based on local needs
TeleHealth – Across the Continuum of Care Transitions In Home Monitoring SNF Ambulatory ED, Nursery, Inpatient Care Acute Care “Smartphone” LTAC Apps Hospice Continuum of Care Other uses: Language interpretation
Telemedicine and Heart Failure Meta analysis … Promising?? Authors Journal Results Clark, Inglis, McAlister, BMJ (2007) Positive effect Dleland, and Stewart Klersy, De Silvestri, JACC (2009) Positive effect Gabutti, Regoli and Auricchio Inglis, Clark, McAlister, et Cochrane Report Structured telephone support and al (2010) telemonitoring effective in reducing risk of all cause mortality Clark, Shah, Sharma J Telemed Telemonitoring in conjunction with Telecare (2011) home visit can be effective to improve QOL
Telemedicine and Heart Failure- Recent Large Trials… Mixed results Trial NYHA Length of Results Class follow up Tele-HF (n= 600) I-III 6 months No significant change TIM- HF (n=710) II-III 27 months No significant change TEN-HMS I-IV 240 days No significant change (n=426) CHAMPION III 15 months Reduction in hospitalizations (n=270) by 30% (implantable PA sensor)
Outcomes of Large Scale Trials Telemedicine and Heart Failure Tele-HF TEN-HMS TIM-HF CHAMPION
Heart Failure at OHSU • Advanced heart failure Program – average 35 VADS per year – average 18 Heart transplants per year . Approximately 400 patients a year discharged with primary • diagnosis of heart failure All disciplines treat heart failure patients • – Advanced Heart failure – General Cardiology – Family Practice – Internal Medicine – Hospitalist Service
Heart Failure at OHSU: Tiered Intervention Based on Needs HOT SPOT Heart Transplant? Ventricular Assist Device? Palliative Care? Telemedicine Unknown Patients already engaged in care
Specific Issues • Approximately 40% of OHSU heart failure patients live outside Portland metro area, making care transitions from the hospital difficult • Low patient self-management leads to increased risk of readmissions
Self-Care Areas of Focus • Education – Symptoms and red flags-recognizing changes in condition (abdomen bloated, more short of breath, less energy) – Impact of adherence – What do the numbers mean • Impact of lifestyle choices AAHFN
Heart Failure and Self Management: Moving the Patient from Novice to Expert Reigel B, Lee CS et. al: From Novice to Expert:Nurs Res. 2011 Mar- April; 60(2): 132-8
Heart Failure and Self-Management Riegel B et al. Circulation 2009: 1141-1163
Fundamentals of Teaching for the Heart Failure Patient • Daily weights • Symptom recognition and reporting • Low sodium diet • Medications • Activity • Fluid restriction if needed • Follow-up
Basic Heart Failure Daily Education - RNs assess patient every day - Patient given scale if needed - Whiteboard used Developed by: Cecil G. Sheps Center for Health Services Research UNC at Chapel Hill Feinberg School of Medicine Northwestern University UCSF Hfeducationalmaterial@schsr.unc.edu NIH Grant, NHLBI
In-Home Monitoring • FY11: 887 adult related 30-day readmissions to OHSU for patients discharged home (5.1% of total admissions) • Center for Medicare Services (CMS) to begin penalties for readmissions for CHF, AMI and PNEU • To prevent readmissions, OHSU implemented a 30- to 60-day in- home monitoring program for high-risk CHF patients in coordination with Care Management and the Cardiac Service Line
Program Administration Overall Cost (January – December 2013): $15,861 • – Excludes time (no full-time staff, four part-time people devoted to program) • Administration – Spreadsheet tracks all patients over time (including after disenrollment from program) – Bi-weekly check-in phone calls with vendor to discuss issues – Invoice management/shipping • Stocking & Retrieval of Devices – Have had to adjust to shipping timelines (very slow, which forces us to think ahead) – Retrieval of devices has been difficult due to short enrollment timeline • Overcoming Technical Issues – Rural patients – Phone lines vs. modems – Setup issues
Roles & Responsibilities Heart Failure NP Care Mgmt Admin Asst Telehealth Svcs Identifies potential patients Enrolls/disenrolls patients Assists with triaging to (online, spreadsheet, customer support paperwork) Educates patients about Assists patient with Assists with maintaining device & processes prior to troubleshooting & setup at metrics discharge home (via phone) Monitors patients daily Maintains metrics Provides clinical process support Follows up with patients Receives & processes Brings new services up on about clinical issues monthly invoices, monitors in-home monitoring budget program Communicates with Orders additional devices & PCPs/clinical team following maintains inventory patient
Selection Criteria • Age • Distance • Phone Line Access • Literacy level
In-Home Monitoring Initial Data • Stage C and D Heart Failure, NYHA Class II-IV • 54 patients – 57% Medicare – 24% private pay • 81% from outside Portland metro area
Telemedicine HF Preliminary Results Readmit Expired 13% 5% Refused/Unable 15% No Readmit 67%
Health Monitoring Dashboard Example • • http://www.bosch- telehealth.com/en/us/products/health_bud dy/health_buddy.html
In-Home Monitoring Results • Average number of telephone encounters (per patient): – 11-14 telephone encounters per month prior to in-home monitoring program – 7.1 calls per month with in-home monitoring program – Average call length is shorter in duration and more focused • 6 reported ED visits in the interim of 30 days with 65 patients
Telemedicine in Action
Case Studies 64 y/old female from Eastern Oregon with complex history. • EF less than 20% • History of AVR 1999 with redo in 2010 • Afib with RVR • Acute kidney injury Cr. 1.96 • NYHA class III on discharge
Case Study Heart rate up to 101 history of atrial fib
Case Study 67 year old male from Central Oregon • Previous MVR 2006 • Recent onset of dyspnea, weight gain poor intake of food • Prior to hospitalization unable to walk 2-3 steps before getting short of breath • Acute kidney disease In hospital diuresed 31 pounds NYHA class III on discharge
Daily Weights from Patient Weight Data Table Date (A) Weight Fri 12/14/2012 09:37 AM PST. 156 Sat 12/15/2012 09:02 AM PST. 155 c/o dizziness and Sun 12/16/2012 09:13 AM PST. 155 lightheadedness with Mon 12/17/2012 08:41 AM PST. 155 rising Tue 12/18/2012 06:34 AM PST. 156 Wed 12/19/2012 08:27 AM PST. 158 Thu 12/20/2012 09:16 AM PST. 157 Fri 12/21/2012 09:08 AM PST. 156 Sat 12/22/2012 07:32 AM PST. 157 Sun 12/23/2012 05:39 AM PST. 157 Mon 12/24/2012 06:04 AM PST. 157 Tue 12/25/2012 08:38 AM PST. 157 Wed 12/26/2012 07:38 AM PST. 157 Thu 12/27/2012 07:00 AM PST. 157 Fri 12/28/2012 08:26 AM PST. 156 Sat 12/29/2012 06:10 AM PST. 155 Sun 12/30/2012 08:07 AM PST. 155 Mon 12/31/2012 08:35 AM PST. 155 Complains of Tue 01/01/2013 08:23 AM PST. 157 Wed 01/02/2013 07:56 AM PST. 158 increased Thu 01/03/2013 07:15 AM PST. 161 shortness of breath Fri 01/04/2013 07:36 AM PST. 164 Sat 01/05/2013 08:34 AM PST. 164 and feeling full. Sun 01/06/2013 09:56 AM PST. 163
Summary • In home monitoring in heart failure patients is cost effective and decreases all cause readmissions. • For our complex patients, we believe this is a good adjunct to help transition care from hospital to community.
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