February 12, 2014 Practice Gap/ Objectives / Disclosures Practice - - PowerPoint PPT Presentation

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February 12, 2014 Practice Gap/ Objectives / Disclosures Practice - - PowerPoint PPT Presentation

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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

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Northwest Regional Telehealth Resource Center Conference 2014

Jayne Mitchell, ANP,-BC Jean McCormick, RN, MSN Kristi Horne, MS

February 12, 2014

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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

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OHSU Telemedicine

Commitment to improving access to care Keeping patients as close to home as safely possible Meeting the Triple Aim

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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

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TeleHealth – Across the Continuum of Care

Other uses: Language interpretation

Ambulatory Care ED, Nursery, Acute Care Inpatient Transitions SNF LTAC Hospice In Home Monitoring “Smartphone” Apps

Continuum of Care

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Telemedicine and Heart Failure Meta analysis …Promising??

Authors Journal Results

Clark, Inglis, McAlister, Dleland, and Stewart BMJ (2007) Positive effect Klersy, De Silvestri, Gabutti, Regoli and Auricchio JACC (2009) Positive effect Inglis, Clark, McAlister, et al Cochrane Report (2010) Structured telephone support and telemonitoring effective in reducing risk of all cause mortality Clark, Shah, Sharma J Telemed Telecare (2011) Telemonitoring in conjunction with home visit can be effective to improve QOL

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Telemedicine and Heart Failure- Recent Large Trials…Mixed results

Trial NYHA Class Length of follow up Results Tele-HF (n= 600) I-III 6 months No significant change TIM- HF (n=710) II-III 27 months No significant change TEN-HMS (n=426) I-IV 240 days No significant change CHAMPION (n=270) (implantable PA sensor) III 15 months Reduction in hospitalizations by 30%

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Outcomes of Large Scale Trials Telemedicine and Heart Failure

TIM-HF Tele-HF

CHAMPION TEN-HMS

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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

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Heart Failure at OHSU: Tiered Intervention Based on Needs

HOT SPOT

Heart Transplant? Ventricular Assist Device? Palliative Care?

Patients already engaged in care Telemedicine Unknown

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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

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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

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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

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Heart Failure and Self-Management

Riegel B et al. Circulation 2009: 1141-1163

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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
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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

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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

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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

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Roles & Responsibilities

Heart Failure NP Care Mgmt Admin Asst Telehealth Svcs Identifies potential patients Enrolls/disenrolls patients (online, spreadsheet, paperwork) Assists with triaging to customer support Educates patients about device & processes prior to discharge Assists patient with troubleshooting & setup at home (via phone) Assists with maintaining metrics Monitors patients daily Maintains metrics Provides clinical process support Follows up with patients about clinical issues Receives & processes monthly invoices, monitors budget Brings new services up on in-home monitoring program Communicates with PCPs/clinical team following patient Orders additional devices & maintains inventory

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Selection Criteria

  • Age
  • Distance
  • Phone Line Access
  • Literacy level
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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
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Telemedicine HF Preliminary Results

Readmit 13% Expired 5% Refused/Unable 15% No Readmit 67%

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Health Monitoring Dashboard Example

  • http://www.bosch-

telehealth.com/en/us/products/health_bud dy/health_buddy.html

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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

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Telemedicine in Action

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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
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Case Study

Heart rate up to 101 history of atrial fib

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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
  • f breath
  • Acute kidney disease

In hospital diuresed 31 pounds NYHA class III on discharge

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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 Sun 12/16/2012 09:13 AM PST. 155 Mon 12/17/2012 08:41 AM PST. 155 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 Tue 01/01/2013 08:23 AM PST. 157 Wed 01/02/2013 07:56 AM PST. 158 Thu 01/03/2013 07:15 AM PST. 161 Fri 01/04/2013 07:36 AM PST. 164 Sat 01/05/2013 08:34 AM PST. 164 Sun 01/06/2013 09:56 AM PST. 163

c/o dizziness and lightheadedness with rising

Complains of increased shortness of breath and feeling full.

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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.