Innovative use of Telemedicine in Primary Care and Transitions of - - PowerPoint PPT Presentation

Innovative use of Telemedicine in Primary Care and Transitions of Care

Kentucky Health

• F. Rose Rexroat, R.N.,C., MSN

Manager, Telemedicine and Community Services KentuckyOne Health a Market Based Organization of Catholic Health Initiatives

Rural Infrastructure

Access

41.6% of Kentucky’s population live in a rural area

Transportation

Poverty

Challenges

• Integrated Health Care Delivery System –moving

from a hospital centric to patient / community based chronic disease management environment

• Primary care strategy – assure every patient has a

primary care physician / medical home

Floyd Pike Marion Wayne McCreary Pulaski Lincoln Nelson Bullitt Jefferson Oldham Trimb le Carroll Kenton Henry Shelby Spencer Owen Franklin Scott Grant Perry Woodford Fayette Bourbon Harrison Clark

Madison

Jessamine

Knox Laurel Leslie Letcher Bell Clay Lee Jackson Owsley Wolfe Breathitt Johnson Magoffin Estill Morgan Lawrence Martin Menifee Rowan Elliott Powell Lewis Fleming Mason Boyd Carter Greenup Secondary Service Area Primary Service Area Tertiary Service Area Saint Joseph Hospital & SJE RN 1 & 2 Primary Location

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Counties served by RN #1 Counties served by RN #2

1 2 2 2 2 2 Integrated Patient Management through Rural Outreach Services 1 1 1 1 1

SJHS Hospitals

Clay City/Powell County

Opened July 6, 2011 867 Patients 2109 Visits

Integrated Physical and Mental Health Opened August 7, 2012 207 Patients 690 Visits Collaboration with Kentucky River Community Care Saint Joseph Primary Care Clinic – Campton / Wolfe County

Telehealth = Primary Care Access to Specialists

Timeline for Penalties: The Clock Started Ticking October 1, 2011

“Hospitals with high rates of readmission will be paid less if patients are readmitted to the hospital with the same 30 day period”

• Office of Management and Budget

*Reduced CMS Payment 1%

2% 3% _______________________________________________________________________________ 2010 2011 2013* 2014 2015** 2020 *CMS authorized to start ** CMS may withhold payments for excessive penalizing for excess readmissions COPD, CABG, and percutaneous coronary For HF, CA Pneumonia, and AMI intervention (PCI) readmissions Source: Preparing for CMS Penalties, sg2 Insight, J. Moss, RN, MSN, Neal Gold, MD, 2/8/11

Transitions of Care Overview

• Best Practices:

– Eric Coleman, University of Colorado, Model of Transition Coaching – Dr. Tim Ferris, Massachusetts General Hospital, Boston model of Health Coaching – Geriatric Care Managed as model in “Handbook of Geriatric Care Management” by Cathy Jo Cress

Transitions of Care Overview

• Patient Population and Diagnosis: 65 years old + with

COPD, AMI, CHF and CAP

– Care Transitions Coaching: minimum of 30 days – Health Coaching: period of 180 days in PCP – Care Management by SW: available for total 210 days Study was done with Saint Joseph (SJ) Hospital and SJ East expanded December 2012 to include SJ Mt. Sterling

Transitions of Care Overview

• Care Transition Study: November 1, 2010 through October 31, 2011

– 134 coached (216) Patients approached

• 21 readmitted within 30 days 15.67%

– 8 patients were readmitted within first 8 days (38%) – 15 patients were readmitted within first 15 days (71%)

• 8 patients died (5.9%)

– Readmission rate for patients refusing to be coached for first 30 days after discharge (18.5%) – SNF patients – readmitted within 30 days: 6 of 13 (46.2%)

• Care Transition: November 1, 2011 to February 28, 2013

– 435 coached (560) Patients approached

• 47 readmitted within 30 days 10.8%

– 11 patients were readmitted within first 8 days (23%) – 26 patients were readmitted within first 15 days (55%)

• 4 patients died (0.9%)

– Readmission rate for patients refusing to be coached for first 30 days after discharge (18.6%)

– SNF patients – readmitted within 30 days: 4 of 14 (28.6%)

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2 5 3 2 3 2 2 1 1 2 2 1 2 1 4 2 4 1 2 2 6 3 3 8 4 9.3 9.3 12.5 8.3 6.8 9.3 9.0 7.8 7.5 10.5 7.3 9.3 2 4 6 8 10 12 14 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB

Readmits By Month

Study (11/10-10/11) 21 Readmits Post Study (11/11-12/12) 47 Readmits SJH/SJE (10/09 - 9/10) 106.9 Readmits

0risk 1risk 2risk 3risk 4risk 5risk 6risk 7risk 8 Risk All (N=435) 0% 2% 14% 27% 31% 17% 6% 2% 0% Readmits (N=47) 0% 2% 9% 9% 36% 32% 9% 4% 0% Deceased (N=18) 0% 0% 0% 17% 28% 39% 17% 0% 0%

0% 2% 14% 27% 31% 17% 6% 2%

2% 9% 9% 36% 32% 9% 4%

17% 28% 39% 17%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45% % of Patients Transitions of Care Post Study (11/11 - 2/13) Number of Risk Characteristics

85% of DECEASED have 3-5 Risk Characteristics 75% of ALL have 3-5 Risk Characteristics 77% of READMITS have 3-5 Risk Characteristics

AGE 70 OR > MULT MEDS OR TX 2 + CHRONIC CONDITIONS ADL IMPAIRMENT MULTIPLE READMISSIONS >2 IN 12MO PRIOR COGNITIVE IMP LIVES ALONE SUSPECETED NON- ADHERENCE 3 Risks (N=4) 100% 75% 100% 0% 25% 0% 0% 0% 4 Risks (N=17) 53% 100% 100% 53% 18% 0% 29% 24% 5 Risks (N=15) 73% 100% 100% 87% 73% 27% 7% 33%

100% 75% 100% 0% 25% 0% 0% 0%

53% 100% 100% 53% 18% 0% 29% 24%

73% 100% 100% 87% 73% 27% 7% 33%

0% 20% 40% 60% 80% 100% 120% % of Patients

Transitions of Care - Post Study (11/11 - 2/13) 36 of the 47 Readmits have 3-5 Risks Characteristics

0CM 1CM 2CM 3CM 4CM 5CM 6CM 7CM All (N=435) 3% 8% 22% 28% 20% 14% 4% 0% Readmits (N=47) 0% 9% 11% 15% 30% 30% 4% 2% Deceased (N=18) 0% 0% 6% 17% 33% 39% 6% 0% 3% 8% 22% 28% 20% 14% 4% 0% 0% 9% 11% 15% 30% 30% 4% 2% 0% 0% 6% 17% 33% 39% 6% 0% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

% of patients

Transitions of Care - Post Study (11/11 - 2/13) Number of CoMorbids

86% Readmits have 2-5 CoMorbids

Afib DM Renal Failure CHF COPD HTN CAP 2CM (n=5) 40% 0% 0% 40% 40% 60% 20% 3CM (n=7) 14% 14% 14% 29% 71% 100% 57% 4CM (n=14) 21% 50% 29% 79% 71% 93% 57% 5CM (n=14) 36% 57% 43% 100% 64% 100% 100%

40% 40% 40% 60% 20% 14% 14% 14% 29% 71% 100% 57% 21% 50% 29% 79% 71% 93% 57% 36% 57% 43% 100% 64% 100% 100%

0% 20% 40% 60% 80% 100% 120% Axis Title

Transitions of Care Post Study (11/11 - 2/13) 40 Of 47 Readmits have 2-5 CoMorbids

1 2 3 4 5 6 7 Risk Factors 0% 2% 9% 9% 36% 32% 9% 4% CoMorbids 0% 9% 11% 15% 30% 30% 4% 2% 2% 9% 9% 36% 32% 9% 9% 11% 15% 30% 30% 4% 2% 0% 5% 10% 15% 20% 25% 30% 35% 40% Axis Title

Transition Coaching - Post Study (11/11 - 2/13) 47 Readmits Risks/CoMorbids Comparison

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