US USING ING TE TELEH LEHEAL EALTH TH TO O ACHIEVE CHIEVE THE THE TRIPLE TRIPLE AIM AIM TERRY YONKER, RN, MS, FNP-BC TELEMEDICINE CLINICAL CARE COORDINATOR FINGER LAKES COMMUNITY HEALTH
Obje jectives 1. Discuss applications of telehealth in primary care 2. Identify how telehealth provides opportunities to increase access to care 3. List ways in which telehealth has tangible and intangible cost benefits 4. Explain how telehealth programs can improve quality of care
Dis isclosure I have no financial relationship with a commercial entity producing health-care related products and/or services relative to the content I am presenting
Who We Are… • Community/Migrant Health Center Program • Migrant Voucher Program in 42 Counties • Clinical Sites: 9 Health Center Sites • Administrative Office: Penn Yan, NY
Where We Are…
Challenges in Providing Health Care to Rural Poor Transportation barriers • Language differences • Cultural beliefs • Cost of health care services • Uninsured/Underinsured • Lack of trust in health care • system Poverty • Migrant lifestyle •
Tele lehealth th Pro rogram Develo lopment Funding Sources USDA – Dist US Distance HRSA – Rura ural Ne Network Learnin Le ing an and d De Development Telemedicin ine FINGER LAKES COMMUNITY HEALTH – HIT INFRASTRUCTURE DEVELOPMENT Fed ederal Co Communic icatio ions s NY NYS DOH DOH Co Commissio ion – Rura ural Hea ealthcare Broadband Proj Br Project
Telehealth Programs at FLCH Teledentistry Neurology Telepsychiatry TelePulmonolog y Telemental Health TeleAC Tele-ENT TeleRD TeleDiabetes TeleMD (DRS) TeleHCV TelePeds
Benefits of f Tele lehealth Providers Health Care Systems Patients /Families Direct patient interaction Improved access Reduced travel Expanded Services Improved outcomes Timely appointments Access to other experts Resources utilization Services in their community Access to CME Cost and Time efficient Additional support
The Trip iple Aim im • IMPROVE ACCESS 1 • IMPROVE QUALITY 2 • DECREASE COST 3
HOW TO ACHIEVE THE TRIPLE AIM PART 1 PROGRAM DEVELOPMENT
GUIDING PRINCIPLES #1 Telemedicine is a tool #2 Program Management can uncover strengths and weaknesses in operations #3 Quality Improvement is Forever #4 Management by facts = DATA #5 Need to see cost benefits from different perspective #6 Keep a sense of humor!
TELEMEDICINE AS A TOOL • Identify gaps in service • Tap the resources • Champions are your best friend IT’S NOT ABOUT THE GADGETS, IT’S ABOUT THE CARE
PROGRAM PLANNING • Administration – IT – Clinical – Operations – Quality • Spend time with specialty provider • Pay attention to details • Document clinical workflow • Always do a pilot – start small, think big • Goal is to integrate into operations of a PCMH • Change Theory
QUALITY IMPROVEMENT • Data Collection • Monitor and Report Outcomes • Continuous Quality Improvement (PDSAs) • Regularly Evaluate Program
MANAGE BY FACTS • Data! Data! Data! • Facts can trump emotion • Facts = Outcomes And remember: A Vision Without a Plan is a Hallucination!
COST BENEFIT IS NOT ALWAYS IN REAL $$$ • Saved travel time/gas for families and enabling staff • Less lost work time for families • Increased volume of visits to PCMH • Relationships between primary care and specialty care • PCP job satisfaction and morale • Changing health care delivery system and policy
KEEP A SENSE OF HUMOR CHANGE THEORY HELPS! • Start Small, Think Big • Communicate for Success & Celebrate Victories • Pause Points: What is working? What is not working? What could be done better? • Identify and Deal with Fears/Concerns • Keep Decision Makers in the Loop • Keep Process Moving Down the Track • Give Feedback (timelines, performance measures) There is no such thing as a small problem
HOW TO ACHIEVE THE TRIPLE AIM PART 2 FRONT LINE STAFF HOLD THE KEYS Excellence in Patient Care Drives Everything
Create a Registry MR # LDL Malb DR Foot Sm Last visit A1C Date Result B/P date Result Date Result Date Result Date Result Exam oke <6 7/26 mild A07362500 10/20/11 10/20/11 7.3 10/20/79 124/79 4/11/11 71 7/26/11 6/21/11 N NPDR mild A07343203 11/28/11 11/28/11 10.3 11/28/11 124/80 3/1/11 38 11/28/11 150 1/5 3/3/11 N NPDR A07317705 11/15/11 11/15/11 5.9 11/15/11 107/72 6/20/11 59 4/8/11 13 7/21 neg 4/8/11 N <6 9/29 ?glauco 3617386 11/01/11 9/8/11 14 11/1/11 106/66 9/25/11 231 9/8/11 9/8/11 N ma 10002 12/06/11 12/6/11 6.4 12/6/11 126/83 12/6/11 ACE-I N A07273833 10/25/11 8/25/11 7.3 10/25/11 129/80 6/2/11 85 8/25/11 16 8/25 neg 8/25/11 yes mild A07228967 12/29/11 11/22/11 7.7 12/29/11 145/85 12/1/11 100 8/16/11 131 8/2 NPDR 11/22/11 N
Care Coordination *Scheduling *Pre-Visit Requirements *Concurrent Chart Review *Coordinate with PCMH Team/Specialty Team *Quality Assurance Reports *Lead Case Conferences *Quality Improvement PDSA
Train Telepresenter History Exam Treatment
Actively Decrease Barriers to Care • Outreach • Insurance Access • Transportation • Language/Cultural Interpretation • Motivational Interviewing/Pt Centered Goals • Education Relationships = Trust
The Finished Product… Here are some examples ……
TeleDentistry Eastman Institute for Finger Lakes Oral Health Community Health
EARLY CHILDHOOD CARIES IN MIGRANT CHILDREN Early onset & increased severity due to cultural feeding practices Prevalence: Migrant > Underserved urban > US general population
Mobile Dental Services • * Lake Ontario ABCD * Red Creek ABCD • *Migrant Summer Schools (Sodus, North Rose, Red Creek) **FLCH mobile dental teams and primary prevention strategy has decreased rate from 60% to 22%** ***For children with advanced decay, pediatric dentist and treatment under sedation or general anesthesia*** For those requiring treatment of ECC….. 15% COMPLETION RATE
LIVE VIDEOCONFERENCING
TELEDENTISTRY Intraoral Camera Digital Images Real Time Images
Bilingual/Bicultural Community Health Workers Outreach Insurance Access Transportation Language/Cultural Interpretation Pediatric Dentistry Access Education Relationships = Trust
TeleDentistry Outcomes 4/10 – 4/14 N = 290 consults Triaged Correctly = 88% Decreased travel costs Decrease in lost work time Improved access to care Decreased time to treatment Decrease no show rates Increased interaction between dental providers 94% COMPLETION RATE 54% require treatment under general anesthesia
TelePeds Neurology URMC Finger Lakes Child Community Neurology Health
TelePeds Neurology Site Visit – Create Remote Office – Registry – Care Coordination – IT Connectivity – Train PA in Neuro Exam – Use PCMH Team – Leverage HIT – Case Conference – Monitor Outcomes – Ongoing QI 2013 Pilot Outcomes: *** Decreased time to treatment (38d vs 60d) *** Exceeded national averages on NCQA performance measures *** 75% had changes or additions to their med regimens *** 87.5% diagnosed with mental health co-morbidity *** 100% referred to behavioral health *** 63% showed improvement in function at school and home *** High provider and patient satisfaction
TeleAC (HIV/AIDS Care) Trillium Finger Lakes Health Community Health
TeleAC TeleAC Pilot Program Clinical Measures Indicator Goal Baseline 7/1/13 End Pilot 6/30/14 Appointment Adherence PCP 85% 57% 91% AC 85% 86% 100% HIV CARE CD4 >500 50% 29% 64% CD4 >200 85% 86% 91% Negative viral load 50% 29% 67% HAART > 95% 85% 71% 73% OI PCP if indicated 100% 100% 100% Prevention Screening TB Testing 85% 86% 80% HCV Screening 85% 57% 100% Cervical PAP 85% 66% 100% Anal PAP 85% Colon cancer screening 85% 86% 50% Annual Lipid Screen 85% 100% 100% Annual urinalysis 85% 71% 60% A1C 85% 71% 100% STD Screen 85% 86% 92% PHQ 9 85% 29% 80%
TelePsychiatry FL Health & Finger Lakes John D Kelly Community Behavioral Health Health Unit
TelePsychiatry Outcomes 2010-2012 • 55% had decrease in PHQ9 scores • Mean time to consult = 19 days • Mean time to treatment = <24 hours • High patient and provider satisfaction • 39% lost to follow up • 0% referred to ED • 17% referred to higher level of care (Article 31)
Tel eleDia eDiabetes betes Fundus Photography in Primary Care
So Sodus us Com ommun unit ity Healt lth h Retinopa inopathy thy Pi Pilo lot Screeni eening ng Resul ults ts
SODUS COMMUNITY HEALTH DIABETES QUALITY INDICATORS 100 90 80 70 60 May '11 50 March '12 40 June '12 30 20 10 0 A1C < B/P < LDL < Kidney Foot DRS 7 130/80 100 check Exam National Committee on Quality Assurance(NCQA) > 40% >25% >36% >80% >80% >60% FLCMH 1.2012
USING TELEHEALTH TO ACHIEVE THE TRIPLE AIM
THANK YOU! For more information: TerryY@flchealth.org 585-314-7548
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