The Role of Telemedicine in Home Monitoring and Long Term Care June 7, Penny S. Milanovich President UPMC Visiting Nurses Association

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1 The Role of Telemedicine in Home Monitoring and Long Term Care June 7, 2012 Penny S. Milanovich President UPMC Visiting Nurses Association

2 Cost of Chronic Conditions An average of 40-50% of healthcare spending in Organization for Economic Co-operation and Development (OECD countries) which includes Europe, Japan and the United States is for care of disease and conditions of the elderly 1 1 (Intel White Paper: Connective Technologies Support the Emergency of New Models of Care, 2006) 2

3 Cost of Chronic Care Hospitalizations account for about one-third of the annual $2 trillion US cost of healthcare. 2,3 A total of 17.6% of all Medicare hospitalizations are due to 30-day readmissions at a cost of $15 billion. 4 Approximately 75% of rehospitalizations are deemed to be avoidable or potentially preventable. 5 2 Fazzi R,Agoglia R, Mazza G, et.al. The Briggs National Quality Improvement/Hospitalization Reduction Study. Caring. 2006; 25: Alliance for Health Reform. Covering health issues July 17, Medicare Payment Advisory Commission Report to Congress: Reforming the delivery system. February 18, Jiang H, Russo C, Barrett. M. Nationwide frequency and costs of potentially preventable hospitalizations. November 16,

4 Cost of Chronic Conditions Within the United States, almost one in five patients age 65 and over are readmitted within a month of hospital discharge. These readmissions are most often due to inadequate discharge planning, poor coordination between hospital and community and the lack of effective community-based care. 6 6 Jencks SF, William MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. New England Journal of Medicine 2009; 360 (14):

5 Cost of Chronic Care Within the state of Pennsylvania: 80% of healthcare costs and hospitalizations 91% of filled prescriptions 96% of total Medicare costs are attributed to chronic diseases 7 Medicare Costs 2008 State of Pennsylvania 4% 96% 7 (Pa. Prescription for Pa, February, 2008) Chronic Conditions Other 5

6 UPMC Visiting Nurses Association Part of a large integrated health care system Home health organization that provides healthcare services to patients within their homes Services are physician ordered and intermittent in nature 6

7 UPMC Visiting Nurses Association Statistics Census Average daily census: 3,800 patients Admissions FY11 admissions: 36,116 Visits FY11 visits: 452,860 Area Coverage area is expansive: Requiring staff to drive a total of 3,079,344 miles in FY11. 7

8 UPMC Visiting Nurses Association Supports the Health System s not-for-profit Core Mission of clinical excellence, advancement in science and education Contributes to the integrated delivery network through the development and refinement of post acute care services. 8

9 Introduction With adequate education, medication management, multi-disciplinary care and the implementation of a telemonitoring program, patients with chronic diseases that are provided appropriately and timely intervention will realize: Reduction in exacerbation of disease process Reduction in costly readmissions to the hospital Reduction in frequent visits to the Emergency Department 9

10 Disease State Management Program Goals Improve patient quality of life, reduce mortality without increasing utilization of healthcare resources Reduce cycle of Emergency Department visits Provide appropriate and timely interventions to prevent exacerbation of disease process Reduce rehospitalizations within 30 days at targeted hospitals Increase patient compliance with care Allow patient to remain independent resulting in improved patient satisfaction 10

11 Disease State Management Program Benefits Provides clear, concise and accurate patient data in a timely manner Permits opportunity for trending of patients specific data Provides a scalable solution for automated tracking Elimination of travel time for patients and providers Assists in addressing the growing nursing shortage 11

12 Methods for Success Develop formalized Disease State Management (DSM) Programs Develop criteria for admission into DSM programs Hire appropriate staff for program oversight Develop partnerships with affiliated hospitals, physicians and payors Introduce Telemonitoring as an adjunct to care 12

13 Disease State Management Programs High Risk Patient Populations Congestive Heart Failure Chronic Obstructive Pulmonary Disease Pneumonia Diabetes Wounds 13

14 Heart Failure Approximately 5.8 million Americans suffer from congestive heart failure (CHF), with more than 670,000 new diagnoses per year. In 2010, the cost of CHF, to include health care services, medications and lost productivity, was estimated at $39.2 billion. 8 8 Lloyd-Jones D. Adam RJ, Brown TM, et al. Heart Disease and Stroke Statistics 2010 Update. A Report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2010; 121; el-e

15 Heart Failure It is the most frequent reason for hospitalization and the most common discharge diagnosis in those over age 65. Studies have consistently shown high readmission rates, ranging from 10%-50% re-admission within three to six months of discharge. 9, 10 During 2010 in the state of Pennsylvania, the readmission rate for heart failure patients within 30 days of discharge was 24.3% Dang, et al. Evaluating the Evidence Base for the Use of Home Telehealth Remote Monitoring in Elderly with Heart Failure. Telemedicine and e-health. 2009; 15 (8): Woodend AK, et. al. telehome monitoring in patients with cardiac disease who are at high risk of readmission. Heart & Lung. 2008; 37: Pennsylvania Healthcare Cost Containment Council. Hospital Readmissions in Pennsylvania April 2012; 1 Print. 15

16 Program Components for Heart Failure Developed Patient Admission Criteria Diagnosis of Class III or IV Heart Failure History of repeated hospitalizations History of frequent Emergency Department visits History of non-compliance Established parameters of care Supplemental telephone assessments Depression Inventory assessment Nutritional Counseling Institute EDU Turn Program 16

17 Telemedicine: An adjunct to patient care What is Telemedicine? Telemedicine is defined by the American Telemedicine Association as the use of medical information exchanged from one site to another via electronic communications to improve patients health status American Telemedicine Association (2007) ATA Defining Telemedicine. January 21,

18 Telemedicine: An adjunct to patient care What Does this mean? Telemedicine (Telemonitoring) provides access to real time patient data that is transmitted via a POTs (plain old telephone) and/or broadband line to the Disease State Management Coordinator s desktop. This allows clinicians to assess data: vital signs, pulse oximetry, weight, track their progress and make recommendations to their plan of care if discrepancies are identified. Early intervention often can prevent a readmission to the hospital or unnecessary visit to the Emergency Department. 18

19 Telemedicine: An adjunct to patient care EQUIPMENT DECISION: Interactive vs. Non-Interactive 19

20 Telehealth: Interactive (Video) A live, two-way connection via telephone lines allows health care providers and patients to have direct audio and video access. Patients and providers engage in virtual check-ups using medical instruments-such as telephonic stethoscope, blood pressure meter, glucose meter, pulse oximeter and a digital scale. The readings are transferred to the clinician s desk top. The clinician, then can easily track patient s progress. Life View Interactive This monitor is specific to UPMC Visiting Nurses Association. 20

21 Sample Patient Data Chart 21

22 Telehealth: Non-interactive A non-interactive unit is placed in the patient s home with peripherals appropriate for the management of their condition. The clinician prepares the monitor by selecting disease specific algorithms and educational questions with answers to assist the patient to learn how to manage their disease. When the patient initiates the session by tapping on the screen, he or she is then directed through the program in taking their vital signs, answering the questions and completing the educational components. The data is then sent automatically to the clinician station for monitoring. In-Life Non-interactive This monitor is specific to UPMC Visiting Nurses Association. 22

23 Geisinger Health System Study Geisinger Health System implemented a large scale*, two year telehealth program with an interactive voice response protocol which included a post-hospital discharge telemonitoring system used as an adjunct to case management oversight for the Medicare population *875 patients were compared to 2,420 matched control patients who were only case managed Primary goal: Reduce 30 day hospital readmission 23

24 Geisinger Health System Study Geisinger quasi-experimental study results demonstrated that patients who received a combination of telemonitoring and case management had a statistically significant result, reducing all-cause 30 day readmission rates by 44% compared to a control group who had case management but not interactive video response protocol Graham G, Tomcavage J, Salek D, Sciandra J, Davis D, Stewart W, Postdischarge Monitoring Using Interactive Voice Response System Reduces 30-day Readmission Rates in a case-managed Medicare Population, Medical Care, Volume 50, No. 1 January pp Geisinger Study 30 day readmission rates Down 44% 24

25 Partnership with Third Party Payors Payor #1 Home Health-oversight and intervention Collaborative data collection and analysis 42 patients participated Over 70% of participants had monitors for 60 days or more 25

26 Payor #1 Pilot identified patients who met specific criteria: Medicare patients Diagnosis of Heart Failure Member or caregiver must understand the program and use of equipment Member living situation can vary (live alone, Caregiver, Assisted Living) Monitors installed to measure blood pressure, pulse, weight and oxygen saturation 26

27 Payor #1 Outcomes Realized The use of Telemonitors significantly reduced per member per month costs of patient care on an average of $1,000 The monitors were tolerated well by 64% of the population still in the program Emergency Room visits demonstrated a slight increase following monitor placement 27

28 Payor #1 Outcomes Realized Average admissions per month for pilot population of 42 patients showed a statistically significant decrease following monitor placement in two categories: Hospital Admissions Decreased 47% Readmissions within 60 days Decreased 68% 28

29 Partnership with Third Party Payor Payor #2 Three-year Pilot identified impact on utilization and cost of health services for patients with Congestive Heart Failure (CHF) 260 CHF patients participated compared to 512 CHF patients discharged without monitors 29

30 Payor #2 Pilot identified patients who met specific criteria: Patients had diagnosis of Congestive Heart Failure Required home care services Monitors installed to measure blood pressure, weight, oxygen saturation, heart rate Outcomes calculated for 1-30 days after hospital discharge 30

31 Payor #2 Results Within 30 days of hospital discharge, monitored patients had a higher number of total visits (Primary Care Physician as well as Specialist) Total Medical expenses were lower for the monitored group during the first 30 days resulting in a total medical expense savings of $2,469 per patient Greater percentage of comparison group were readmitted to the hospital (25% vs. 17%) 31

32 Payor #2 Monitored patients had fewer inpatient admissions, shorter length of stays, lowered inpatient expenses and less Emergency Department visits. Pattern suggest telemonitoring may have steered patients to outpatient services, increased patient compliance with recommendations of care following earlier detection of decomposition. Study illustrated the overall cost benefits of telemonitoring. Study drilled down to examine costs such as testing, imaging and pharmacy costs. This provides policy makers opportunity to identify attainable domains to target. 32

33 UPMC Visiting Nurses Association Telehealth Program 33

34 UPMC VNA Telehealth Heart Failure Readmission Rate FY 2005 thru FY ,324 Patients 4.15% Readmission Rate 138, 4.15% 3186 Total # of patients readmitted for Heart Failure <31 days 34

35 UPMC VNA Telehealth Heart Failure Readmission Rates 25% 20% Average of 554 Telehealth Patients/Year 2010 Pennsylvania Heart Failure Readmission Rate 24.3% 15% 10% 5% 5.7% 5.2% 6.1% 2.8% 2.10% 3.1% 0% FY2006 FY2007 FY2008 FY2009 FY2010 FY2011 % HF Readmission Rate 35

36 Technology: Foundation of Cost Reduction and Care Quality Improvement Healthcare s Change Agent Incredibly beneficial to health care field, not only through reducing costs, but also as an adjunct for an effective delivery system of preventive consistent care Increases ability to monitor patients remotely through consistent, constant data capture and analysis 36

37 Technology: Foundation of Cost Reduction and Care Quality Improvement Allows for centralizing the control and management of patient data coupled with on call clinicians to promote patient triage/clearing to determine appropriate interventions for care/treatment Results in maximization of efficiencies through providing the right care in the right setting at the right time 37

38 Technology: Foundation of Cost Reduction and Care Quality Improvement Promotes real time and accurate patient data availability for an entire Health System through coordination for all patient services between hospital and community Provides capability of organizing care over lifespan of individual patients with chronic care conditions across settings Provides opportunities to raise awareness of your Health System Creates opportunity for a Health System to establish and maintain a connectedness with a Patient for Life 38

39 Barriers to Wide-Spread Adoption of Technology High initial start-up costs for devices and software Inadequate reimbursement for telemonitoring services Lack of patient-centered care coordination and care transition models Lack of coordination with existing federal or state resources Lack of integration and interoperability among various technologies Lack of reliable internet access Concerns about privacy and security 39

40 Projecting the Future of Telehealth Like many of the unsung heroes of our healthcare system, telehealth markets address some of our most serious healthcare problems in a behind the scenes, yet powerful way. Telehealth applications continue to push our healthcare systems to new heights of efficiency and effectiveness. Over the next five years, telehealth markets will transition from the best kept secret in healthcare, to being consistently demanded by professionals and patients alike." ~Zachary Bujnoch, Senior Industry Analyst Frost & Sullivan 40

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