11 date april 19th, 2013 (friday) 8:00am-7:30pm location location ucsf mission bay conference center...
TRANSCRIPT
11
DateApril 19th, 2013 (Friday)
8:00AM-7:30PMLocation
UCSF Mission Bay Conference Center
1675 Owens Street, San Francisco, CA 94158
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Starting point
People are not the sum of their
disease states
People typically have >1 condition
Loneliness as critical risk factor
43% of 1,604 seniors 60+ reported feeling lonelyMore likely to develop or experience decline, difficulties in:
• Activities of daily living
• Upper extremity tasks
• Mobility
• Climbing
Associated with nearly 2x increase in risk of death
- Archives of Internal Medicine, June 2012
We can do better …•Medicare beneficiaries with two or more conditions and functional limitations have the highest costs
15% of beneficiaries
32% of Medicare costs=
Individuals who are dually eligible for Medicare and Medicaid are a key subset of this population
Using Technology to Support Care for Individuals with Complex Needs
Lisa Mangiante, MPP, MPHApril 19, 2013
What is a “Complex” Patient?
No single definition, similarities across populations
Medical condition(s) often complicated by psychosocial issues Social isolation Decreasing independence Loss of familial relationships Lack social supports Depression (in elderly Medicare, this is most common) Other serious mental illness (SMI)
Navigating the health system confusing & care is fragmented, resulting in lack of engagement and non-adherence
While often many things going on that affect health, it’s not always about number of issues, but the particular combination
Examples of “Complex” PatientsUninsured/Medicaid/Dual Eligible (from
FUHSI)65 % chronic medical conditions, many with
2 or 354% substance abuse disorders
33 % mental illness45% homeless
Seniors w/ Medicare (from IOCP, CMHCB)69% Congestive Heart Failure
43% Pain32% Diabetes Mellitus
29% Depression/Psychological (under-reported)25% Gastrointestinal18% COPD/ Asthma
Often more than one condition
Use of Technology Riverbend Community Mental Health Center
Purpose: Assess feasibility and effectiveness of telehealth + care management for people with Serious Mental Illness (SMI) and
co-morbid medical illness
Major DepressionSchizophrenia or Schizoaffective Disorder
BiPolar DisorderPTSD
PlusCongestive Heart Failure
COPDDiabetes
Chronic Pain
• Received remote monitoring device to help manage their medical condition (vital signs, self management & education)
• Used almost daily (~5x per week)
Phase I Successful…
Clients with SMI were engaged relatively easily to use the device (Health Buddy)
Paranoia or fear of the device present only in a very small number of clients
Compliance was high - clients anthropomorphized the device so felt less isolated and more supported
by clinical team
Positive effects on health measures, symptoms, self-management and illness knowledge
Results were especially strong for clients with diabetes
Clients wanted more – prompts helped with specific techniques that helped manage symptoms
…And Led to Phase IIPurpose: Assess effectiveness of telehealth + care management for
people with SMI and psychiatric instability
2 hospital admissions or ER visit in past year, or>10 calls to crisis line over 3 months
Several dimensions of improvement possiblepsychiatric symptoms
service useillness self management
improvements in:
High cost service use, including ER, crisis team and hospitalizations
Psychiatric symptoms (reduced symptoms, depression, overall severity)
Illness self-management and knowledge
Sense of well-being
Quality of life
Use of Technology Care Management for High Cost Beneficiaries Demo
•Purpose: Assess feasibility and effectiveness of telehealth + care management for seniors with complex illness
Seniors with Heart Failure, Diabetes and COPD
Often with co-morbid conditions
High risk due to frequent hospital admissions and ED use and risk scoring techniques
Results
Reductions in cost and hospital use (9% - 13%) for entire population in study
Most dramatic in CHF, followed by COPD
Results achieved with only 1/3 actually using device
Parting Thoughts
Both examples used technology to support the work of a person (not standalone)
Workforce impact: technology in both examples enabled care managers to maintain higher
caseloads
MD impact: patients came to visits better prepared and with better understanding of their conditions,
so time more productive
CMHCB results were dramatic: greater patient engagement in actually using technology could
achieve huge outcomes – but issue not specific to technology
Citations• Lewin Group. Summary report of evaluation findings.
Published by the California HealthCare Foundation and The California Endowment. 2008. www.chcf.org.
• Sample Population Profile provided courtesy of Milliman based on Medicare 5% Sample 2010, Northern California
• Riverbend Example: unpublished data
• Baker L, Johnson S, McCauley D, Birnbaum H. Integrated telehealth and care management program for Medicare beneficiaries with chronic disease linked to savings. Health Aff (Millwood). 2011; 30(9):1689-1697.
VA Care InnovationsTransforming care delivery for improved patient &
provider experience
VA Overview•22 Million Veterans
•8.75 Million VA Enrollees
•6.2 Million Patients Treated
VA Patient Aligned Care Team
•Patient-centered
•Ongoing relationship with a primary care team
•Patient is full partner with team
•Whole person orientation
•Improved communication
VA Telehealth - 2012•Provided care to 500K patients
•1.4 million episodes of care
•49% Rural patients
•29% annual patient growth.
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Clinical Video Telehealth •150K patients – FY2012
•44 clinical specialties
•Access to specialist and primary care services
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Store-and-Forward Telehealth
•260K patients - FY2012
•Local acquisition of clinical Images
•Remote interpretation
•Care Areas:
•TeleRetinal Imaging
•TeleDermatology
•TelePathology. 20
Home Telehealth•120K patients –
FY2012
•Chronic care management
•Acute care management
•Health promotion/disease prevention.
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TeleMental Health• 217K telemental health consultations - FY 2012
• 76K patients
• over 800,000 consultations since FY2003
• Areas of focus:
• post-traumatic stress disorder
• Depression
• Bipolar disorder,
• behavioral pain
• Evidence-based psychotherapy
• compensation and pension exams
Telehealth Outcomes•Utilization Reduction
•Bed days of care – 58%
•Hospital admissions – 38%
•Mental health care bed days of care - 56%
•Annual Savings - $2,000 per patient
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Patient Satisfaction•Home Telehealth - 85% mean score
•Store-and-Forward Telehealth –96% mean score
•Clinical Video Telehealth - 93% mean score
VA Innovation Center•Accelerating VA transformation
•Employee innovations
•Industry innovations
•Prize challenges
•Special projects
Strategies for Designing Programs and Products for
Persons with Complex Needs
Health Technology ForumApril 19, 2013 San Francisco
David Lindeman, PhDDirector
Center for Technology and Agingwww.techandaging.org
CTA Technology Demonstration Grants 2010-2012
Medication Monitoring and AdherenceRemote Patient Monitoring
Technologies for Improving Post Acute Care Transitions
Mobile Health Solutions
Improve efficiency of care delivery
Improve health outcomes
Reduce the cost of care
Improve chronic disease management
Increase the rate of adoption
Program Impact: Advancing the Triple Aims
12 programs focused on reducing 30-day readmissions – 10 succeeded in reducing readmissions – 5 programs achieved a reduction of 50% or more.
All 15 programs measuring patient satisfaction and engagement with care management reported marked improvements
10 programs measured cost savings and ROI – 9 demonstrated significant cost savings and positive ROI
Program Impact: Demonstrating Success At Scale
Of 22 programs, 10 have demonstrated scalability within their organizations or externally to other organizations and 10 others are capable of being taken to scale.
Of the 10 programs taken to scale, 6 have been expanded throughout a health care system, while 4 have been replicated nationally.
Central Texas Coach Tool
mHealth Diabetes ManagementHealthInsight
•Regional Health Care System and Community Clinics Salt Lake City, Utah – ONC Beacon Community
•SMS-based mobile program •Improving diabetes care management and education in safety net population
Care4Life. Reminder:
Time to check your
BEFORE meal glucose.
Reply with your
BEFORE meal glucose
reading (e.g. 125).
Family Health Centers of San Diego • Community Health Center and Clinic, San Diego, CA
• SMS-based mobile program
• Improving diabetes education and behavior change in Spanish-speaking safety net population
User can set glucose reminders according to their doctor’s recommendations (e.g., before breakfast daily)
System sends glucose reminders & provides immediate feedbackUser can track all glucose recordings on web portal
System sends education messages & tips
Care4Life | Glucose Monitoring/Education
Care4Life. Reminder:
Time to check your
BEFORE meal
glucose. Reply with
your BEFORE meal
glucose reading (e.g.
125).
Care4Life. Before meal
readings under 70 can
be dangerous. Do you
know what to do when
readings fall below
your target? Text LOW
for more info
Glucose recordings graph
on web portal
Glucose reminder System feedback
Care4Life Diabetes Texting Program
•Lessons Learned
Patient driven: Patient engagement – the holy grail
Patient enrollment: Multiple methods to enroll patients
Provider efficiencies critical: Minimal cost to provider; no new work; build enrollment and program operations into workflow
Patient Data: Data can motivate and empower clinicians
Challenges: Scalability; attention to patient privacy; linkage to EMRs
Telehealth and Remote Patient Monitoring for CHF and COPD
Sharp HealthCare • Integrated Delivery System, San Diego,
CA• Remote patient monitoring to improve care management for patients with CHF
and COPD• Patients with multiple chronic
conditions; Medicare, Medicaid and uninsured
Care4Life. Reminder:
Time to check your
BEFORE meal glucose.
Reply with your
BEFORE meal glucose
reading (e.g. 125).
Goal: Reduce 30-day readmissions by 30% from 22% to 15%
Patient Population: Underserved (Medi-Cal, Unfunded, County
Medical Services) with primary or secondary diagnosis of CHF or
COPD
Intervention: Mobile health device used daily to measure pulse oximetry and functional status via yes/no questions
coupled with nurse education and health coaching which
included at least two home visits
Sharp HealthCare Remote Patient Monitoring
Lean Six Sigma Department
Lessons Learned
• Program Staffing/Coordinator: Time invested in recruitment of staff
resources is time well spent
• Patient Selection and Enrollment: Program can’t help every patient;
inclusion/exclusion criteria is critical
• Assessment of Patient Environment/Resources: Lack of landlines;
lack of primary care physicians
• Organizational Support: Need for senior /executive leadership
support
Sharp HealthCare RPM Program
mHealth Medication AdherenceFront Porch Center for Technology
Innovation and Wellbeing • Continuing Care Retirement Center, Los
Angeles, CA• Cell phone texting
• Addressing medication adherence among active, independent older adults using a
mHealth medication texting solution
Care4Life. Reminder:
Time to check your
BEFORE meal glucose.
Reply with your
BEFORE meal glucose
reading (e.g. 125).
Front Porch mHealth Program
Demonstrating Senior Medication Adherence with Cell Phone Texting
Reminders
Goal: Improve medication adherence among active, independent older adults through mHealth solution.
Outcomes: Mobile alerts and monitoring led to
improved medication adherence. Replicable model that combines
education, training, and other resources.
Front Porch Medication Adherence Program
•Lessons Learned Utilization: Significant variation in consumer utilization
Patient engagement: Consumer champions are key; embrace feedback & engage in dialogue
Communications: Personalize discussions to consumers and organizations
Technology integration and interoperability: Need to consider at outset
Plan for success: Make sure program will scale; have a Plan B
Using Technology to Support Persons with Complex Needs
Technology is 10% of the issue
90% of technology deployment and adoption is:
• Organizational leadership - Champion
• Organizational familiarity with change management
• Staff engagement and buy-in
• Work flow processes/standardized
• Patient selection, engagement, consumer champions
• Technology deployment strategy
• Communication and staff/patient training
Tools and Protocols
ADOPT Toolkit
ROI of RPM Calculator Do-it-Yourself Tool
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