cerebral palsy of new york state telemedicine project · 2019-10-31 · cerebral palsy of new york...
TRANSCRIPT
Cerebral Palsy of New York State Telemedicine Project
Meghan Calichman Matthew Kaufman, MD
Cerebral Palsy Associations of New York State
2019 Annual Conference
Agenda
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Review of the State of Telemedicine
Impact of ER Utilization on Individuals with I/DD
Telemedicine and Provider Agency Staff
Status of Transformation Grant
Future Directions
Telemedicine Hype
• Worker absenteeism cost businesses $226 billion annually1
• Telemedicine can save businesses $6 billion annually2
• 90% of large employers are offering telemedicine in 20173
1. Greenwell C, “Worker Illness and Injury Costs US Employers $225.8 Billion Annually,” CDC Foundation https://www.businessgrouphealth.org/pressroom/pressRelease.cfm?ID=281, TowersWatson, “Current 2. Telemedicine Technology Could Mean Big Saving 3. Beckers Hospital Review, August 2016
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Telemedicine Hype
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Telemedicine Hype and Gadgets
• Telemedicine Avoided Hospital Visit 29% of Time in SNFs (AJMC, 2018) 5
Telemedicine Data
• RAND study- 88% of telemedicine represented new use 1
• Veterans Health Administration- telemedicine produced $6500 annual savings per person 2
• 29% of SNF patients avoided hospital admissions with telemedicine 3
• 85% reduction in ER use for people with I/DD4
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1. https://www.rand.org/news/press/2017/03/06.html2.2017, AAMC.3. August 2018, AJMC4. StationMD Data
Telemedicine Policy
• Congressional Budget Office Concerned about higher utilization*
• State Medicaid Programs increasingly cover telemedicine and now reducing originating site restrictions
• Parity Laws becoming more prevalent
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• *CBO Blog. Telemedicine. Congressional Budget Office. July 29,2015. www.cbo.gov/publication/50680
People with I/DD and ER Utilization
• People with I/DD use the ER significantly more than other groups
• Five times more likely to use for UTIs and pneumonia
• People with I/DD get hospitalized more frequently than other people
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People with I/DD in the Hospital
• Up to 5x more likely to have complications
• More likely to get re-hospitalized on discharge
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Causes of Frequent ER Use for People with I/DD
High Risk/Multiple
Co-Morbidities
Lack of Access to Medical Care
Otherwise
Regulatory Requirements
Primary Doctor Lacks
Immediate Availability
How can individuals with I/DD access personalized care in a non-disruptive and stable environment?
Challenges for Providers
Regulatory compliance
Complex medical care needs
Staffing• Overtime pay• Shortages, scheduling• Turnover
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Patient TraumaExposure to
infection
Unspecialized CareDisruption of
RoutineSuboptimal Care
Unnecessary TestsUnnecessary
Hospitalizations
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The Problem with the ER – Expensive yet Suboptimal Care
=+
+ Excessive Costs=
Why is cost particularly important for this population?
• Expenditures have increased at compound annual growth rate of 5% over last 10 years
• Inefficiencies, inconsistencies, redundancies= bad care• Among last populations to transfer to managed care due to complexity
of their medical conditions• Poor coordination between HCBS services and medical side
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Changing approach: Person Centered
Self-Determination/Independence
Individualized/Integration
Emphasis on Quality of Life
StationMD Solution Addressed Key Expectations
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Our Goals
Expand Access to the Optimal Care
Decrease Healthcare Costs
Improve the lives of people with I/DD and
their caregivers
Help vulnerable populations lead healthy, independent, and productive lives.
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StationMD’s Experience Leads to Specialized Telemedicine Care
Founded by four experienced ER doctors
A healthcare solution delivering sophisticated medical care for high risk/multiple co-morbidities
All doctors are emergency physicians, trained to handle complex medical issues
Our SolutionProblem Solution
• Lack of Access • Tehealth technology Removes the Geographic Impediments
• Suboptimal care for specialized needs • SMD Doctors have specialized I/DD training
• Access to Medical records/database• Personalized care provided in safety of
person’s own environment
• Primary Care Evaluation Unavailable Off-Hours
• StationMD System is on and Available 24 hours/day
• Regulatory pressures • StationMD Doctors evaluate immediately
• Provide Full Documentation 17
StationMD Telemedicine Augments but does not Replace Primary Care
StationMD Primary Care
• Addresses high glucose readings with immediate medication adjustment
• Manages daily meds for chronic conditions (i.e., insulin regimen, cholesterol medications)
• Medicationrefills/clarification/reconciliation
• Prescribe long-term medications
• Evaluates after an incident to meet regulatory requirements
• Performs regular “check-ins” as needed
• Manages long-term goals of treatment
• Handles urgent medical issues • Monitors medical screening issues (i.e., colonoscopy)
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Back-end System that Assures Quality
StationMD offers immediate access at anytime to high-quality ER doctors, specially trained in the care of people with I/DD.
Copyrighted treatment guidelines
Doctor training
Quality reviews
Educational series
A turnkey, packaged model that can be rolled out with success anywhere in the country
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Creating Standards of Care
Standardize Guidelines Created by Clinical Team for Optimal Quality of Care
UTI Dyspnea
Hyperkalemia Chest Pain
Increase in BUN/Creatine PT/INR
Abnormal CXR Hyperglycemia/Hypoglycemia
Vomiting Foley Care
Hypotension Cellulitis/Abscess
Infection/Sepsis Abdominal Pain
URI Anemia
Elevated blood pressure Constipation
Falls GI Bleed
Agitation PEG tube care
Fever Influenza
Seizure C-diff
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Reporting/Data Analysis
Comprehensive reporting package
Monthly data by site
• Number of visits/calls by• Hour of Day• Day of Week• Physician• Outcome i.e. observe, transfer, etc.• Diagnosis
Comparison on before and after implementation data with regards to transfers to Emergency Departments and other regulatory reporting.
The StationMDProcess Step-by-
Step
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Change in Condition Activate24 year-old female with CP, asthma• Develops cough• Fever of 101°• Oxygen saturation 90%
• Facility Staff initiates SMD encounter• StationMD doctor reviews patient’s
records
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Physician Assessment• Telemedicine consultation initiated• A physical exam is performed
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Treat Patient Share Treatment Plan/Follow-up• Asthma exacerbation and Respiratory infection• StationMD provider prescribes nebulizers,
steroids and antibiotics
• Follow-up exam by StationMD doctor• Breath sounds show improvement. Patient
comfortable. Oxygen 95%• Documentation in EHR, Primary Care Physician Notified
Unnecessary trip to ER avoided
If patient had not improved-StationMD would contact ER to expedite visit & review history
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Other Typical Cases (not always emergent!)
Medication Refill Order clarification Behavior change Constipation
Evolution of Transformation
Grant in NYS
Initial Phase- DSRIP Grant
• 2 ICFs• 26 Individuals• 89% Treated in place• 85% Decrease in ED use compared to historical data
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Second Phase- DASNY Grant
• DASNY- Dormitory Authority of the State of NY Nonprofit Infrastructure Capital Investment Program Grant
• 598 Individuals• 104 sites• 2018 Data-94% Treated in place• 2019 Data (through September)-86% Treated in place
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Third Phase- DOH Transformation Grant
• Statewide Health Care Facility Transformation Program Grant• 7315 people • 1028 sites• We are excited to get started!
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Results to Date for all I/DD Clients
• 86-89% Treated in place• 2018-all IDD clients for StationMD-89.1% observe in place• 2019-all I/DD clients for StationMD-86.9% observe in place
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320
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Jan19 Feb19 Mar19 Apr19 May19 Jun19 Jul19 Aug19 Sep19 Oct19
Visits by Month of Service by Outcome
ER Transfer
Avoided ER Transfer
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Most calls result in avoided ER transfers across diagnoses
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Proven Outcomes
85%
Data for Individuals with I/DDMarch 2016-September 2019
StationMD Visits by Outcome
Time Period % Observed in Place
03/2016-12/2016 86.4%
01/2017-12/2017 86.0%
01/2018-12/2018 89.1%
01/2019-09/2019 86.9%
87.1% of StationMD Clients with I/DD Are Treated in Place
Historical Data from Clients Demonstrates an 85% reduction in
ED Transfers
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StationMD’s Solution is Growing
Skilled nursing facilities (nursing homes; rehab
centers)
~3000 patients covered
daily
Over 6,800 calls in 2018
Payer Partner
Camp & school
programs
Rural Urgent Care/ Clinic
127 group homes/ adding 1000+
in 2019
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Significant Savings for Provider Agencies & Payers
*Assumes 3-day LOS for admissions
Estimated I/DD Agency SavingsNumber of Consumers
Est. ED Visits in 12-month period
Est. Reduction in ED Visits
200 440 374
Estimated Payer SavingsEstimated 123 of 374 ED Transfers were Avoided
Hospital Admissions
StationMD Telemedicine Estimated Cost Savings
Site Loss of Bed Revenue*
~Cost of Site Bed/Night
Savings
369 Nights $500 $184,500
Site Transportation Costs
~Cost of Transport Savings
176 $500 $88,000
Total Hrs. 3 Staff Members to Cover Avg. ED Visit
StaffSalary/Hr.
Savings
5,610 $15 $84,150
Total Projected Annual Savings for Agency
$356,650
Averted ED Transfers
Average Cost/ED Visit
Savings
251 $1,000 $251,000
Averted HospitalAdmissions
Average Cost/TopDX w. Avg. LOS of 3 Nights
Savings
123 $15,000 $1,845,000
Total Savings (Facility & Payer) $2,452,650
Total Projected Annual Savings for Payer $2,096,000
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Reimbursement: How can we create a sustainable model?
Per member/per month model of
reimbursement with unlimited calls
Shared Savings Model that includes Payer and Telehealth
Provider
Shared Savings Model that Includes
Provider Groups
Medicaid Waiver System