Telehealth Medical Home Model:

Strategies and Successes

Presented by: Bonnie Britton, MSN, RN

Telehealth Clinical Network Director/Development Dir.

Eastern Montana Telemedicine Network RetreatAugust 31, 2009

Roanoke Chowan Community Health Center

RCCHC’s Mission:• Improve health status of underserved and indigent individuals in

northeastern North Carolina by:• Enhancing access to quality health care• Implementing coordinated health care delivery best practices

Located in rural North Carolina• 17 PCP at 3 clinics serving over 14,500 patients

Population:• 21% uninsured• 41% high school completion• 70% African American

Health Disparities• Cardiovascular Disease• Diabetes Mellitus• Hypertension

Barriers to care• Transportation• Economic Status• Low literacy

Roanoke Chowan Community Health Center

Medical Home Model

• Prevention

• Primary Care

• Chronic Care Management

• Patient Education

• Coordination of Care

• Community Outreach

• Longitudinal Care

Patient Provider Telehealth Network

• Driven by PCP

• Individualized to patient

• Daily remote monitoring

• Daily RN chronic care management

• PCP responds to critical indicators allowing early detection and intervention

• Follow-up with patient by PCP

Patient Provider Telehealth Network

NC HWTF Health Disparities Phase I Goals

• Reduce health disparities

• Increase access to care

• Overcome barriers to care

• Contain health care expenditures

• Create community based telehealth network

In-home daily remote monitoring• Objective monitoring (BP, Pulse, Blood Sugar, O2

saturation, Weight)

• Subjective monitoring (signs/symptoms)

Daily Chronic Care Management• Medication compliance assessment

• Nursing health assessment

• Education

PCP intervention and patient follow-up as needed

PPTN Phase I Target PopulationsCVD, DM, HTN

In-home monitoring• 198 CVD/DM/HTN patients

Kiosks screenings• 43 population based CVD/DM/HTN screenings

for 2,507 citizens

PPTN Phase I

Populations Served

Enhanced self-management skills• Increased self care• Empowered patient/caregiver

Improved patient health status• Decreased HgA1c• Decreased FSBS• Decreased BP• Decreased weight

In-home Patient Outcomes

Patient Impact

• Increased access to medical care

• Reduced health disparities

• Increased satisfaction

• Increased compliance to medical regimen

In-home Patient Outcomes

66 40 34

-

10

20

30

40

50

60

70

Number of

Hospitalizatons

Prior During Post

Patient Hospitalizations

n = 17n = 48 n = 16

Total Number of Hospitalizations

Prior Telehealth: $1,693,698 (316 Bed Days)

During Telehealth: $626,387 (154 Bed Days)

Post Telehealth: $503,953 (157 Bed Days)

n = 64 In-home patients

Telehealth patient hospitalizations decreased 39% from 6 months prior to telehealth to during telehealth. Patient hospitalizations decreased 48% from prior to telehealth to post telehealth.

RCCHC / PPCTN Patient Charge Data Ending March 2008

Analyzed charges are related to diseases being monitored.

Total Number of Emergency Department Visits

Before Telehealth: $83,580

During Telehealth: $58,159

After Telehealth: $35,590

30 17 21

-

5

10

15

20

25

30

Nu

mb

er

of

ER

Vis

its

Prior During Post

Patient Emergency Room Charges

n = 17 n = 14n = 10

n = 52 In-home patients

Telehealth patient ED visits decreased 43% from 6 months prior to telehealth to during telehealth. Patient ED visits decreased 53% from prior to telehealth to post telehealth.

RCCHC / PPCTN Patient Charge Data Ending March 2008

Analyzed charges are related to diseases being monitored.

Total Number of Hospitalizations

Prior to Telehealth: 66 (316 days total) and 30 ED visits

During Telehealth: 41 (154 days total) and 17 ED visits

Post Telehealth: 33 (157 days total) and 21 ED visits

$1,777,277 $684,546 $539,543

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

1,800,000

Charges

Prior During Post

Patient Hospital Charges

Telehealth patient charges decreased 61% from 6 months prior to

telehealth to during telehealth. Patient charges decreased 70% from prior to telehealth to post telehealth.

n = 64 In-home patients

RCCHC / PPCTN Patient Charge Data Ending March 2008

Analyzed charges are related to diseases being monitored.

Strategies for ExpansionVertical Networks

• Centers of Aging: kiosk monitoring

• Senior Centers: kiosk monitoring

• PACE Programs: in-home monitoring

• Hospital discharge monitoring: in-home monitoring

• Diagnosis based: in-home monitoring• CHF• DM

Strategies for ExpansionHorizontal Networks

• Expansion to CHCs

• CHC funded

• Grant funded

• Replication to 6 additional CHCs

• Expansion to other PCP practices

RCCHC CVD Pts Roanoke Chowan Community

Health Center

ExistingPatient Provider Telehealth Network

June 30, 2009

RCCHCHTN Pts

RCCHCDM Pts

Gates Co. Medical Center DM & CVD Pts

ECU Cardiology-RCCHC In Home

MonitoringHF Pts

Roanoke Chowan Hospital

Patient Provider Telehealth Network

RCH Hospitalized

DM Pts Post

Discharge

Piedmont Health Systems CVD Pts

Piedmont Senior Care

CVD Pts

Rural Health Group DM Pts

Senior Centers DM &

CVD Pts

Goal 1: Reduce rate of CVD and it’s complicationsObjectives:

Replicate current PPTN

Provide daily in-home monitoring for 6 months50% compliance to remote

monitoring

10% reduction in LDL and BP

Goal 2: Obtain NC Medicaid Reimbursement

Objectives:

Decrease ER visits and hospitalizations 30%

Reduce NC Medicaid expenditures

NC HWTF Phase II PPTN Goals and Objectives

Horizontal CHC Telehealth NetworkJuly 1 2009 – June 30 2012

Greene County CHCPCPs/CVD patients

Tri-County CHCPCPs/CVD patients

Rural Health GroupPCPs/CVD patients

Kinston CHCPCPs/CVD patients

RCCHC Telehealth RN and Team

Cabarrus CHCPCPs/CVD patients

RCCHCPCPs/CVD patients

• NC Medicaid CVD and/or Heart Failure NYSC III/IV and require frequent monitoring, health assessment and education.

• Frequent exacerbations• Frequent use of health care system• Willing to carry out mutually agreed responsibilities• Desire to participate in the program• Have basic cognitive skills• Able to learn to use monitors

Phase II PPTNTarget Patient Population

• In-home remote monitoring equipment • 1.0 FTE RN to provide daily monitoring and chronic

care management• 0.03 FTE Data Analyst for data collection and

evaluation• Customized policies and procedures and

implementation documents • Webinar and on-site implementation and planning

meetings• Equipment training • On-site initial equipment deployment• On-site quarterly meeting

PPTN Phase IIRCCHC Staff Deliverables

• One designated nurse champion• Identifies CVD/HF patients• Completes Plans of Care • Completes patient consent forms • Installs and de-installs telehealth equipment• Troubleshoots and maintains equipment• List of appointed program staff and contact

information• EMR access for RCCHC RN• Quarterly data reports (height, LDL)• Provides oversight care of CVD/HF patients

PPTN Phase IICHC Staff Deliverables

• IRB approved

• Contract with PhD Wake Forest University

Clinical data Financial data

Demographics Hospitalizations/costs

Weight ER visits/costs

Blood Pressure PCP visits/costs

Pulse

LDL

Medication Classifications

Evaluation

Bonnie Britton

252-209-0237

bbritton@pcmh.com

www.rcchc.org

Contact Information