The Role of Telehealth in Accountable Care

HealthLINC ConferenceBloomington, IN

February 17, 2011

Alan Snell, MD,MMMChief Medical Informatics OfficerSt. Vincent Health, IndianapolisEmail: adsnell@stvincent.org

317-583-3248

St. Vincent Health

FY 2011 StatsTotal Admissions: 64,828Total ER Visits: 240,572Total Ambulatory Visits: 2,776,895Total Births: 6,629Total Beds: 1,751Gross Revenue: $5,171,730,145

Posey

Vanderburgh

Warrick

Spencer

Vermillion

Clay

Sullivan

Vigo

Parke

Fountain

Warren

GibsonDubois

Pike

KnoxDaviess

Martin

White

Jasper

Lake

Newton

Porter

Benton

Greene

Owen

Monroe

Morgan

Putnam

Tippecanoe

Montgomery

Hendricks

Boone

Cass

La Porte

Pulaski

Starke

Fulton

Marshall

St. Joseph

Carroll

Perry

Crawford

Harrison

Orange

Lawrence

Washington

Floyd

Clark

Scott

Tipton

Hancock

Hamilton

Madison

Howard

Johnson

Brown

JenningsJackson

Bartholomew

Shelby

Kosciusko

Miami

Elkhart

Wabash

Jay

AdamsHuntington

Wells

BlackfordGrant

Allen

Noble De Kalb

Lagrange Steuben

Whitley

Rush

Delaware

Randolph

WayneHenry

Ripley

Jefferson Switzerland

Dearborn

Ohio

Franklin

Decatur

Fayette

Union

Clinton

Marion

1,4,5,6,7,8,9,10

13

12

16

17

19

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15

3

2

19 St. Mary’s, Evansville- 2 hospitals(Ascension Health)

12 St. Vincent Williamsport CAH

13 St. Vincent Frankfort CAH

15 St. Vincent Mercy, Elwood CAH

16 St. Vincent Jennings CAH

17 St. Vincent Randolph CAH

11 St. Vincent Clay CAH

14 St. Vincent Salem CAH

An Ascension Health Ministry

5 St. Vincent Stress Center

1 St. Vincent New Hope

6 Seton Specialty Hospital- LTAC

8 St. Vincent Women’s

9 St. Vincent Carmel

3 St. Joseph - Kokomo

2 Saint John’s Health System

7 Peyton Manning Children’s Hosp.

4 St. Vincent Indianapolis

10 St. Vincent Heart Center

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18 St. Vincent Dunn CAH

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Ascension Health is the largest Catholic and non-profit health system in the United States, with more than 500 locations in 20 states and the District of Columbia.

www.ihie.org

Telehealth Includes:Patient-Caregiver Virtual Visits

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www.ihie.org

Telehealth Includes:Monitoring in the Home

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Telehealth Includes:Store-and-Forward

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Telehealth Includes:Education

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Ascension Health Telehealth Inventory:36 Programs Across 21 Health Ministries

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*Numbered in alphabetical order by State and City

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2

6

7

10

11

12

15

17

18

20

1

3

5

8

9

13

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1621

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BreakdownVideo Consultation: n = 17 (47%)Teletranslation: n = 8 (23%)Home Teleheatlh: n = 6 (17%)Call Center: n = 3 (9%)Education: n = 2 (6%)

www.ihie.org

Veterans Affairs (VA) Telehealth:Critical Mass Driving Significant Value

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VideoConsults

75,000 Patients

Research & Refinement Dissemination & Implementation

1 Year 7 Years

4,700 Patients

Store & Forward

160,000 Patients3,000 Patients

HomeTelehealth

55,000 Patients3,000 Patients

The average annual cost for a VA home telehealth patient is $1,600 compared to $27,000 for a comparable level of institutionalized care

Research & Refinement Dissemination & Implementation

3 Years 7 Years

Research & Refinement Dissemination & Implementation

3 Years 8 Years

www.ihie.org

Telehealth Value in Different Business/Reimbursement Models

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Business Model Clinical Use Case Applications of Telehealth

Current Environment: Primarily Fee-For-Service (FFS)

Specialist consultations for patients in rural areas Provider-to-provider consultations Teleradiology consultations Access to primary care/urgent care Teletranslation services Provider education

FFS with Value-Based Purchasing

Use cases listed above plus: Transitional care for patients with chronic disease Long term care triage

Population Health Management

Use cases listed in each category above plus: Chronic disease management not connected to a

hospitalization Screening and prevention Health risk assessments Consumer education/engagement/ health

maintenance

www.ihie.org

Beacon Communities Program Overview

• Central Indiana was one of 17 communities selected• The Beacon Program will support these communities to build and strengthen their health IT infrastructure and exchange capabilities.

• The program’s intent is to improve health through information technology while supporting job creation. Focusing on specific and measurable improvement goals in three vital areas for health system improvement:

Quality Cost Efficiency Population Health

• Indiana Health Information Exchange, as the lead organization, received a $16.1 million award to develop the 3 year program.

www.ihie.org

Indiana Beacon Objectives - Quantified

12Copyright 2011 Indiana Health Information Exchange, Inc.

Objective Measure

HbA1c levels Increase by 10% the proportion of patients whose A1C levels are <=9%

LDL-C levels Increase by 10% the proportion of patients whose LDL-C levels are controlled

ACSC Admissions Reduce by 3%

ACSC Re-Admissions Reduce by 10%

ACSC-related ED visits Reduce by 3%

Redundant imaging Reduce by 10%

Colorectal Cancer Screening

5% in proportion of patients screened

Cervical Cancer Screening 5% in proportion of patients screened

Immunization Data Increase by 5% amt. of adult imms data available

Meaningful Use Achieved by 60% of Primary Care Physicians

Facts about Congestive Heart Failure

• Congestive heart failure (CHF) is the most common Medicare DRG accounting for more costs than any other condition.

• 30 day readmission rate for patients with CHF is 21% nationally

• Behavioral factors, such as noncompliance with medications, lack of timely follow up visits and social factors frequently contribute to early readmissions, suggesting that many such readmissions could be prevented

• Total annual healthcare expenditure for both

direct and indirect healthcare cost of CHF

approximates $28 Billion (http://content.onlinejacc.org)

• Allocated funding or estimated cost: $7.1 billion in estimated federal savings

• Effective date: Oct.1, 2012 (data collection started 10/1/11)

• Provision authority: Health and Human Services secretary

• Scope of jurisdiction: Medicare; nationwide• Requirements: HHS secretary to develop

calculations for hospital's readmission payment reduction and publicize hospital readmission rates

Hospital Readmission Reduction Program

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Effect of Tele-monitoring on Reducing Readmissions

A Randomized Study of Short-term Post-Discharge Chronic Disease Management with Tele-monitoring

and Nurse Telephone Support

Goals & Objectives• Reduce readmissions for patients with Congestive

Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD)

• Multidisciplinary treatment approach for early intervention for patients at high risk

• Include hospitals representing diversity in size and geographical locations

• Enroll patients immediately post-discharge for 30 days

( December 2010 – December 2012 )

Home Monitoring Vendor Selection

• Transformation Development Department at Ascension assisted in developing technology selection criteria

• Eight vendors were invited to bid, four presented to the selection committee and Care Innovation’s Health Guide was awarded the offer.

Care Innovations Health Guide

• Allows for video conferencing with the nurse contact center.

• Provides health educational learning sessions

• Monitors daily bio-metric readings (BP, O2 sat, weight)

• Interacts with the patient daily inquiring about health status

Participating HospitalsSt. Vincent Health sites:

St. Vincent Indianapolis St. Vincent Heart CenterSt. Vincent CarmelSt. Johns Hospital (Anderson)St. Joseph Hospital (Kokomo)3 St. Vincent Critical Access Hospitals

Non- St. Vincent Health participating sites: Columbus Regional Hospital (Columbus)Hancock Regional (Greenfield)Henry County Hospital (New Castle)Witham Hospital (Lebanon)Wishard Hospital (Indianapolis)

Baseline Readmissions-Initial Participating Hospitals

Source: Indiana Hospital Association 2009 reported data

Enrollment Process• Hospital Study Coordinator

offers and completes study informed consent

Consents?

• SVH Contact Center completes patient

enrollment

• Randomization into study group

(Randomized by Study Site and Prin

Dx)• Patient enrollment

form completed• Physician notified

• Complete Study Protocol

• SVH Contact Center arranges device

deployment• R

• Not in study

• 50%

• Y

• N

• 50%

Source: Care Innovations 2011 by permission only

Source: Care Innovations 2011 by permission only

Source: Care Innovations 2011 by permission only

Accomplishments

• Establish baseline data for participating hospitals• Obtain IRB approval (Indiana University and St. Vincent)• Integrate with hospital discharge planning • Selected device vendor• Prepared site hospital teams• Selected/trained equipment management company • Selected/trained RNs with cardiac care or ICU

experience• Clinical protocols developed• Communication materials developed (patient welcome

video; physician letter, patient, and nurse resources)

First Year Processes

• Qualify patients & enroll in study

• All patients randomized into either Control Group or Intervention Group

• Device deployment & retrieval in the home

• Daily interaction and monitoring of patients

• Discharge patients from the study after 30 days

• Pre and Post survey instrument “Patient Activation Measure” (PAM). Univ. Oregon; Judith Hibbard

Preliminary PAM Survey Results

InterventionControl

1. I am responsible for my health

2. I can reduce my health problems

3. I know what my medications do

4. I know when I need to call a doctor

5. I can follow through on medical treatments

6. I know the treatments available

7. I have kept up with lifestyle changes

8. I can find solutions to new problems

9. I can maintain changes during stressful times

Goals for 2012-13

• Continue enrollment in randomized trial till Dec 2012• Identify best practices, refine program• Recruit additional patients outside research trial

Other chronic diseases Accept referrals from providers, hospitals, home

health agencies Longer monitoring periods High Risk patients not currently hospitalized Different care settings- long term care, assisted living

• Jan-Mar 2013- Program evaluation and dissemination of results to stakeholders and other Beacon programs

Conclusions

• Challenges Recruiting patients Research study restrictions Lack of physician involvement

• Potential Contributions Cost analysis of early intervention to prevent

readmissions and ED visits Examination of mediating variables: patient

compliance and behavior Telemonitoring study with additional social

support

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“Whole System Demonstrator Programme” results released Dec.2011

National Health Service in the United Kingdom randomized 6,191 patients from 238 practices to be monitored in their homes.

First year preliminary findings show:• 15% reduction in A&E visits (similar to our E&M)• 20% reduction in emergency admissions• 14% reduction in elective admissions• 14% reduction in bed days• 8% reduction in tarriff costs• Most striking was a 45% reduction in mortality rates

www.ihie.org

CMS Innovation Challenge Grant

CMS Center for Innovation was funded with $10 Billion from Patient Protection Act of 2010

• $1 Billion in grant awards announced in Dec. 2011, ranging from $1 million minimum to $30 million max over 3 years

• Challenge Grant required:• Innovative model to meet the Triple Aim (Berwick 2009)

• Better Health, Better Healthcare, Lower Cost• Alternative Payment Model• Workforce Development Plan• Six month rapid deployment with measureable impact• Financial Plan to demonstrate cost savings over 3 years that exceeds

amount of award31

www.ihie.org

Target Populations• High Cost- use data analytic tools to identify based on clinical

data and utilization data or claims data• High Risk- use predictive modeling to identify based on

current conditions, baseline utilization, history of multiple risk factors

• Will Target “Avoidable Events”• Inpatient Admissions for Ambulatory Care Sensitive Conditions (ACSC)• Reduce Readmissions- target CHF, COPD, Acute MI, Pneumonia• Reduce Inappropriate Emergency Dept visits (use Prudent Lay Person

criteria) • Reduce Premature Births- target high-risk pregnancies with prior

history of premature births and/or multiple gestation

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Care Coordination Vision

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CAUTION!

Questions?