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©AAHCM Stephanie R. Bruce, MD Medical House Call Program Medstar Washington Hospital Center Washington, DC.

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Presentation on theme: "©AAHCM Stephanie R. Bruce, MD Medical House Call Program Medstar Washington Hospital Center Washington, DC."— Presentation transcript:

1 ©AAHCM Stephanie R. Bruce, MD Medical House Call Program Medstar Washington Hospital Center Washington, DC

2  None  Questions:

3  Mr H. 91 years old  H/o CAD, MI, known 80% lesion in LAD  Non-CABG candidate  CHF EF 25 %  Mild anxiety about symptoms

4 “Providing after hours, urgent or emergency care is a serious business; patients accessing it are usually doing so at their most frightened and vulnerable, and we have a duty of care to ensure that the system is as seamless and uncomplicated to navigate as possible.” -- Dr. Clare Gerada, RCGP Chair of Council

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6  Frail, older patients can be harmed by ED/hospital ◦ Adverse event ◦ Functional decline  We can provide high intensity care at home ◦ Hospital at home ◦ VA experience

7  Effectiveness of 24/7 care and monitoring  Models ◦ Telephone ◦ VA: CC/HT ◦ Telehealth  Experience in one House calls practice  Lessons learned/discussion

8  Urgent access a tenet of patient-centered medical home (PCMH)  “Medical home runs”

9  Urgent access a tenet of patient-centered medical home (PCMH)  “Medical home runs” ◦ 4 common aspects of high performing practices AM Milstein, E. Gilbertson. Health Affairs 2009; 28(5):

10  Urgent access a tenet of patient-centered medical home (PCMH)  “Medical home runs” ◦ 4 common aspects of high performing practices: ◦ Longer visits, interim support, 24/7 urgent care AM Milstein, E. Gilbertson. Health Affairs 2009; 28(5):

11 Care coordination/HT Protocol phone triage Mixed model

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13  Supported by access to EHR  Supported by protocols  VPA: FL, IN, KY, MI, MO,OH, TX, VA

14 DataResults Cochrane review Phone triage decreases need for visit without increasing ED use NHS (National Health Service)-- safe -- may reduce ED use -- reduces cost (usually through decreasing doctor visit) Telephone consultation and triage: effects on health care use and patient satisfaction (Review) i Copyright © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

15 Care coordination with Health Technologies

16 1995: 2.9 M vets 53,200 beds 30M otpt visits 1995: 2.9 M vets 53,200 beds 30M otpt visits 2007: 5.3 M vets 18,199 beds 50M otpt visits 2007: 5.3 M vets 18,199 beds 50M otpt visits

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18  Key elements ◦ Individualized selection of technology ◦ Combined with a clinical plan  Cost: est $1600 per pt/per year  “Savings” ◦ 19% reduction in hospitalizations ◦ 25% reduction in hospital days  Not designed for urgencies/emergencies

19  86% satisfaction  “I’m here by myself, yet I feel like I have somebody watching over my condition on a daily basis.”

20 SiteInterventionOutcomeCost/Savingscomment Partners Healthcare CHF hospital f/u 51% reduction in readmission net savings: $8,155 per patient Increased patient independence Centura Health All admissions 62% reduction in readmission Savings about $1500 per patient CMS pilot (1700pts) Disease specific (DM, COPD, CHF) Claims billing Savings of 7- 15% pppy Cost about $120/mth A.Broderick and D. Lindeman, Scaling Telehealth Programs: Lessons from Early Adopters, The Commonwealth Fund, January 2013 B.Integrated Telehealth And Care Management Program For Medicare Beneficiaries With Chronic Disease Linked To Savings Laurence C. Baker et al Health AffairsSeptember :

21 ©AAHCM

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23 Called 911 ‘forgot’ Aide/other called Panic Sent by us Medically necessary Not enough info Sent from another MD/faciility

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25  What data will be received  When  By whom? ©AAHCM

26  Improved patient experience  Decreased 911 calls  Decreased urgent calls to NP/MD  Transitioned to hospice  Died in 2013 at home

27  Technology gets lost  New learning ◦ “911 is ingrained”  The technology is just a tool  Access to wireless  The art of telephone triage

28  Grants/hospital systems?  ACO’s, private insurers?  Medicare? ©AAHCM

29  24/7 and urgent care is right for our patients  Ways to provide ◦ As “simple” as the phone ◦ As complex as tele-video and remote ICU  Future? ©AAHCM

30 Thank you QUESTIONS: Stephanie R. Bruce, MD Medstar Washington Hospital Center, Washington, DC

31 ©AAHCM

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35  9 states and the District of Columbia have laws mandating the coverage and reimbursement for telemedicine-provided services under their Medicaid programs:  California California  Colorado Colorado  Kentucky Kentucky  Maryland Maryland  Minnesota Minnesota  Mississippi Mississippi  Nebraska Nebraska  Texas Texas  Vermont Vermont  District of Columbia District of Columbia

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37  Levison D. Medicare Payments for Ambulance Transports. Washington, DC:  Hearld, LR, Alexander JA. Patient-Centered Care and Emergency Department Utilization: A Path Analysis of the Mediating Effects of Care Coordination and Delays in Care. Medical Care Research and Review. 2012;69(560).  Weaver MD, Moore CG, Patterson PD, Yealy DC. Medical necessity in emergency medical services transports. American Journal of Medical Quality. 2012;27(3):  Huibers L, Giesen P, Wensing M, Grol R. Out-of-hours care in western countries: assessment of different organizational models. BMC Health Services Research. 2009;9:105. PubMed PMID: Pubmed Central PMCID:  After-Hours Care In The United Kingdom, Denmark, And The Netherlands: New Models Grol R, Giesen P, vanUden C. doi: /hlthaff Health Aff November 2006 vol. 25 no  Primary Care Collaborative: The Outcomes of Implementing Patient-Centered Medical Home Interventions: A Review of the Evidence on Quality, Access and Costs from Recent Prospective Evaluation Studies, August 2009 Prepared byKevin Grumbach, MD, Thomas Bodenheimer, MD MPH and Paul Grundy MD, MPH  Murray E, Burns J, See Tai S, Lai R, Nazareth I. Interactive health communication applications for people with chronic disease. Cochrane Database Syst Rev. 2005;4:CD [PubMed]PubMed  Integrated Telehealth And Care Management Program For Medicare Beneficiaries With Chronic Disease Linked To Savings Laurence C. Baker et al Health AffairsSeptember :

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41 iCare Desktop  Work list is Color coded for risk stratification  Red flags triage patients who need further investigation and early intervention

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43 Web access Real-time video conferencing Digital photography capabilities Customized question/answer interaction Personalizable advice messages for patients Deliver schedules and reminders for measurements, questions, or medication Graph display of results to identify trends, and Important vital sign and schedule alerts Medical peripherals

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50  Reinforcement ◦ Technology ◦ “call us first”  Your first “success’ will be your best friend  Creative staffing  Protocols for phone triage  Value…

51 SiteOutcomes Washington: Group Health of Washington(Seattle, WA) 2009, % fewer ED visits 11% fewer hospitalizations for ambulatory care-sensitive conditions Net cost savings trend North Carolina: Blue Quality Physician’s Program (BCBSNC) % fewer visits to specialists 70% fewer visits to the ER North Dakota: BCBS of North Dakota MediQHome Quality Program % lower hospital admissions 24% fewer ED visits 30% lower ED use among patients with chronic disease 4. B.D. Steiner et al, Community Care of North Carolina: Improving care through community health networks. Ann Fam Med 2008;6: and v Mercer. Executive Summary, 2008 Community Care of North Carolina Evaluation. Available at 5. BCBSA: Patient-Centered Medical Home Snapshots.

52 Default in the past: 911-> ED (15% of ED patients arrive by ambulance) 15-34% est Medicare pts do not need ED care Why? Litigation Lack of data No eyes on the patient Is there a better way?

53 Called 911 ‘forgot’ Aide/other called Sent by us Medically necessary Not enough info Sent from another MD/faciility

54 DOWN 17% Total Medicare cost (.003) Down 9% ED visits (.001) Down 10% Hospitalizations (.001)

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56 Exceptional individualized caring for chronic illness  Use “extraordinary means” to prevent crises “Ambulatory ICU”  Actively coordinate carefully selected specialists, hospital care  view to behavior/environment (SW, aides, home)

57 Exceptional individualized caring for chronic illness  Use “extraordinary means” to prevent crises “Ambulatory ICU” Longer visits, interim support, 24/7 urgent care  Actively coordinate carefully selected specialists, hospital care  view to behavior/environment (SW, aides, home) AM Milstein, E. Gilbertson. Health Affairs 2009; 28(5):

58 Exceptional individualized caring for chronic illness  Use “extraordinary means” to prevent crises “Ambulatory ICU”  Longer visits, interim support, 24/7 urgent care  Actively coordinate carefully selected specialists, hospital care  view to behavior/environment (SW, aides, home) AM Milstein, E. Gilbertson. Health Affairs 2009; 28(5):

59 1995: 2.9 M Vets 53,200 beds 30M op visits 2007: 5.3M Vets 18,199 beds 50M op visits ©AAHCM

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