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Telehealth Management: Can a new paradigm in managing chronic illness control costs and improve quality? presented by Maria Lopes, MD, MS Doreen Salek,

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Presentation on theme: "Telehealth Management: Can a new paradigm in managing chronic illness control costs and improve quality? presented by Maria Lopes, MD, MS Doreen Salek,"— Presentation transcript:

1 Telehealth Management: Can a new paradigm in managing chronic illness control costs and improve quality? presented by Maria Lopes, MD, MS Doreen Salek, BS, RN, CCS/CPC October 26, 2010

2 Speaker Bios 2 Maria Lopes, MD, MS, Chief Medical Officer Dr. Lopes is an OBGYN by training, but has been serving in senior medical management positions in managed care since 1996. Prior to joining AMC in 2008, she spent 4 years as Senior Vice President and Chief Medical Officer for GHI, New York State’s then largest commercial payor, and before that served in senior positions for 7 years at Horizon Blue Cross Blue Shield of New Jersey. Dr. Lopes received her MD from The University of Connecticut School of Medicine, and an MS in Administrative Medicine from The University of Wisconsin. Doreen Salek, BS, RN, CCS/CPC Ms. Salek is the Director of Business Operations of Health Services for Geisinger Health Plan in Danville, Pennsylvania. She is responsible for leading business planning and Health Services innovation project teams with medical home, medical management, care coordination, quality improvement and clinical reporting as well as strategic implementation and evaluation of outcomes. In her current role she is focused on transitions of care across the continuum, as well as strategies around enhancing quality and reducing readmissions, including telemonitoring. Ms. Salek earned her BS from Colorado State University and nursing diploma from the Geisinger School of Nursing. She holds certifications as a Certified Coding Specialist and Certified Professional Coder. 2

3 3 What is TeleHealth? Remote Telemonitoring or Telehealth: the process of collecting daily biometric and other health-related information from where patient is and transmitting data to clinicians who manage care Two forms of data collection 1.“Hard” biometric data 2.“Soft” self-reported symptom information “Telemedicine” has become a universal term for industry 3

4 4 Telemedicine has been around since early 60’s when NASA developed monitoring methods for the space program The majority of activity described as “Telemedicine” surrounds two-way televideo for clinical consultation In the last 10 years remote physiological monitoring from the home has become a recognized and affordable component of chronic care Evolution 4

5 5 How It Works: Data Collection and Integration Self-reported symptom information via IVR Biometric information via telemonitoring devices “Live” virtual diagnostic assessment via televideo Medication compliance data via dispensing/reporting appliances AMC collects, sorts and verifies raw data and presents it as critical, actionable information on the secure web portal Data integration platform captures timely information from patients when they cannot be physically in front of clinicians 5

6 6 The Problem Telehealth Seeks to Address Acute exacerbation occurs outside clinical scrutiny. It is often preceded by incremental and insidious deterioration whose expression occurs in the home, away from clinical eyes. Existing information systems do not cross boundaries of care settings Electronic Health Records (EHR’s) illuminate what was done to patients (i.e. tests ordered, hospitalizations, Rx written, etc.) but don’t clarify the outcome. “Are their biometrics improving? Are they at reduced risk because of these actions? Are their medications having the right effect? Have barriers to compliance been identified?” As a result, care is often duplicated, applied too late, or in the worst setting due to incomplete clinical information 6

7 7 Knowing what is going on with a patient’s course of illness, in between visits, when he or she cannot be physically in front of the clinician Detecting pre-acute conditions early enough to bring resources to bear before the patient clinically decompensates Not waiting for the call from the ER before knowing that a patient is trending in the wrong direction How TeleHealth is Advancing Patient Care 7

8 8 Not Traditional Disease Management Telemonitoring uses real-time information from the patient’s home to empower them with knowledge of how they are progressing in the context of their personal disease progression and care plans, and how their behaviors are indeed affecting their health Thus, unlike traditional DM, which can educate a patient about what can and usually happens, telemonitoring can tell them what is happening, and how they—and their doctors and caregivers—can react to these events to change course if necessary 8

9 Value Proposition Marketing: differentiate through value- added features Quality: improve compliance & HEDIS metrics Financial: reduce re- hospitalization & optimize ROI Operational: enhance productivity & care coordination Clinical : Improve outcomes Clinical : Improve outcomes 9

10 10 Support for Medical Home Empower the clinician through technology provide critical information to electronic health records (EHR’s) Through daily data collection, PCP can continually monitor patient between doctor visits increases efficiencies in care by allowing PCP to be alerted when intervention is most needed Greater frequency of targeted patient education continual data collection provides physician with real-time quality measures for benchmarking and improvement 10

11 11 Challenges “There is a tendency to overemphasize the technological aspects of telehealth and indeed to equate it with its technology … Telemedicine is not software or hardware, although it employs both. Nor is it ‘clinicianware’ or ‘econoware’ despite its value to clinicians and administrators and payors. When it’s all said and done, it is ‘patientware’, as it should not be defined in terms of its technical components but in terms of utility in reinforcing the clinician-patient bond.” – Jay Sanders, MD, former President, American Telemedicine Association 11

12 12 It can never be about the technology: This has to be about putting accurate and meaningful information in front of the clinician, regardless of the means of collection Must be seamlessly embedded into a care management workflow to maximize efficiency Data must be timely, meaningful and actionable and not simply contribute to the ‘noise’ Challenges (continued) 12

13 PCMH & Telehealth Platform Evolution AMC-Geisinger Strategic Partnership A mutual investment to strategically impact and enhance each other’s core competencies and business models AMC Health: Telemonitoring And IVR Services Real-time Data & Clinical Decision Support Tools Geisinger: Subject Matter Expertise for Predictive Analytics Clinical Content & Decision Support Geisinger: Subject Matter Expertise for Predictive Analytics Clinical Content & Decision Support 13

14 14 AMC’s Telehealth program doubled the ratio of CHF Patients that Geisinger Case Managers were able to cover in complex case management: 1.Track patients in real-time 2.Uncover proactive intervention opportunities 3.Receive unbiased, reliable patient data 4.Reduce the need for clinicians to initiate outreach 96% of Geisinger Case Managers reported AMC technology improved efficiency in monitoring HF patients 85% of Geisinger Case Managers reported telehealth solution prevented patient hospitalization Geisinger Health Plan Outcomes 14

15 Looking Forward New technologies are constantly being assessed for integration potential Motion Analysis and Access Detection Technologies GPS Tracking and Communications Exercise Monitoring Wearable Sensors for Recording Events Over Time Smart Bandages and ClothingBringing the Lab Home 15

16 16 Comprehensive, cross-setting, interdisciplinary care coordination models that utilize Extended Care Pathways ACO models Less comprehensive care management models housed within the payor or community-based care entity Synthesis with New HIT Priorities Patient at Home Data Collection Technologies Webportal for Shared Reporting & Analytics Telecare Management Nurse Call Center Data Mining and Population Analytics Thread telehealth technology unobtrusively into best-of-breed care coordination models that best fit each unique structure, including: 16

17 17 The Goal: Open-Ended Integration Universally-Accessible Webportal with Decision-Support Analytics EHR’s PBM & Other Pharma Data External Care Management Data Claims Telehealth Data 17

18 Impact of Telecare Management (TCM) on Medicare Advantage (MA) Members after 8 months: Study Parameters: Results: TCM Intervention Group N=69 8 Month Period Random Selection Intervention and control cohorts had similar claims histories CHF, Hypertension, Diabetes, COPD, CAD, Atrial Fibrillation 66% >3 diagnoses CostIntervention Group Control Group Total ↓ 23% ↑ 6% Inpatient↓ 20%↑ 16% Outpatient ↓ 64% ↓ 17% ER ↓ 14% ↓ 8% ROI 3:1 If ESRD is included, 43% reduction in total costs compared to control represents ROI 6:1 Outcomes 18

19 19 Comparison of Total Costs (8 Months) Care Management vs. Care Management + Telemonitoring* * MEMBER MONTHS: Control Group – pre: 5,106, post: 4,698, Telemonitored Group - pre: 538, post: 543 Impact of Telecare Management (TCM) on MA Members after 8 months (continued): Outcomes 19 PMPM

20 20 Majority of non-diabetics reached BP goals, as did nearly half the diabetics Improvement in BP translates into 29% reduction in risk of cardiac events and 21% reduction in risk of stroke 83% of diabetics reached blood glucose targets Average blood sugar reduction equates to a 1.7 point drop in HbA1c : 63% reduction in risk of microvascular complications 73% reduction in risk of peripheral vascular disease Impact of Telecare Management (TCM) on MA Members after 8 months (continued): Outcomes 20

21 21 Impact of Telemonitoring Combined with Home Care Case Management (Medicare Advantage Plan): Study Parameters Results N = 47, Intervention period > 12 months Longitudinal Primary Dx CAD, CHF, COPD or DM Control members in Case Management without Telemonitoring TM GroupControl Group Hospital Admissions ↓ 50% ↑ 8% Total Costs ↓ 55% ↑ 6% Total Claims Savings TM Group > Control Group for All Diagnosis CHF ↓ 37% ↑ 43% COPD ↓ 70% ↓ 16% Outcomes 21

22 22 * MEMBER MONTHS: Control Group - pre 1644, post 853, Telemed Group - pre 586, tele 219 Impact of Telemonitoring Combined with Home Care (cont.) Outcomes 22

23 23 * MEMBER MONTHS: Control Group - pre 1644, post 853, Telemed Group - pre 586, tele 219 Impact of Telemonitoring Combined with Home Care (cont.) Outcomes 23

24 24 Pre-Intervention Levels * MEMBER MONTHS: Telemed Group tele 219, post 107 Impact of Telemonitoring Combined with Home Care (cont.) Outcomes 24

25 Value of Telemonitoring in Achieving A1c and Blood Pressure Goals in Medicaid Managed Care Population N= 440 on telehealth for a minimum of 40 days Identified through outpatient clinics Glycemic Control 79% sustained improvement % hypertensive at baseline who improved BP 69% improved by an average of 6mmHg diastolic Reduction of cardiac risk25% Reduction of risk of stroke18% For the 21% with no glycemic improvement, 66% of those hypertensive at baseline improved by an average of 5mmHg diastolic Outcomes 25 Results

26 26 Value of Telemonitoring in Achieving A1c and Blood Pressure Goals in Medicaid Managed Care Population (cont.) Of the group with improvement, the higher the baseline HgA1c, the greater the improvement: Those with Improvement (79%) Baseline HbA1c Tier Baseline HbA1c Mean Latest HbA1c Mean Point Improvement < 7.0 (n=13)6.45.80.6 7.0 to 8.9 (n=129)8.07.01.0 9.0 to 9.9 (n=60)9.47.61.8 10.0 to 11.9 (n=91)10.98.32.6  12.0 (n=53) 14.09.34.7 For the subset of members with a minimum of 12 mos of claims both pre-telemonitoring and for 12 mos of telemonitoring (n=77): 36% reduction in hospitalization 47% reduction in emergency room visits Outcomes 26

27 27 Impact of Telemonitoring (TM) Post-Discharge from Acute Care Setting Fee-for-Service Medicare Home Care: Study Parameters Pre/Post intervention study N = 1,451 for 2 years Results: Subsequent Controlled Study: N= 510 for 18 months Result: ↓34% reduction in 30-day readmission compared to control Pre-TMPost TM 60-day Readmission Rate 27%11% RN Weekly Visits ↓50% Cost/ Home Care Episode ↓ $750 ER Visits ↓ 40% Outcomes 27

28 28 Impact of Telecare Management on Biometric Outcomes – 1 st 90 Days Medicaid (SSI, non-Medicare Eligible) Diabetes Pilot  Average PMPM costs prior to pilot: $1,943  Reductions in average blood pressure: 17% reduction in risk of cardiac events 12% reduction in stroke risk  Blood sugar reductions for 25% most severe at baseline = 2 pt reduction in HbA1c: 10% reduction in overall health care costs 80% reduction in risk of eye, kidney and nerve disease complications* * Source: National Diabetes Clearinghouse GoalsReached Average Blood Glucose67% Systolic BP26% Diastolic BP39% Outcomes 28

29 29 Impact of Telecare Management on Biometric Outcomes – 1 st 120 Days Medicaid (SSI, ABD & Medicare Eligible) Telehealth Pilot  Average PMPM costs prior to pilot: $2,893  High risk, rural population  COPD, Diabetes, Heart Failure, Hypertension, Renal Failure :  Reductions in average blood pressure for 25% most severe non-diabetics: 43% reduction in risk of cardiac events 27% reduction in stroke   Blood sugar reductions for 25% most severe at baseline = >1.2 pt reduction in HbA1c: 24% reduction in overall health risk  for  Sources: Lewington S, Clarke R, Qizilbash N, Peto R, Collins R. Prospective Studies Collaboration. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002;360:1903-1913 and Heart Disease and Stroke Statistics – 2007 Update Dallas, TX: American Heart Association 2007. e million adults in Goals Reached Systolic BP Diastolic BP Blood Glucose Non- diabetics 60%82%N/A Diabetics40%54%70% Outcomes 29

30 30 Metoprolol Case Study Patient 54 year old female TIA, CAD; Hx of palpitations, dizziness Intervention Telehealth initiated 7/15/09 Pulse above 100 daily as high as 120 bpm RN notified physician and presented data RN monitoring daily B/P and pulse BP within normal range. Started Metoprolol OutcomePulse average 98 bpmContinue to follow medication effects 30


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