1. Mission: to improve the health and well-being of the individuals, families and communities we serve Remote Patient Monitoring: An inside look at lessons learned from an FQHC Presenter: Andy Eck, MBA

2. Agenda Introduction Patient story RPM in rural FQHC Background Implementation Lessons learned Milestones Data Resources

3. Meet Ken

4. Background

5. Partners

6. Implementation

7. How it works Process Personnel Equipment Management

8. Key Aspects/ Lessons Learned Workflows Referrals Equipment Ready Kit

9. The Change: Paper referrals  Referrals Module in Epic. Why: paper process, 48 hour wait time, difficult to scale. When: Implemented January 2014. Outcome: Increased referrals, increase provider satisfaction, faster patient care, staff can process offsite. Workflow modification example: internal referrals

10. Workflow modification example: the Visio diagram

11. Workflow Modification Example: Ready Kit ™

12. Sustained health improvements ED utilization Patient engagement Enrollment/Participation Data

13. Age of patients What is the age of patients on the program?

14. Patients diagnoses 59.43% of all patients have at least 2 diagnoses Hypertension and Diabetes are most prevalent primary diagnoses What is the most prevalent diagnosis of patients?

15. Patients Status Results 76% of all patients – 161 Patients - have successfully graduated or remain on the program Did patients successfully complete the program? DISCHARGE – OTHER 8%

16. Mental health screening Are patients up to date with mental health screening?

17. Blood pressure monitoring Are blood pressure readings improving?

18. Blood pressure before and after enrollment Are blood pressure readings improving (continued) ?

19. Diabetic A1C before, during and after Did Diabetic A1C readings improve?

20. Enrollment related to 0 2 saturation RPM impact on blood oxygen saturation

21. Pre and post intervention PAM scores Did Patient Activation Metric (PAM) score improve?

22. ED visits Is RPM keeping patients out of the Emergency Department? RPM Status at time of ED Visit

23. In closing… Lessons learned Metrics Next steps

24. Ken

25. Resources BLOG: http://cotnexperience.blogspot.comhttp://cotnexperience.blogspot.com Andy Eck Regional Operations Director Mosaic Medical Andy.eck@mosaicmedical.org