The Role of Telehealth in Accountable Care HealthLINC Conference Bloomington, IN February 17, 2011 Alan Snell, MD,MMM Chief Medical Informatics Officer St. Vincent Health, Indianapolis

St. Vincent Health FY 2011 Stats Total Admissions: 64,828 Total ER Visits: 240,572 Total Ambulatory Visits: 2,776,895 Total Births: 6,629 Total Beds: 1,751 Gross Revenue: $5,171,730, St. Marys, 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 Womens 9 St. Vincent Carmel 3 St. Joseph - Kokomo 2 Saint Johns Health System 7 Peyton Manning Childrens Hosp. 4 St. Vincent Indianapolis 10 St. Vincent Heart Center St. Vincent Dunn CAH 18

3 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.

Telehealth Includes: Patient-Caregiver Virtual Visits 4

Telehealth Includes: Monitoring in the Home 5

Telehealth Includes: Store-and-Forward 6

Telehealth Includes: Education 7

Ascension Health Telehealth Inventory: 36 Programs Across 21 Health Ministries 8 *Numbered in alphabetical order by State and City Breakdown Video Consultation: n = 17 (47%) Teletranslation: n = 8 (23%) Home Teleheatlh: n = 6 (17%) Call Center: n = 3 (9%) Education: n = 2 (6%)

Veterans Affairs (VA) Telehealth: Critical Mass Driving Significant Value 9 Video Consults 75,000 Patients Research & Refinement Dissemination & Implementation 1 Year7 Years 4,700 Patients Store & Forward 160,000 Patients3,000 Patients Home Telehealth 55,000 Patients 3,000 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 Years7 Years Research & Refinement Dissemination & Implementation 3 Years8 Years

Telehealth Value in Different Business/Reimbursement Models 10 Business ModelClinical 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

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 programs 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.

Indiana Beacon Objectives - Quantified 12 Copyright 2011 Indiana Health Information Exchange, Inc. ObjectiveMeasure 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 AdmissionsReduce by 3% ACSC Re-AdmissionsReduce by 10% ACSC-related ED visitsReduce by 3% Redundant imagingReduce by 10% Colorectal Cancer Screening 5% in proportion of patients screened Cervical Cancer Screening5% in proportion of patients screened Immunization Data Increase by 5% amt. of adult imms data available Meaningful UseAchieved 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 (

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

15 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 Innovations 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 Hospitals St. Vincent Health sites: St. Vincent Indianapolis St. Vincent Heart Center St. Vincent Carmel St. 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 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 R Not in study 50% Y N

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 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 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

30 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

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 award 31

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 32

Care Coordination Vision 33

34 CAUTION!

Questions?