Innovative use of Telemedicine in Primary Care and Transitions of Care
Kentucky Health F. Rose Rexroat, R.N.,C., MSN Manager, Telemedicine and Community Services KentuckyOne Health a Market Based Organization of Catholic Health Initiatives
Rural Infrastructure
Access
41.6% of Kentucky’s population live in a rural area
Transportation
Poverty
Challenges • Integrated Health Care Delivery System – moving from a hospital centric to patient / community based chronic disease management environment • Primary care strategy – assure every patient has a primary care physician / medical home
Saint Joseph Hospital & SJE Integrated Patient Management through SJHS Hospitals Rural Outreach Services Primary Service Area Kenton Secondary Service Area Tertiary Service Area RN 1 & 2 Primary Location le Trimb Grant Mason Carroll Lewis Greenup Owen Henry Harrison Fleming Carter Boyd Oldham Scott Franklin Bourbon Shelby Rowan Elliott Jefferson 1 Lawrence Woodford 1 Spencer Fayette Bullitt Menifee Morgan Clark 1 Johnson Jessamine 2 Powell 1 Martin Madison Nelson Wolfe 2 Magoffin 2 Estill 1 Lee 2 Breathitt Floyd Pike Marion Lincoln 2 Jackson Owsley Perry Clay Letcher Leslie Laurel Pulaski 1 Counties served by RN #1 Knox 2 Counties served by RN #2 Wayne Bell McCreary
Clay City/Powell County Opened July 6, 2011 867 Patients 2109 Visits
Saint Joseph Primary Care Clinic – Campton / Wolfe County Integrated Physical and Mental Health Opened August 7, 2012 207 Patients 690 Visits Collaboration with Kentucky River Community Care
Telehealth = Primary Care Access to Specialists
Timeline for Penalties: The Clock Started Ticking October 1, 2011 “Hospitals with high rates of readmission will be paid less if patients are readmitted to the hospital with the same 30 day period” -Office of Management and Budget * Reduced CMS Payment 1% 2% 3% _______________________________________________________________________________ 2010 2011 2013* 2014 2015** 2020 *CMS authorized to start ** CMS may withhold payments for excessive penalizing for excess readmissions COPD, CABG, and percutaneous coronary For HF, CA Pneumonia, and AMI intervention (PCI) readmissions Source: Preparing for CMS Penalties, sg2 Insight, J. Moss, RN, MSN, Neal Gold, MD, 2/8/11
Transitions of Care Overview • Best Practices: – Eric Coleman, University of Colorado, Model of Transition Coaching – Dr. Tim Ferris, Massachusetts General Hospital, Boston model of Health Coaching – Geriatric Care Managed as model in “Handbook of Geriatric Care Management” by Cathy Jo Cress
Transitions of Care Overview • Patient Population and Diagnosis: 65 years old + with COPD, AMI, CHF and CAP – Care Transitions Coaching: minimum of 30 days – Health Coaching: period of 180 days in PCP – Care Management by SW: available for total 210 days Study was done with Saint Joseph (SJ) Hospital and SJ East expanded December 2012 to include SJ Mt. Sterling
Transitions of Care Overview • Care Transition Study: November 1, 2010 through October 31, 2011 – 134 coached (216) Patients approached • 21 readmitted within 30 days 15.67% – 8 patients were readmitted within first 8 days (38%) – 15 patients were readmitted within first 15 days (71%) • 8 patients died (5.9%) – Readmission rate for patients refusing to be coached for first 30 days after discharge (18.5%) – SNF patients – readmitted within 30 days: 6 of 13 (46.2%) • Care Transition: November 1, 2011 to February 28, 2013 – 435 coached (560) Patients approached • 47 readmitted within 30 days 10.8% – 11 patients were readmitted within first 8 days (23%) – 26 patients were readmitted within first 15 days (55%) • 4 patients died (0.9%) – Readmission rate for patients refusing to be coached for first 30 days after discharge (18.6%) – SNF patients – readmitted within 30 days: 4 of 14 (28.6%) 18
Readmits By Month 14 12.5 12 10.5 10 9.3 9.3 9.3 9.3 9.0 8.3 8 8 7.8 7.5 Study (11/10-10/11) 21 Readmits 7.3 6.8 Post Study (11/11-12/12) 47 Readmits SJH/SJE (10/09 - 9/10) 106.9 Readmits 6 6 5 4 4 4 4 3 3 3 3 2 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 0 0 0 0 0 OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEPT OCT NOV DEC JAN FEB
Transitions of Care Post Study (11/11 - 2/13) 75% of ALL Number of Risk Characteristics have 3-5 Risk Characteristics 45% 40% 39% 77% of READMITS 36% have 3-5 Risk Characteristics 35% 32% 31% 30% 28% 27% 85% of DECEASED have 3-5 Risk Characteristics % of Patients 25% 20% 17% 17% 17% 14% 15% 10% 9% 9% 9% 6% 4% 5% 2% 2% 2% 0% 0% 0risk 1risk 2risk 3risk 4risk 5risk 6risk 7risk 8 Risk All (N=435) 0% 2% 14% 27% 31% 17% 6% 2% 0% Readmits (N=47) 0% 2% 9% 9% 36% 32% 9% 4% 0% Deceased (N=18) 0% 0% 0% 17% 28% 39% 17% 0% 0%
Transitions of Care - Post Study (11/11 - 2/13) 36 of the 47 Readmits have 3-5 Risks Characteristics 120% 100% 100% 100% 100% 100% 100% 100% 87% 80% 75% 73% 73% % of Patients 60% 53% 53% 40% 33% 29% 27% 25% 24% 18% 20% 7% 0% 0% 0% 0% 0% 0% MULTIPLE SUSPECETED MULT MEDS OR 2 + CHRONIC ADL READMISSIONS AGE 70 OR > COGNITIVE IMP LIVES ALONE NON- TX CONDITIONS IMPAIRMENT >2 IN 12MO ADHERENCE PRIOR 3 Risks (N=4) 100% 75% 100% 0% 25% 0% 0% 0% 4 Risks (N=17) 53% 100% 100% 53% 18% 0% 29% 24% 5 Risks (N=15) 73% 100% 100% 87% 73% 27% 7% 33%
Transitions of Care - Post Study (11/11 - 2/13) Number of CoMorbids 45% 39% 40% 35% 33% 86% Readmits 30% 30% have 2-5 30% 28% CoMorbids % of patients 25% 22% 20% 20% 17% 15% 14% 15% 11% 10% 9% 8% 6% 6% 4% 4% 5% 3% 2% 0% 0% 0% 0% 0% 0% 0CM 1CM 2CM 3CM 4CM 5CM 6CM 7CM All (N=435) 3% 8% 22% 28% 20% 14% 4% 0% Readmits (N=47) 0% 9% 11% 15% 30% 30% 4% 2% Deceased (N=18) 0% 0% 6% 17% 33% 39% 6% 0%
Transitions of Care Post Study (11/11 - 2/13) 40 Of 47 Readmits have 2-5 CoMorbids 120% 100% 100% 100% 100% 100% 93% 79% 80% 71% 71% 64% Axis Title 60% 60% 57% 57% 57% 50% 43% 40% 40% 40% 40% 36% 29% 29% 21% 20% 20% 14% 14% 14% 0% Afib DM Renal Failure CHF COPD HTN CAP 2CM (n=5) 40% 0% 0% 40% 40% 60% 20% 3CM (n=7) 14% 14% 14% 29% 71% 100% 57% 4CM (n=14) 21% 50% 29% 79% 71% 93% 57% 5CM (n=14) 36% 57% 43% 100% 64% 100% 100%
Transition Coaching - Post Study (11/11 - 2/13) 47 Readmits Risks/CoMorbids Comparison 40% 36% 35% 32% 30% 30% 30% 25% Axis Title 20% 15% 15% 11% 10% 9% 9% 9% 9% 4% 5% 2% 2% 0% 0 1 2 3 4 5 6 7 Risk Factors 0% 2% 9% 9% 36% 32% 9% 4% CoMorbids 0% 9% 11% 15% 30% 30% 4% 2%
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