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Kim A. Schwartz CEO Roanoke Chowan Community Health Center November 2012

Remote Monitoring and Chronic Care Management: A Community Health Center Model of Care. Kim A. Schwartz CEO Roanoke Chowan Community Health Center November 2012.

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Kim A. Schwartz CEO Roanoke Chowan Community Health Center November 2012

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  1. Remote Monitoring and Chronic Care Management: A Community Health Center Model of Care Kim A. Schwartz CEO Roanoke Chowan Community Health Center November 2012

  2. Area Demographics The service area for RCCHC and RCH encompasses 1,930 square miles in northeastern North Carolina including Bertie, Gates, Hertford, and Northampton counties. All four counties are rural counties with a population density ranging from 28 to 64 residents per square mile. Area Ethnicity 60% African American 38% Caucasian 1.6% Hispanic .4% Other

  3. Eastern North Carolina The per capita income for Hertford County is $15,641, compared to $20,307 for the state, and $21,587 for the country. US Congressional District 1 – ranked 4th poorest in the nation. 18% of county residents have incomes below 100% of the Federal Poverty Level (FPL), compared to the national rate of 12.3%. North Carolina ranks 12th nationally in terms of the numbers of health care uninsured individuals. Hertford County uninsured is at 25.6%

  4. RCCHC Remote Monitoring and Chronic Care Management • Patient-centered care • PCP to patient in their home/residence • Long term daily monitoring, health assessment, nursing assessment, health education and intervention as needed • Medical Home Model • Chronic Care Model

  5. EMR Phone Equipment Installer: Installs equip/ trains patient Nurse: Monitors data Chronic case management Notifies PCP and sends updates to providers every 2 weeks Daily for abnormal readings Weekly for patient education As needed PCP: Identify/Refer patients Oversees/changes medical care Patient: Daily monitoring As needed RCCHC Conceptual Model

  6. RCCHC Remote Patient Monitoring NC Network Piedmont Health Services Gateway Community Health Center Solid Foundations Ocracoke Medical Center Roanoke Chowan Community Health Center Wake Health Services Kinston Community Health Center Robeson Health Care Corporation Greene County Health Services Chowan Hospital East Carolina Heart Institute Rural Health Group

  7. HWTF Phase I Study Protocol 2006-2009 IRB Approved External evaluation – ECU/WFU Hypothesis: CVD, DM, HTN patients who participate in daily in-home remote monitoring and chronic care management will experience: • Enhanced compliance • Increased self care • Reduced hospitalizations and bed days • Reduced ER visits • Reduced health care expenditures

  8. HWTF Phase I Payor Source

  9. Hospital Bed Days and ER Visits • n=64 Statistically Significant Reductions • Hospital Bed Days • 6 mos. prior to Telehealth = 199 • During 6 mos. Telehealth = 99 • ER Visits • 6 mos. prior to Telehealth = 27 • During 6 mos. Telehealth = 5 Analyzed Charges are related to diseases being monitored RCCHC/PPTN Patient Charge Data Ending June 2009

  10. Hospital Bed Days and ER Visits • n=64 Statistically Significant Reductions • Hospital Bed Days • 24 mos. post Telehealth = 70 • ER Visits • 24 mos. post Telehealth = 23 Analyzed Charges are related to diseases being monitored RCCHC/PPTN Patient Charge Data Ending June 2009

  11. Hospital and ER Charges • n=64 Statistically Significant Reductions • Hospital Charges • 6 mos. prior to Telehealth = $1.2 million • During 6 mos. Telehealth = $365 k • ER Charges • 6 mos. prior to Telehealth = $64 k • During 6 mos. Telehealth = $16 k Analyzed Charges are related to diseases being monitored RCCHC/PPTN Patient Charge Data Ending June 2009

  12. Hospital and ER Charges • n=64 Statistically Significant Reductions • Hospital Charges • 24 mos. post Telehealth = $438 k • ER Charges • 24 mos. post Telehealth = $44 k Analyzed Charges are related to diseases being monitored RCCHC/PPTN Patient Charge Data Ending June 2009

  13. Estimated Savings Hospitalization Charges $4,362,000 Emergency Room Charges $212,000 Total Savings $4.5 Million

  14. What We Measure Patient • Satisfaction • PAM Clinical Indicators • HgA1c • LDL • BP, Pulse • Weight • Blood glucose • Oxygen saturation Health Services Use: • # PCP visits • Hospital Bed Days • Emergency Room visits Medical Costs • PCP visits costs • Hospitalization costs • ER visit costs

  15. Kiosk Monitoring • Care Coordination • Self Management

  16. Challenges and Opportunities • Vulnerable populations – rural & urban • Equipment/Vendor issues • Connectivity • Provider adoption • Staffing

  17. Emerging Trends • Aging of Population • Wireless • Efficiencies • Industry Alliances • Cost-effectiveness • Healthcare market emphasis on patient experience • Increased costs • Government pressure • Dwindling economic resources • Decreased healthcare staffing • Emphasis on error reduction

  18. Remote Patient Monitoring • How do we pay for it? Annual savings from remote monitoring could amount to as much as $10.1 Billion for U.S. Residents with congestive heart failure; $6.1 billion for patients with diabetes; and $4.9 billion for patients with COPD. -Wall Street Journal Report

  19. Establishing Innovative Partnerships

  20. Kim A. SchwartzChief Executive Officerkschwartz@rcchc.org252-209-0237

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