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Interactive Voice Response (IVR) Care Transition Systems

Interactive Voice Response (IVR) Care Transition Systems. TM. Support for patients transitioning from hospital to home. Care Transitions. TM. The transition from hospital to home High risk for patients Not feeling 100% yet Information overload at discharge Medications Follow-up care

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Interactive Voice Response (IVR) Care Transition Systems

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  1. Interactive Voice Response (IVR)Care Transition Systems TM Support for patients transitioning from hospital to home

  2. Care Transitions TM • The transition from hospital to home • High risk for patients • Not feeling 100% yet • Information overload at discharge • Medications • Follow-up care • Diet • Exercise • Special instructions • Specialist care • Possible pending test results

  3. Patient Perspectives TM • Knowledge needs • Who is in charge – who is the primary provider? I have LOTS of doctors… • Who should I call? My primary doctor? The doctor who took care of me in the hospital? The name on this paperwork? When should I call? • Is this really a health problem or am I just having a bad day? • Am I having medication side effects? How do I know? • Who should I tell? • How do I know if my medicine is working? • Do I know why I am taking all these medicines?

  4. Talking with the Provider TM • Patients looking for guidance about how to engage with their providers • Common patient beliefs • Doctors and nurses are busy • I should not question their authority • If it is important, my doctor would have talked about it • If I ask questions, my doctor might think I am being disrespectful

  5. Care Transitions TM • Patients in need • Outpacing number of available providers • Patients have more complex illness • Multiple chronic conditions • Multiple complex medications • Multiple providers • Multiple settings

  6. Heathcare Costs TM • Healthcare costs are rising at a faster pace than inflation! • Human costs • Decreased quality of life • Decreased community tenure • Stress and worry • Confusion • Financial burdens

  7. Heathcare Costs TM • Issues driving healthcare costs ↑ • Chronic conditions • Cardiovascular disease • Highest costs • > $40 Billion, 2010 • Chronic obstructive pulmonary disease (COPD) • Kidney disease • Pneumonia • Diabetes • Obesity • Asthma • Pain management…

  8. Heathcare Costs TM • Economic strain on Healthcare System • Rehospitalizations • Emergency department visits • US Hospital 30-day readmission rates of 20% • Annual cost to Medicare fee for service > $17 Billion • Readmission rates for chronic illness with respiratory implications • CHF: 27% • COPD 23% • 90% of these readmissions unplanned • 40% – 75% preventable if existing standards of care were in place (Jencks, 2009) Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-28

  9. Cost of Chronic Disease TM • Why is chronic illness so costly? • Difficult to diagnose • Often occurs with other conditions • Symptoms overlap • Affects older population disproportionately • Develops over time • Cumulative effects of multiple issues • Requires ongoing management – not curative • Frequent doctor visits • Ongoing changes in complex medication regimes • Potential for adverse events always looming…

  10. Access to Care TM • Limited access to care • Geographic boundaries • Cost barriers • Insufficient preventive care services • Gaps in provider-patient communication • Insurance barriers • Barriers in referral process • Long waiting lists for an appointment • Transportation barriers • Mobility barriers…

  11. “Bundled Care” TM • Part of the Affordable Care Act of 2010 • Public Law 111-148 and Public Law 111-152 • Purpose: • Reduce costs • Reduce preventable rehospitalizations • Reduce preventable ED visits • Improve communication across care settings • Improve quality of care • Improve safety for patients • Incentivize providers to “engage” in coordinated care activities within and between care settings

  12. “Bundled Payment” TM • Agency for Healthcare Research and Quality (AHRQ) • Bundled Payment: “a method in which payments to health care providers are related to predetermined expected costs of a grouping or ‘bundle’ of related health care services” (AHRQ, Publication No. 12-E007-EF, August 2012).

  13. “Bundled Payment ” TM • How does Bundled Payment work? • Intended to hold providers and healthcare organizations “accountable” • Type of services provided • Number of services provided • QUALITY of services provided • Financial penalties • Gaps in care • Preventable rehospitalizations • Preventable ED visits

  14. What can we do? TM • Improve the process of Care Transitions • Include ALL the stakeholders • Patients & Families • Providers • Hospitals • Clinics • Private Practices • Payers/Insurors • Specialists

  15. Strategic Requirements TM • The effective solution must be: • Affordable • Simple • Effective & Useful • Meaningful • Available to all • Evidence-based • Clinically Relevant • Sustainable • Scalable

  16. The Solution: IVR Care Transition Systems, Inc. TM Support for patients transitioning from hospital to home

  17. Our Professional Team TM Heather J. Sobko, PhD, RN Mark Glenny, BA, MS, RN Charles W. Callans, III, MPH Douglas Mitchell, BS Octavio E. Pajaro, MD, PhD K. Randall Young, MD Monika Safford, MD Benjamin B. Taylor, MD, MSPH Andrew Tyson, BS Edward M. Sobko, BSME Donald Schnader, MS, MSHI Rob Rader Shelli Andros Kevin Leon, MD NivedithaThota, MSHI Dan Piper, MS Jody Fann Steven Schnader, MS Paul Crigler, ABPMP, CBPP Gary West, MS, MBA Susan Andreae, BS, BFA, MPH Derek Mathews, BS, MS Barbara A. Sobko, MS Brian Gugerty, DNS, RN Gregory L. Rohde, BS, ME F. Don Siegal, Esquire Scott J. McKay, MSE James W. Conrad, III, CPA, CFP Joshua S. Richman, MD, PhD Zack Schaper Joseph Fisher NachiketaMishra, MSHI Kenneth M. Bush, Esquire Donald Schnader, MSHI Cindy Boggs, MS Robert Gilbert, BS Thomas G. Spurlock, MD, DC

  18. Our Mission TM Provide affordable, meaningful, technological tools to extend healthcare support for patients making the transition from the hospital to home so that the transition is successful and potential complications or problems are minimized

  19. Our GOALS TM • Reduce burden on human resources • Increase efficiency and effectiveness of clinician time • Reduce preventable Rehospitalizations • Reduce preventable ED visits • Provide meaningful relevant data • ongoing monitoring of patients • reporting outcomes • improving processes

  20. Our GOALS TM • Improve provider-patient communication • Increase and enhance provider communication across settings of care • Integrate relevant clinical data into existing workflows • Focus on inclusion of all stakeholders: • Patients & families • Providers • Hospitals • Clinics • Payers/insurers • Private practices • Specialists

  21. Our GOALS TM • Increasing patient engagement in managing chronic health needs • Create a comprehensive system that patients actually enjoy and use because they like it and it is easy to use • Allow choices for patients and families wherever possible • Keep it simple and make it affordable • Design a scalable model so that it can meet the growing needs of all the stakeholders WITHOUT increasing costs!

  22. IVR Care Transition Systems, Inc. TM • An Interactive Voice Response System designed to provide support for patients during care transitions • A comprehensive, self-contained system • Calls out to patients electronically • Evidence-based queries about specific health needs (very focused) • Calls scheduled to meet patient preferences

  23. IVR Care Transition Systems, Inc. TM • Patients respond to queries using their telephone keypad • Information is securely transmitted to a clinician for review via a computer “dashboard” • System has a built-in triage system to support clinical personnel in identifying patients in need

  24. IVR Care Transition Systems, Inc. TM • Patients whose survey responses indicate a need for some guidance, information or support receive a personal phone call from a Care Transition nurse • The system database gathers information and can create aggregate data in the form of reports to support quality improvement and process improvement efforts • Data can be used to support research efforts aimed at resolving challenges associated with care transitions

  25. IVR Care Transition Systems, Inc. TM We have an affordable solution for the growing costs of healthcare and the critical need to support patients who are transitioning across care settings Additional information on our website: www.CareTransitionSystems.com

  26. Interactive Voice Response (IVR)Care Transition Systems TM Support for patients transitioning from hospital to home

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