Patient Centered Medical Home and Telehealth Application MaryJo Vetter, MS RN, GNP

1. Patient Centered Medical Home and Telehealth Application MaryJo Vetter, MS RN, GNP Director of Clinical Product Development, Visiting Nurse Service of New York Christina Coons, RN, BSN Manager of Telehealth Services

2. Opportunity Knocks… • Converging forces in healthcare today are placing great emphasis on efficiency and effectiveness of patient care • Chronic illness population with steep trajectory • Workforce shortages growing with increased demand • Technology adoption by end user more commonplace • Government funding has increased • Reimbursement strategy is changing • Self Management techniques are cutting edge • Healthcare organizations are presented with vital growth opportunities amidst the challenges

3. Visiting Nurse Service of New York Overview VNSNY is the largest not-for-profit home health care organization in the nation and was founded in 1893 by Lillian Wald, the first public health nurse. Serving:Bronx, Brooklyn, Manhattan, Queens, Staten Island, Nassau and Westchester counties Chief Executive: Carol Raphael: President & CEO Statistics (Calendar Year 2007): • Total Patients Served: 138,600 • Total Professional Visits: 2,456,000 • More than 25% of our patients spoke languages other than English • Diabetes and hypertension were among the most frequent diagnoses of our patients • On any given day, VNS has more than 30,000 patient in our care that’s more patients than are seen in one day in all NYC Hospitals Staffing • Has over 13,300 care givers. • Collectively, VNSNY staff members speak more than 50 languages

4. Our Major Lines of Business VNSNY Research Center Hospice / Palliative Care LTC/MC Private Care CHHA • Adult Care • Maternal Newborn • Pediatrics • LTHHCP • Infusion • Managed LTC • Medicare Advantage • Advantage Plus

5. The Scope of VNSNY’s Services Extends Beyond Traditional Home Care Community Mental Health Services FRIEND’s Clinic (Article 31) - Bronx Centers of Excellence Programs Advanced Illness Management COPD Care Diabetes Care Heart Failure Care Stroke Care Telehealth Wound, Ostomy and Continence Care Children and Family Services Bronx Fatherhood Program Maternity, Newborn and Pediatrics Community Care for Children Early Intervention Program Early Health Start Program and Early Steps Family Center Father’s First Initiative Nurse-Family Partnership Medicaid and Medicare Health Plans VNS CHOICE MLTC VNS CHOICE MLTC Plus VNS CHOICE Medicare Acute Care Skilled Nursing Physical, Occupational and Speech Therapy Social Work Home Health Aide Services Long Term Care AIDS Long Term Home Health Care Program Congregate Care (Geriatric:Adult Home Care) Family Care Services Long Term Home Health Care Program Meals on Wheels Nutrition Services End of Life Hospice Care Palliative Care Bereavement Services Community Outreach Community Connections TimeBank Private Care Skilled Nursing Care Home Health Aide Services Geriatric Case Management

6. Medical Home Overview • Patient Centered Medical Home was promoted by NCQA as an approach to providing comprehensive primary care for children, youth and adults • Developed in collaboration with the ACP, AAFP, AAP and AOA • First modeled in 1967 by AAP to enhance care coordination for special needs Peds • Partnership between individual patients, and their personal physicians, and when appropriate, the patient’s family. • Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner. • NCQA provides verifiable certification of a host of best practices for ambulatory care • Practices will demonstrate that they meet certain standards and elements, which are then scored and assigned a level to become eligible for reimbursement • State, government, and commercial insurers are looking for ways to reimburse for processes that deliver better care Source: http://www.ncqa.org

8. Medical Home’s 7 Core Principles Source: http://thepcmh.org/

9. Optimal Care Requires a Paradigm Shift for all Payers and Providers Wagner’s Chronic Care Model Developed by the MacColl Institute for Healthcare Innovation®

10. VNSNY’s Chronic Care Program Can Provide Supporting Infrastructure to Medical Homes for Managing Patients with Chronic Illness at Home Patient Health Plan VNSNY’s Chronic Care Management Patient Centered Medical Home

11. VNSNY’s CCM Program Improves Interactions between Patients and Healthcare Providers VNSNY’s Core Elements of Chronic Care Management Theory-Based Self Management Support Specialist Oversight & Decision Support Technology Community Resources High Touch Delivery System • Telemanagement • Clinical information • systems • Support of patient • registry • Use of data for care • coordination • Outcome data • measurement • Initial in-home • comprehensive • assessment • Proactive planned • phone visits • Telehealth • Interactions • In-home crisis • visits • Motivational • interviewing • Health coaching • Self management • education • Individualized- • goal oriented • Action Plan • Self-efficacy • improvement • APN specialist oversight • Medical management • via NP-MD collaboration, • when needed • Care coordination with • Primary Care/Specialty • Physicians • Use of evidence-based • guidelines and practice • Partnership • with payers & • community • agencies • Linkage of • members to • community • resources

12. VNSNY Telehealth Background • Program infrastructure established over past 5 years to support wide rollout and increased service offerings • Telehealth Equipment Vendor Contracts & Logistics Company (DME) • Training Courses and Materials: Patient/Member, Caregiver, Clinician, Physician • Policies, Procedures, Evidenced Based - Best practices • Research • Billing • VNSNY Telehealth Web Browser developed for clinicians at point of care • Physician Web Portal • Telehealth programs for VNSNY Internal and External customers • Based on Risk for Hospitalization & ER use • Specific disease focused – Diabetes, CHF, ESRD, Wound Care • Baseline safety tools- PERS • Wide involvement in NY state grants and HCA activities • HEAL 10 • NYSDOH • HCA Telehealth Workgroup Member • National participation & partnerships with large Telehealth Corp. • Viterion Healthcare – Bayer, Intel Corporation, AMAC • American Telemedicine Association – Multiple SIG membership • NAHC Chronic Care Congress attendee

13. VNSNY Telehealth Monitoring: Subjective & Objective Assessment Data

14. Patients Measure Their Vital Signs in The Home

15. Patients Can Answer Questions Based on Branch Logic Education and Assessment * Enhances Self Care Techniques & Lifestyle Management, Promotes Health Coaching Opportunities

16. Vital Sign & Symptom Data is Transmitted in Real Time with Automated Clinical Stratification *Promotes Targeted Interventions by Telehealth Staff and Facilitates Communication to Providers

17. Telehealth Trend Reports Are Created for Patients, Nurses, & Providers * Prioritizes Clinical Decision Making

18. VNSNY Telehealth Web Browser Gives Access to Patient Data for All Clinicians VNSNY Telehealth Portal

19. VNSNY Physician Portal

20. Telehealth Intervention Overview Based on the plan of care, the nurse will perform a range of interventions appropriate to meet the patients clinical needs Patient vitals signs and symptoms are accessed and monitored daily by the nurse using the electronic tablet A nurse assesses the patient in the home, coordinates the equipment set up, and education of the telehealth program • Conducting telephonic assessment and education with the patient • Customizing Telehealth clinical questions and messaging to be delivered via the Telehealth monitor to further assess and/or educate the patient • Provide a home for hands-on intervention or education as needed • Contacting the patients doctors to discuss further interventions • Sending the provider individual patient Telehealth trend data to facilitate clinical decision making

21. ‘Medical Home’ and Telehealth Data Workflow Exchange RHIO Network 5 Telehealth Vendor Database 4 1 6 Home Care Database 10 2 EHRs Hosp Patient Centered Medical Home 7 Patient Transmits Her Vital Sign Data Via Communication Method PCP 9 8 3 RN MSW

22. Case Study of Medical Home and Telehealth Use Mrs. T is a 61 year old woman with Type 2 Diabetes who develops an infected foot ulcer and presents to the ER. After a brief admission, she is discharged to her patient centered medical home, where her PCP coordinates home care to keep her from returning to the hospital. • VNSNY Home Care EHR extracts relevant patient info from the PCMH via the RHIO • After initial nursing assessment, patient receives telehealth monitoring and wound imaging, all incorporated from VNSNY Home Care EHR via the RHIO into the PCMH EHR • The VNSNY Wound Care Nurse Specialist provided recommendations of wound care through the RHIO • PCP made interim changes to the treatment plan through the RHIO • Mrs. T improves in her self care techniques, wound healing progresses, while she has minimal in-person doctors visits and is not rehospitalized. • The PCMH promotes operational, financial, and clinical efficiencies to achieve improved outcomes and contain costs.

23. Questions ? MaryJo Vetter, MS, RN, GNP 212 609 6358 MaryJo.Vetter@vnsny.org Christina Coons RN, BSN 212 609 6353 Christina.Coons@vnsny.org