Top Rated Bangalore Call Girls Majestic ⟟ 9332606886 ⟟ Call Me For Genuine S...
What We're Working On Now: Getting the "System" to be a Real System for Heart Failure Patients
1. What We’re Working On Now
*moderator or couple of respondents?*
- Getting the “System” to be a Real System for Heart
Failure Patients –
Douglas McClure
Corporate Manager, Operations & Technology, Center for
Connected Health
ALL PROCEEDINGS WILL BE VIDEO RECORDED
2. System “partners” @ Partners
• High Performance Medicine – Care Coordination for
Special Populations
• Allison McDonough, MD, Medical Director of
Population Management
• Partners HomeCare
• Judith Flynn, BSN, MBA, Chief Clinical and
Compliance Officer
• Center for Connected Health
• Corporate Manager, Technology and Operations
5. Readmission Outcomes - 180 days
0.8
0.7
Control Intervention Refused
Mean 180 days readmissions
0.6
0.5
0.4
0.3
0.2
0.1
0
All-cause CHF
6. Heart Failure Population Overview, Partners
• 30,000+ heart failure patients under care within Partners
• 2,700 admits per year
• 25-30% deceased within 1 year of discharge (no national
benchmarks)
• >90% connected to heart failure management program
after discharge
• 400+ under active management by heart failure NP at any
given time
• 1,300+ patients followed by Partners Home Care each
year
• 300+ have been followed by telemonitoring in past year
(~ 60 active at any given time)
7. Disease Management Approaches
Low High
Engagement Engagement
Risk Screening Remote Monitoring
High Tech Stratify patients for different Use devices to monitor patients
program interventions based on at home
(Emerging) medical criteria
NP Clinic, Practice-based
Case managers
Supported by real-time alerts,
workflow software, clinical
decision support
Population Screening Call Center
Target patients by disease and Centralized case managers call
age group patients to monitor progress
Low Tech
(Traditional) Patient Education Guidelines/Support
Distribute brochures on how to Promote best practices among
manage chronic disease providers
Concept Source: California HealthCare Foundation
9. A Coordinated and Targeted Program
2,700 Discharges
2,100 Patients
Triage
Home Care Remote Monitoring
~60 days
Continuing Cardiac Care
~4 months
Step Down Monitoring
~1 year
Health Coaching
Under
Development
12. Heart Failure Population Overview, Partners
Approximately 50% of DRG 127
discharges have a Partners PCP
13. Challenges of HF Dz Mgt
•Patient Identification
•Choosing an intervention
•Reaching and Engaging
•Patient and MD barriers to
engagement
14. ID Partners HF patients
appropriate for telemonitoring
Send file to CCH
Note: HPM 4 team
has experience
“Opt-in” note sent to MD: with this and will work
closely with CCH to
•Can pt be enrolled? develop
•Would you like to enroll other
appropriate HF patients?
Approved patients
Key are enrolled
in telemonitoring
HPM Team 4
HPM4 and CCH will work
CCH together to refine criteria (if
necessary), consider
HPM Team 4 & CCH expansion to other PHS sites,
Monitor & and measure outcomes of
these uniquely enrolled
Evaluate patients
15. Challenge
Managing the Patient
Efficiently and Effectively
16. Managing the Patient Efficiently and Effectively
• Determining Who best to Manage the Patient
– Longitudinal care is difficult in the existing fragmentation and silos
– Multiple care providers all trying to direct care
• Finding the Right Mode of care delivery impacted by
– Patient acuity, ability and preference
– Location of care
– Acceptance of intervention by patient and physician
– Effectiveness of intervention
– Coordination of various interventions has been challenging within a
large and complex system.
• Ensuring High Reliability in Care
– Requires Coordinated delivery across disparate systems
17. Managing the Patient Efficiently and Effectively
• Relative cost effectiveness of various
interventions unknown
– Cost savings remain undetermined
• Discharge process marked by
– Inpatient-outpatient discontinuity
– Changes and discrepancies in care
plan/medications
– Problems with self-care and social support
– Ineffective physician-provider communication
18. Managing the Patient Efficiently and Effectively
Nurse Practitioners (1998)
4 NPs at each of 4 sites, focus on the most acutely ill
Number of current active patients ~450
Cumulative enrollment since 2004 ~1,400
Partners Home Care (2004)
Integration of field staff (400 RNs) who serve 1,200 HF pts/yr
Cumulative enrollment since 2004 ~4,000
Identify and Connect (2005)
Assure >90% discharged patients at high risk of readmission are connected to
longitudinal services
Outcomes and process measures (2006)
Measurement of readmission rates, mortality
System-wide HF Registry (2006)
Collaboration with Team 3, Partners IS, MGH LCS
Telemonitoring (2006)
Collaboration with Partners Center for Connected Health
Physician and patient decision support tools (2009 and beyond)
