USING TELEHEALTH TO ACHIEVE THE TRIPLE AIM TERRY YONKER, RN, MS, FNP-BC TELEMEDICINE CLINICAL CARE COORDINATOR FINGER LAKES COMMUNITY HEALTH

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1 USING TELEHEALTH TO ACHIEVE THE TRIPLE AIM TERRY YONKER, RN, MS, FNP-BC TELEMEDICINE CLINICAL CARE COORDINATOR FINGER LAKES COMMUNITY HEALTH

2 Objectives 1. Discuss applications of telehealth in primary care 2. Identify how telehealth provides opportunities to increase access to care 3. List ways in which telehealth has tangible and intangible cost benefits 4. Explain how telehealth programs can improve quality of care

3 Disclosure I have no financial relationship with a commercial entity producing health-care related products and/or services relative to the content I am presenting

4 Who We Are Community/Migrant Health Center Program Migrant Voucher Program in 42 Counties Clinical Sites: 9 Health Center Sites Administrative Office: Penn Yan, NY

5 Where We Are

6 Challenges in Providing Health Care to Rural Poor Transportation barriers Language differences Cultural beliefs Cost of health care services Uninsured/Underinsured Lack of trust in health care system Poverty Migrant lifestyle

7 Telehealth Program Development Funding Sources USDA Distance Learning and Telemedicine HRSA Rural Network Development FINGER LAKES COMMUNITY HEALTH HIT INFRASTRUCTURE DEVELOPMENT Federal Communications Commission Rural Healthcare Broadband Project NYS DOH

8 Telehealth Programs at FLCH Teledentistry Telepsychiatry Telemental Health Tele-ENT TeleDiabetes (DRS) TelePeds Neurology TelePulmonolog y TeleAC TeleRD TeleMD TeleHCV

9 Benefits of Telehealth Patients /Families Reduced travel Timely appointments Services in their community Additional support Providers Direct patient interaction Expanded Services Access to other experts Access to CME Health Care Systems Improved access Improved outcomes Resources utilization Cost and Time efficient

10 The Triple Aim 1 IMPROVE ACCESS 2 IMPROVE QUALITY 3 DECREASE COST

11 HOW TO ACHIEVE THE TRIPLE AIM PART 1 PROGRAM DEVELOPMENT

12 GUIDING PRINCIPLES #1 Telemedicine is a tool #2 Program Management can uncover strengths and weaknesses in operations #3 Quality Improvement is Forever #4 Management by facts = DATA #5 Need to see cost benefits from different perspective #6 Keep a sense of humor!

13 TELEMEDICINE AS A TOOL Identify gaps in service Tap the resources Champions are your best friend IT S NOT ABOUT THE GADGETS, IT S ABOUT THE CARE

14 PROGRAM PLANNING Administration IT Clinical Operations Quality Spend time with specialty provider Pay attention to details Document clinical workflow Always do a pilot start small, think big Goal is to integrate into operations of a PCMH Change Theory

15 QUALITY IMPROVEMENT Data Collection Monitor and Report Outcomes Continuous Quality Improvement (PDSAs) Regularly Evaluate Program

16 MANAGE BY FACTS Data! Data! Data! Facts can trump emotion Facts = Outcomes And remember: A Vision Without a Plan is a Hallucination!

17 COST BENEFIT IS NOT ALWAYS IN REAL $$$ Saved travel time/gas for families and enabling staff Less lost work time for families Increased volume of visits to PCMH Relationships between primary care and specialty care PCP job satisfaction and morale Changing health care delivery system and policy

18 KEEP A SENSE OF HUMOR CHANGE THEORY HELPS! Start Small, Think Big Communicate for Success & Celebrate Victories Pause Points: What is working? What is not working? What could be done better? Identify and Deal with Fears/Concerns Keep Decision Makers in the Loop Keep Process Moving Down the Track Give Feedback (timelines, performance measures) There is no such thing as a small problem

19 HOW TO ACHIEVE THE TRIPLE AIM PART 2 FRONT LINE STAFF HOLD THE KEYS Excellence in Patient Care Drives Everything

20 Create a Registry MR # Last visit A1C Date Result B/P date Result LDL Date Malb ResultDate DR Foot ResultDate Result Exam Sm oke A /20/11 10/20/ /20/79 124/79 4/11/ /26/11 <6 7/26 mild NPDR 6/21/11 N A /28/11 11/28/ /28/11 124/80 3/1/ /28/ /5 mild NPDR 3/3/11 N A /15/11 11/15/ /15/11 107/72 6/20/ /8/ /21 neg 4/8/11 N /01/11 9/8/ /1/11 106/66 9/25/ /8/11 <6 9/29?glauco ma 9/8/11 N /06/11 12/6/ /6/11 126/83 12/6/11 ACE-I N A /25/11 8/25/ /25/11 129/80 6/2/ /25/ /25 neg 8/25/11 yes A /29/11 11/22/ /29/11 145/85 12/1/ /16/ /2 mild NPDR 11/22/11 N

21 Care Coordination *Scheduling *Pre-Visit Requirements *Concurrent Chart Review *Coordinate with PCMH Team/Specialty Team *Quality Assurance Reports *Lead Case Conferences *Quality Improvement PDSA

22 History Exam Treatment Train Telepresenter

23 Actively Decrease Barriers to Care Outreach Insurance Access Transportation Language/Cultural Interpretation Motivational Interviewing/Pt Centered Goals Education Relationships = Trust

24 The Finished Product Here are some examples

25 TeleDentistry Finger Lakes Community Health Eastman Institute for Oral Health

26 EARLY CHILDHOOD CARIES IN MIGRANT CHILDREN Early onset & increased severity due to cultural feeding practices Prevalence: Migrant > Underserved urban > US general population

27 Mobile Dental Services * Lake Ontario ABCD * Red Creek ABCD *Migrant Summer Schools (Sodus, North Rose, Red Creek) **FLCH mobile dental teams and primary prevention strategy has decreased rate from 60% to 22%** ***For children with advanced decay, pediatric dentist and treatment under sedation or general anesthesia*** For those requiring treatment of ECC.. 15% COMPLETION RATE

28 LIVE VIDEOCONFERENCING

29 TELEDENTISTRY Intraoral Camera Digital Images Real Time Images

30 Bilingual/Bicultural Community Health Workers Outreach Insurance Access Transportation Language/Cultural Interpretation Pediatric Dentistry Access Education Relationships = Trust

31 TeleDentistry Outcomes 4/10 4/14 N = 290 consults Triaged Correctly = 88% Decreased travel costs Decrease in lost work time Improved access to care Decreased time to treatment Decrease no show rates Increased interaction between dental providers 94% COMPLETION RATE 54% require treatment under general anesthesia

32 TelePeds Neurology Finger Lakes Community Health URMC Child Neurology

33 TelePeds Neurology Site Visit Create Remote Office Registry Care Coordination IT Connectivity Train PA in Neuro Exam Use PCMH Team Leverage HIT Case Conference Monitor Outcomes Ongoing QI 2013 Pilot Outcomes: *** Decreased time to treatment (38d vs 60d) *** Exceeded national averages on NCQA performance measures *** 75% had changes or additions to their med regimens *** 87.5% diagnosed with mental health co-morbidity *** 100% referred to behavioral health *** 63% showed improvement in function at school and home *** High provider and patient satisfaction

34 TeleAC (HIV/AIDS Care) Finger Lakes Community Health Trillium Health

35 TeleAC Appointment Adherence HIV CARE PCP 85% 57% 91% AC 85% 86% 100% CD4 >500 50% 29% 64% CD4 >200 85% 86% 91% Negative viral load 50% 29% 67% HAART > 95% 85% 71% 73% OI PCP if indicated 100% 100% 100% Prevention Screening TeleAC Pilot Program Clinical Measures Indicator Goal Baseline 7/1/13 End Pilot 6/30/14 TB Testing 85% 86% 80% HCV Screening 85% 57% 100% Cervical PAP 85% 66% 100% Anal PAP 85% Colon cancer screening 85% 86% 50% Annual Lipid Screen 85% 100% 100% Annual urinalysis 85% 71% 60% A1C 85% 71% 100% STD Screen 85% 86% 92% PHQ 9 85% 29% 80%

36 TelePsychiatry Finger Lakes Community Health FL Health & John D Kelly Behavioral Health Unit

37 TelePsychiatry Outcomes % had decrease in PHQ9 scores Mean time to consult = 19 days Mean time to treatment = <24 hours High patient and provider satisfaction 39% lost to follow up 0% referred to ED 17% referred to higher level of care (Article 31)

38 Fundus Photography in Primary Care TeleDiabetes

39 Sodus Community Health Retinopathy Pilot Screening Results

40 100 SODUS COMMUNITY HEALTH DIABETES QUALITY INDICATORS May '11 March '12 June ' A1C < 7 B/P < 130/80 LDL < 100 Kidney check Foot Exam DRS National Committee on Quality Assurance(NCQA) > 40% >25% >36% >80% >80% >60% FLCMH

41 USING TELEHEALTH TO ACHIEVE THE TRIPLE AIM

42 THANK YOU! For more information: