Building a Sustainable Telemonitoring Program from the Ground UP Kathy Duckett RN, BSN Director of Clinical Programs Partners Home Care kduckett@partners.org 781-290-4058 Objectives Upon completion the learner will be able to discuss the principles of program sustainability Upon completion the learner will be able to cite 5 Truths of program development Upon completion the learner will be able to identify 3 key elements needed to develop a sustainable telemedicine program Outline Principles of sustainability in program development The 7 Truths of program development 9 Essential Steps to developing a successful telemonitoring program Partners Home Telemonitoring Program 1
Sustainability Support something from below: to keep something in position by holding it from below Encarta World English Dictionary The ability of a system to produce benefits valued sufficiently by users and stakeholders to ensure enough resources to continue activities with long term benefits. International Development Management Center at the University of Maryland (UNICEF, 1992) Not a static condition, but rather an ever evolving process Stefanini & Ruck, 1991 How to Achieve Sustainability 1. Establish clarity of purpose or aim and revisit that often 2. Distinguish between knowledge vs. compliance issues 3. Don t address emotion with a logical response 4. Education must focus on the practice change rationale 5. Create standardized toolkit to support reliable implementation Used by permission: Diane R. Lancaster, RN, Ph.D. (2009) How to Achieve Sustainability 6. Clinical coach / champion at the staff level that is mentored by an improvement advisor 7. Hold staff accountable for thinking critically and providing care that goes beyond protocols and scripts 8. Ongoing audit process and timely feedback to staff 8. Create an environment for reflection that supports ongoing staff input into how its working or what else could be tweaked Used by permission: Diane R. Lancaster, RN, Ph.D. (2009) 2
The art of progress is to preserve order amid change and to preserve change amid order. Alfred North Whitehead (1861-1947) Kathy s 7 Project Planning Truths 1. It will always takes longer than I think it will 2. Nothing is as easy as I think it s going to be 3. There is no such thing as a small problem someone thinks it s a major issue 4. No matter how much planning I do something will come up that I haven t thought of 5. Try to remain flexible without being confusing or wishy-washy 6. Ongoing, clear, consistent communication is crucial and never to be taken for granted 7. Keeping a sense of humor and perspective is essential Adapted from Murphy s Laws by Kathy Duckett - 2009 9 Essential Steps for Sustainability 1. Set Program Goals 2. Gain Insight of Stakeholders 3. Get Buy-in 4. Patient Selection choose wisely 5. Care Coordination 5 Ws 1 H 6. Establish Clinical Standards 7. Equipment Management DME matters 8. IS Infrastructure - IS is your friend 9. Quality Improvement implement soon, evaluate often Success Follows 3
1. Set Program Goals What is the problem you want to solve? Set goals based on measureable outcomes Why telemedicine? Improved care decrease number of emergency room visits decrease number of hospital re-admissions Increase patient involvement in care Decrease home visits Improved outcome and access/decreased costs You ve decided to choose to start a telemedicine program What s Next? Recognize the Nature of a Paradigm Shift Telemonitoring changes traditional notions of care delivery Incredible opportunity to improve care and increase access It builds careers and new skill-sets sets and improves peoples lives..but People resist change Doing it right requires set up and perseverance The 1st time takes longer than one would think 2. Gain Insight of Stakeholders Senior Leadership Nurses & Allied Health Physicians Operations Patient Finance Information Systems Quality & Compliance 4
3. Get Buy In 4 Main Groups Senior Organizational Leadership CEO Field Staff Patient Getting equipment in MD/nurse confidence Clinicians/Allied Health Professionals Champions Touch and Play sessions Manager accountability/feedback loop Prizes Physicians Education Just in time reports Promised decreased calls from patients d/t triage by TM staff 4. Patient Selection Choose Wisely Determine Patient Population Based on program goals Partners Telemonitoring criteria: Moderate to high risk for re-hospitalization Will benefit from telemonitoring Can be managed with decreased nursing visit frequency Patient or caregiver is able/willing to assume responsibility for monitoring Working phone line in patient s home Home is safe environment for equipment 5. Care Coordination 5Ws, 1H Determine process flow SN evaluations for program admission By Whom? Referrals Who refers? Where do referrals go? Who processes them? Telemonitoring of patients Centralized requires dedicated TM staff Decentralized integrated into primary clinician work flow Reporting Why? Who What When Where How 5
6. Establish Clinical Standards Best practice, evidence based standards Must be able to individualize standards Use clinical experts that clinicians will accept to set standards Educate clinicians i i regarding standards d Give clinicians autonomy to modify standards as they deem necessary Give clinicians algorithms/guidelines for further autonomy in practice 7. Equipment Management DME Matters Rent vs. purchase Identify who will manage Establish responsibility and accountability for electronic inventory control system set- up and provisioning installation/testing/break-fix equipment recovery, sanitizing, storage and redeployment Training, retraining, written protocols Begin with decentralized process (greater buy-in at local level), migrate to centralized process (efficiency & consistency) over time, selecting best of breed processes Cultivate leadership 8. IS Infrastructure IS is your Friend Networks How things viewed Transporting data Servers Where they sit Who manages them How EMR/Telemedicine systems integrate for care delivery process Ongoing IS support 6
9. Quality Improvement Implement Soon Evaluate Often Establish QI program at beginning of process Establish planned review periods Initially weekly Include stakeholders as appropriate Include all 8 essential elements as part of formal QI program Establish database for statistics at start of program If you think you might need it, get it Build mechanisms for gathering data if not inherent in EMR program Excel, Access databases 9. Quality Improvement Ear to the ground Eye on the Future Partners Home Care Stats and Facts 175 Towns and Cities 2,500 Average Daily Census 24,000 Admissions Annually 360,000 Visits/Year 46% of Admissions are from non-partners Healthcare System Sources 4 Hospitals: Massachusetts General Hospital, Brigham and Women s Hospital, North Shore Medical Center, Newton Wellesley Hospital - core hospitals for PHS Technology 383 Clinicians on POC 305 Telemonitoring devices remote monitoring 3800+ Personal Emergency Response units Clinicians and Staff 700 Full, Part-time, Per-visit 244 Registered Nurses 25 Licensed Practical Nurses 131 Therapists: physical, occupational, speech 7 Social Workers 61 Home Health Aides 32 Liaisons 11 Intake Nurses 4 Nutritionists 185 Other managers, clinical, admin 7
Telemonitoring at PHC PHC Telemonitoring Program - 2006 Patient Selection Criteria Available for Medicare pts currently receiving PHC Connected Cardiac Care Program - 2007 4 month home telemonitoring program Patient Criteria Strong educational component 1 Nurse visit to establish clinical status and knowledge deficits, then no further nursing Bi-weekly telephonic educational phone calls Encourage direct patient/pcp relationship Patient Choice Program Private Pay Hospice Telehospice Pilot CMS Pilot program Positive Patient Outcomes > 2100 patients cared for 2006- present Average LOS 70 days Average LOS with no rehospitalizations 53 days Average LOS with > 1 hospitalzation 103 days Average rehospitalization PHC program 25% CCCP 30% decrease year over year 1.3% - 1 st 30 days 3% -program completion Positive Patient Outcomes 98% of patients stated they would recommend the program, with 2% neutral and no one stating they wouldn t recommend it. 87% say they know more about their heart failure now because of the program 8
300 250 200 150 10 0 50 0 Combined Program Census FY10 Oct ob er December February April June A ugust 6/4/2010 Positive Patient Outcomes 82% feel they are in more control of their heart failure because of our program. 69% feel the program helped them stay out of the emergency room 78% feel the program helped them avoid a rehospitalization MD Acceptance - CCCP Clinician Response Decrease average SNV to 10 visits/episode with improved outcomes for rehospitalization Consistent referrals to programs Clinician comments: I love it. I feel like I have a better handle on my fragile heart failure patients using telemonitoring they look at them every day and let me know if there is a problem I need to be aware of. I think it s great it s made a huge difference for my patients. Admissions by Region FY10 45 40 35 30 25 South Central 20 North 15 10 5 0 Q1 Q2 Q3 Q4 9
Sustainability Support something from below: to keep something in position by holding it from below Build it well to last The ability of a system to produce benefits valued sufficiently by users and stakeholders to ensure enough resources to continue activities with long term benefits. Get buy-in at all levels, goals based on outcomes Not a static condition, but rather an ever evolving process QI Technology is just another tool in the clinician s tool belt. It s never about the technology it s always about the care. Thank you 10