Home Telehealth: Enhancing Access to MS Health Care Jodie K. Haselkorn, MD, MPH Director, MS Center of Excellence West Professor, Rehabilitation Medicine Adjunct Professor, Epidemiology University of Washington
PVA Summit Orlando 2013
No Disclosures
Objectives Describe the development of Care
Coordination and Home Telehealth in the Veterans Health Administration Discuss MS Home Telehealth Disease Management Protocol
Investment in Resources and Processes 2011 Budget $80.5 million 2012 Budget $105 million
Standardized training in home telehealth Expanded development of evidence-based
disease management protocols Performance plan incentives for VISN and medical center executives
Features of National Telehealth Infrastructure
Conditions of participation for Vendors Blanket purchase agreements Centralized handling of equipment Codified procedures Credentialing and privileging Centralized scheduling Quality control and risk management Systematic collection and analysis of outcomes
Three Telehealth Training Centers: Sunshine Training Center: Home Telehealth Staff Training through Asynchronous and Synchronous Modalities
Best Practice Training
Lead Care Coordinators & Care Coordinators
Home Telehealth Clinical Community of Practice
Program Support Assistants & IT Support
Innovations and Advancements in Technology
VISN Telehealth Leads and Leadership Master & Support Preceptors Telehealth Clinical Technicians Facility Telehealth Coordinators
Lessons from the Masters: Disease Specific Care Advancing Home Telehealth Practice Home Telehealth Annual Competency program
HomeTelehealth Census FY2008-2012
100,000
92,000
80,000
66,000
60,000 40,000
35,406
40,348
48,345
20,000 0
FY08
FY09
FY10
FY11
FY12
Mission: High quality, consistent care to veterans regardless of where they are located geographically. Implement Wagner’s Chronic Care Model using and enhancing the VA’s informatics backbone.
MSCoE Telehealth and Chronic Care Model Self Management Support MS Disease Management Protocol
Delivery System Design Provide health services at the right time and right place, in the
home Reduce unscheduled visits and hospitalizations
Information System Evaluate with ProClarity and VA MS National Data Repository
Decision Support www.va.gov/ms and community links Connect to MSCoE using My HealtheVet and secure messaging Link with Care Coordination and Home Telehealth and provider
when necessary
MSCoE Telehealth Goals Veteran and Caregiver Increase access to
specialty care Reduce the burden of Veteran and caregiver travel Provide in-home support to delay or prevent longterm institutional care Help reduce wait times
Organization Deliver appropriate
services to a population of Veterans with MS Decrease non-scheduled visits and phone calls Decrease transportation costs Provide alternatives to long-term institutional care
VA Puget Sound HCS
WA ME MT
Portland VAMC
OR
ND
1
MN
20
VT
12
Minneapolis VAMC
ID
SD
NH Syracuse VAMC Buffalo VAMC
WI
23
Rapid City VAMC
Madison VAMC
MI
11
Iowa City VAMC
IA
19
NV
NE
VA Salt Lake City HCS
Sacramento Mather VAMC San Francisco VAMC
CO
IN
IL
UT
PA OH
10 WV
15
KS
St. Louis VAMC
VA
MO
KY
22 AZ
18
Oklahoma City VAMC
NM
Little Rock VA HCS
VA North Texas HCS
TX
DE
Baltimore VAMC Washington DC VAMC Richmond VAMC
SC
Birmingham VAMC
Ralph H. Johnson VAMC
7
16
Carl T. Hayden VAMC
MD
Memphis VAMC
AR
OK
MS
AL
GA
GV (Sonny) Montgomery VAMC
LA
17
New Orleans VAMC
FL
20
Tampa VAMC
AK MSCoE Coordinating Center MSCoE East Regional Hub Site MSCoE West Regional Hub Site
21 HI
VISN
NY Harbor VAMC
NC
TN
Long Beach VAMC
3
6
9
Los Angeles VAMC
NJ
Philadelphia VAMC
5
Indianapolis VAMC
Eastern Colorado HCS
CA
4
Cleveland VAMC
Jesse Brown VAMC Edward Hines Jr. VAMC
RI CT West Haven VAMC
2
Detroit VAMC
VA Boston HCS
MA
NY
WY
21
Albany VAMC
8 Miami VAMC
Anchorage
Seattle
2,266 miles driving
1,444 miles flying
Care Coordination & Home Telehealth MS Disease Management Protocol (DMP) Vital Signs MS Symptom Monitoring Medication Persistence Secondary Symptom Monitoring Depression, Fatigue, Pain, Spasticity, Bladder, and Bowel
Disease Management Education and Strategies Care Partner Support
Home Telehealth and Disease Management Pilot • Observational Cohort Veterans (n=41)
• VA Puget Sound Healthcare and Washington DC VA • 66% participated with 8-33 weekly questions for 6
months; 85% for 5 months
Characteristics of Participants Age, mean (SD) Gender (male) White Married Employed
Duration of MS mean (SD) EDSS score, mean (range) Relapsing remitting Secondary progressive Primary progressive DMT
52.6 (8.7) years 80.5% 68.3 % 67.5% 20.0% 14.56 (10.72) years 6.5 (2–8.5) 17.9% 59.0% 23.1% 61%
Characteristics of Participants
Drive Driven by someone else Distance mean (max) Travel time mean (SD)
42.5% 35.0 % 93.57 (351.37) miles 71.8 (68.6) minutes
Endorsed symptoms at baseline: fatigue (95%),
depression (78%) and pain (71%)
Change in Percent Reporting Symptoms Months 1 and 6 Month 1 Neurologic 48.8 Pain 70.7 Fatigue 95.7 Bladder 65.9 Bowel 65.9 Depression 78.0 DMT side effects 43.2 DMT missed doses 13.5
6 29.0 67.7 83.9 54.8 48.4 54.8 34.5 10.3
Change −19.8 − 3 −11.2 −11.1 −17.5 −23.2 - 8.7 − 3.2
Outcomes Easy to understand
93.8% Easy to use 93.8% Worked like it is supposed to 75.0% Worked when needed 87.6% Satisfaction 87.5% Improved care 62.5% Would prefer home telehealth 50.0%
Themes from Care Partners Increases competent care Extends time at home
Decreases care partner depression and fatigue Allows for more personal time and less travel
Turner AP, Wallin, MT, Sloan A, Maloni H, Kane R, Martz L, Haselkorn JK. Clinical management of MS through home telehealth: Results of a pilot. Int J of MS Care, in press.
Cost Outcomes with Home Telehealth Reduced bed days of care 50% Lowered rates of institutional placement
Reduced fee basis care Reduced clinician travel Reduced payment for Veteran travel
Disease Management Protocol MS National Roll-out Pilot in 2 regions of the county Revised Disease Management Protocol
Re-pilot Vendor implementation FY 2014 MSCoE developing educational support for
Care Coordination and Home Telehealth Nurses
CCHT Disease Management Protocol System Examples Patient data responses load in CPRS to help monitor clinical care Example: Home Telehealth Monitor Example: Home Telehealth Monitor
Example: Answers to MS questions with color-coded alerts on CPRS
Example: MS education message to increase patient self-care
26
