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USING TELEHEALTH TO ACHIEVE THE TRIPLE AIM TERRY YONKER, RN, MS, FNP-BC TELEMEDICINE CLINICAL CARE COORDINATOR FINGER LAKES COMMUNITY HEALTH
USING TELEHEALTH
TO
ACHIEVE THE TRIPLE AIM
TERRY YONKER, RN, MS, FNP-BC
TELEMEDICINE CLINICAL CARE COORDINATOR
FINGER LAKES COMMUNITY HEALTH
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
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
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
Where We Are…
• Transportation barriers
• Language differences
• Cultural beliefs
• Cost of health care services
• Uninsured/Underinsured
• Lack of trust in health care
system
• Poverty
• Migrant lifestyle
Challenges in Providing Health Care to Rural Poor
FINGER LAKES COMMUNITY HEALTH –
HIT INFRASTRUCTURE DEVELOPMENT
USDA – Distance Learning and Telemedicine
HRSA – Rural Network Development
Federal Communications Commission – Rural Healthcare
Broadband Project
NYS DOH
Telehealth Program Development Funding Sources
Teledentistry
Telepsychiatry
Telemental Health
Tele-ENT
TeleDiabetes (DRS)
TelePeds
Neurology
TelePulmonology
TeleAC
TeleRD
TeleMD
TeleHCV
Telehealth Programs at FLCH
Patients /Families
Reduced travel
Timely appointments
Services in their
community
Additional support
Benefits of Telehealth
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
The Triple Aim
1 •IMPROVE ACCESS
2 •IMPROVE QUALITY
3 •DECREASE COST
HOW TO ACHIEVE THE TRIPLE AIM
PART 1
PROGRAM DEVELOPMENT
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!
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
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
QUALITY IMPROVEMENT
• Data Collection
• Monitor and Report Outcomes
• Continuous Quality Improvement (PDSAs)
• Regularly Evaluate Program
MANAGE BY FACTS
• Data! Data! Data!
• Facts can trump emotion
• Facts = Outcomes
And remember:
A Vision Without a Plan is a Hallucination!
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
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
HOW TO ACHIEVE THE TRIPLE AIM
PART 2
FRONT LINE STAFF HOLD THE KEYS
Excellence in Patient Care Drives Everything
MR #
Last visit A1C Date Result B/P date Result LDL Date Result
Malb Date Result
DR Date Result
Foot Exam
Smoke
A07362500 10/20/11 10/20/11 7.3 10/20/79 124/79 4/11/11 71 7/26/11 <6 7/26 mild
NPDR 6/21/11 N
A07343203 11/28/11 11/28/11 10.3 11/28/11 124/80 3/1/11 38 11/28/11 150 1/5 mild
NPDR 3/3/11 N
A07317705 11/15/11 11/15/11 5.9 11/15/11 107/72 6/20/11 59 4/8/11 13 7/21 neg 4/8/11 N
3617386 11/01/11 9/8/11 14 11/1/11 106/66 9/25/11 231 9/8/11 <6 9/29 ?glauco
ma 9/8/11 N
10002 12/06/11 12/6/11 6.4 12/6/11 126/83 12/6/11 ACE-I N
A07273833 10/25/11 8/25/11 7.3 10/25/11 129/80 6/2/11 85 8/25/11 16 8/25 neg 8/25/11 yes
A07228967 12/29/11 11/22/11 7.7 12/29/11 145/85 12/1/11 100 8/16/11 131 8/2 mild
NPDR 11/22/11 N
Create a Registry
*Scheduling
*Pre-Visit Requirements
*Concurrent Chart Review
*Coordinate with PCMH
Team/Specialty Team
*Quality Assurance Reports
*Lead Case Conferences
*Quality Improvement PDSA
Care Coordination
History
Exam
Treatment
Train Telepresenter
• Outreach
• Insurance Access
• Transportation
• Language/Cultural Interpretation
• Motivational Interviewing/Pt Centered Goals
• Education
Relationships = Trust
Actively Decrease Barriers to Care
Here are some examples……
The Finished Product…
Finger Lakes Community
Health
Eastman Institute for Oral Health
TeleDentistry
EARLY CHILDHOOD CARIES IN MIGRANT CHILDREN
Early onset & increased severity due to cultural
feeding practices
Prevalence:
Migrant > Underserved urban > US general population
Mobile Dental Services
**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
• * Lake Ontario ABCD * Red Creek ABCD
• *Migrant Summer Schools (Sodus, North Rose, Red Creek)
LIVE VIDEOCONFERENCING
TELEDENTISTRY
Intraoral Camera
Digital Images
Real Time Images
Bilingual/Bicultural Community Health Workers
Outreach
Insurance Access
Transportation
Language/Cultural Interpretation
Pediatric Dentistry Access
Education
Relationships = Trust
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
4/10 – 4/14
N = 290 consults
54% require treatment under general anesthesia
TeleDentistry Outcomes
Finger Lakes Community
Health
URMC
Child Neurology
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
TelePeds Neurology
Finger Lakes Community
Health
Trillium
Health
TeleAC (HIV/AIDS Care)
TeleAC
Appointment Adherence
PCP 85% 57% 91%
AC 85% 86% 100% HIV CARE
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
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%
TeleAC Pilot Program Clinical Measures
Indicator Goal Baseline 7/1/13 End Pilot 6/30/14
Finger Lakes Community
Health
FL Health
&
John D Kelly Behavioral Health Unit
TelePsychiatry
• 55% 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)
TelePsychiatry Outcomes 2010-2012
Sodus Community Health Retinopathy Pilot
Screening Results
SODUS COMMUNITY HEALTH
DIABETES QUALITY INDICATORS
FLCMH 1.2012
0
10
20
30
40
50
60
70
80
90
100
A1C <
7
B/P <
130/80
LDL <
100
Kidney
check
Foot
Exam
DRS
May '11
March '12
June '12
National Committee on Quality Assurance(NCQA)
> 40% >25% >36% >80% >80% >60%
USING TELEHEALTH TO
ACHIEVE THE TRIPLE AIM
