What We’re Working On Now*moderator or couple of respondents?*

- Getting the “System” to be a Real System for Heart Failure Patients –

Douglas McClureCorporate Manager, Operations & Technology, Center for

Connected Health

ALL PROCEEDINGS WILL BE VIDEO RECORDED

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

What have we achieved so far …

Enrollment

Oct-07 8 47

Nov-07 19 75

Dec-07 24 110

Jan-08 43 134

Feb-08 55 162

Mar-08 71 192

Apr-08 84 242

May-08 115 259

Jun-08 145 270

Jul-08 174 293

Aug-08 201 301

Sept-08 220 318

Month CCCP HC

Readmission Outcomes - 180 days

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

All-cause CHF

Mea

n 18

0 da

ys re

adm

issi

ons

Control Intervention Refused

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)

Disease Management Approaches

High Tech(Emerging)

Low Tech(Traditional)

Low Engagement

High Engagement

Risk ScreeningStratify patients for different

program interventions based on medical criteria

Population ScreeningTarget patients by disease and

age group

Patient EducationDistribute brochures on how to

manage chronic disease

Remote MonitoringUse devices to monitor patients

at home

NP Clinic, Practice-based Case managers

Supported by real-time alerts, workflow software, clinical

decision support

Call CenterCentralized case managers call

patients to monitor progress

Guidelines/SupportPromote best practices among

providers

Concept Source: California HealthCare Foundation

Heart Failure Program Components: System-wide Reach

A Coordinated and Targeted Program

Home Care Remote Monitoring~60 days

Continuing Cardiac Care~4 months

Health Coaching

Step Down Monitoring~1 year

Triage

2,700 Discharges2,100 Patients

Under Development

There are challenges ☺

Challenge

Enrollment & Recruitment

Heart Failure Population Overview, Partners

Approximately 50% of DRG 127 discharges have a Partners PCP

Challenges of HF Dz Mgt

•Patient Identification

•Choosing an intervention

•Reaching and Engaging•Patient and MD barriers to engagement

Approved patients are enrolled

in telemonitoring

Send file to CCHSend file to CCH

ID Partners HF patients appropriate for telemonitoring

ID Partners HF patients appropriate for telemonitoring

Monitor & Evaluate

Monitor & Evaluate

HPM4 and CCH will work together to refine criteria (if

necessary), consider expansion to other PHS sites,

and measure outcomes of these uniquely enrolled

patients

Note: HPM 4 team has experience

with this and will work closely with CCH to

develop

“Opt-in” note sent to MD:•Can pt be enrolled?

•Would you like to enroll other appropriate HF patients?

KeyHPM Team 4CCHHPM Team 4 & CCH

Challenge

Managing the Patient Efficiently and Effectively

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

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

Managing the Patient Efficiently and EffectivelyNurse Practitioners (1998)

4 NPs at each of 4 sites, focus on the most acutely illNumber of current active patients ~450Cumulative 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)

Challenge

Integrated Systems & Communications

Heart Failure Registry: A Multi-Year Project

21

Connected Health Care Suite

Care Portals (Diabetes, HF, etc.)

Patients Care GiversCare ProvidersPhysicians

CCH Apps• Asset & Patient Mgmt

• Program Mgmt & Evaluation

Partners Enterprise Clinical Apps

• LMR, CDR, EMPI

Remote Monitoring Services

• RMDR, Internet

Partners Entity Apps• Care Registries, PtCT,

4Next

Services

Decision Support

Common Clinical Mgmt System

Services

ServicesServices

CHCS - CHF Care Portal