Jim Roxburgh, RN, MPA - Home - ACHD€¦ · •The DHTN provides 13 different specialty services •The DHTN provides > 10,000 consults annually . ... InTouch Health Remote Presence

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Jim Roxburgh, RN, MPA Director, Dignity Health Telemedicine Network

Disclosure

Jim Roxburgh, and Dignity Health have reported no

relevant financial interest/relationship with any commercial entities that may have ties to this presentation.

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Efficiency is

doing things

right

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Effectiveness is

doing the right

things

Objectives

• Get familiar with the available telemedicine technology

• Identify advances in telemedicine

• Detail aspects of how telemedicine works in the acute, ambulatory and home settings

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CTA

Angioplasty balloon Post procedure

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250,000

90,000

Leverage Telehealth Services to Costs, Quality Outcomes

& Enhance the Patient Experience

Growth of the Internet

Benefits of Telemedicine

Improved Access

Cost Efficiencies

Improved Quality

Patient Demand

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DHTN PROGRAM GOAL

Provide timely access to high quality specialized healthcare services that are not readily

available

“LEAD WITH SERVICE…

DELIVER ON QUALITY”

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Director

Telehealth Assistant

Senior Analyst Telehealth Solutions Manager

Medical Director

Medical Director Stroke

Medical Director ICU

Medical Director Psych

Physician Leader Ambulatory/LTC

Program Manager

RN Coordinator

Neuro/Stroke

RN Coordinator

ICU

RN Coordinator

Psych

RN Lead

Ambulatory/LTC

DHTN Team

Denise Pimintel, RN, MN, MS, CCRN RN COORDINATOR - TELEICU

John MacKenzie, RN, BSN RN COORDINATOR – MENTAL HEALTH SPECIALIST

Jim Roxburgh, RN, RRT, MPA DIRECTOR

Nafees Coleman, MS, PMP SENIOR ANALYST

Tammy Mitchell, RN,MS, CCRN RN COORDINATOR - TELESTROKE

Alan J. Shatzel Jr., DO, FAASM President & Chairman, Mercy Medical Group Inc.

Medical Director, Dignity Health Neurological Institute Medical Director, Dignity Health Telemedicine Network

The Facts…

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• The Mercy Telehealth Network(MTN) was founded in 2008

• The MTN officially became the Dignity Health Telemedicine Network (DHTN) in 2014

• The DHTN provides services to 39 Hospitals/Clinics/Long Term Facilities; 72 End Points (Telemedicine Robots)

• The DHTN provides 13 different specialty services

• The DHTN provides > 10,000 consults annually

The Facts…

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The DHTN one of the largest

Acute Care Telemedicine

Networks in the United States (# of Clinical Sessions & Services per End Point)

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DHTN Services ACUTE

• Stroke/Neurology • Mental Health • Critical Care • Nephrology • Pediatrics • Newborn Care • Cardiology • Infectious Disease

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CLINIC/LTC • Geriatrics • Neurology • Endocrinology • Pulmonology • Thoracic Surgery • Oncology

TRANSITIONAL • CHF • COPD • Diabetes • Post Surgery • Wound Care

HOME • CHF • COPD • Diabetes • Post Surgery • Wound Care

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TELE-INTENSIVIST

TELE-NEUROLOGIST

TELE-NEPHROLOGIST

Can change individual settings & see profile information

Type message or attach pics

Secure Texting

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Patient Care Need

Call Dignity Health Transfer Center @

1(888)637-2941

Page/Call Psychiatrist

Page/Call Intensivist

Page/Call Neurologist

Page/Call Nephrologist

Page/Call Neonatologist

Page/Call Pediatrician

Page/Call Geriatrician

RAPID RESPONSE

DOCUMENTATION REPORTING IMAGES

TELESTROKE

AVERAGE RESPONSE

TIME 2 minute call back 6 minute beam in

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tPA Rate

24%

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When To Call For A TeleNeurology Consult

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PRACTICE!! PRACTICE!!! PRACTICE!!!!

PRACTICE!! PRACTICE!!! PRACTICE!!!!

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Transfer Center Checklist

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Partner Site Telestroke Checklist

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Partner Site Telestroke Checklist

(continued)

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Endovascular Treatment in Acute Ischemic Stroke

• Berkhemer OA, et al. A randomized trial of intraarterial treatment for acute ischemic stroke (MR CLEAN). N Engl J Med 2015

• Goyal M, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke (ESCAPE). N Engl J Med 2015

• Campbell B, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection (EXTEND-IA). N Engl J Med 2015

• Saver J, et al. Invited Presentation: Solitaire FR as Primary Treatment for Acute Ischemic Stroke (SWIFT PRIME). ISC 2015

Endovascular Treatment in Acute Ischemic Stroke

• Indications: • Acute Ischemic Stroke within 6 hours of symptom onset/LKW or unknown

symptom onset/LKW or wake up stroke with normal CT Head & disabling neurologic deficits

• Age > 18 • NIHSS > 2 or disabling neurologic deficits irrespective of NIHSS • Contraindications to IV tPA • Baseline modified rankin score (mRS) < 3 • ASPECTS Score > 6 AND suspected large vessel occlusion AND/OR hyperdense

MCA, MCA dot or basilar artery sign on CT head • CTA/MRA with intracranial/extracranial ICA, M1, M2, A1 or A2 occlusion AND

moderate to good collaterals AND/OR CT/MR Perfusion with core infarction < 50 ml, ischemic penumbra > 10ml & mismatch ratio > 1.2 or > 1.8 if using the RAPID Automated Software

• CTA or MRA with basilar thrombosis within 12 hours of symptom onset/LKW

Drafted: Asad A. Chaudhary, MD 2/15/2015

Endovascular Treatment in Acute Ischemic Stroke

• Contraindications: • CT or MRI evidence of hemorrhage • CT hypodensity or MRI hyperintensity > 1/3 of the MCA territory (or in other

territories, > 100ml of tissue) • ASPECTS Score < 6 • Baseline modified rankin score (mRS) > 3 • CTA/MRA with no intracranial or extracranial ICA, M1, M2, A1 or A2 occlusion

AND/OR poor collaterals AND/OR CT/MR Perfusion with core infarction > 50 ml, ischemic penumbra < 10ml & mismatch ratio < 1.2 or < 1.8 if using the RAPID Automated Software

• Non-disabling neurologic deficits • Recent history of large ischemic stroke in the same territory (< 14 days)* • DNR Comfort Care or on Hospice

Drafted: Asad A. Chaudhary, MD 2/15/2015

Endovascular Treatment in Acute Ischemic Stroke

• Relative Contraindications: • Carotid dissection or complete cervical carotid occlusion that might require

stenting at the time of mechanical thrombectomy* • Unable to transfer to endovascular capable facility to achieve successful

reperfusion by 8 hours from symptom onset/LKW* • H/O connective tissue disorder like Marfans or Ehler Danlos Syndrome* • Terminal illness or co morbid conditions with life expectancy < 1 year* • *at the discretion of the neurointerventionalist and neurologist • Berkhemer OA, et al. A randomized trial of intraarterial treatment for acute

ischemic stroke (MR CLEAN). N Engl J Med 2015 • Goyal M, et al. Randomized assessment of rapid endovascular treatment of

ischemic stroke (ESCAPE). N Engl J Med 2015 • Campbell B, et al. Endovascular therapy for ischemic stroke with perfusion-

imaging selection (EXTEND-IA). N Engl J Med 2015 • Saver J, et al. Invited Presentation: Solitaire FR as Primary Treatment for Acute

Ischemic Stroke (SWIFT PRIME). ISC 2015

Drafted: Asad A. Chaudhary, MD 2/15/2015

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TeleStroke Hospital Case Study One Year Comparison

CY 2011 CY 2012

# of ED Visits (approx) 50,000 50,000

Ischemic Stroke 14 169

tPA 9 28

tPA Cont. Margin (approx) $7,000 $7,000

Total Contribution Margin $63,000 $196,000

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EMS TRIAL

ICU “Round & Respond”

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Remote Specialist Service

24/7/365

InTouch Health Remote Presence

Services available by ALL qualified Specialists (Pulmonologists, Cardiologists, Neurologists, Surgeons, etc…)

• Labs

• Meds

• vital signs

• EKGs

• Wave Forms

• Images

• Ventilator Settings

• Real Time

Assessment and

Communication from

any location

• Ability to consult with

multiple Specialists

via Multipresence™

Airstrip Bedside Monitoring

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Dignity Health – TeleICU – “Round and Respond” Immediate access to live and

historic patient data

Local and remote

critical care team on

rounds

Critical care

or in-patient

Leveraging shared patient data and connectivity…

…for better data driven decision-making

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Eric – This is a perfect slide – can we remove all the company

Logos?

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ICU

65/FEMALE

Gonzales, Marie

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Balancing Resources w/ Remote Coverage

MGH

Traditional Model

SNMH WMH

MTMC

Affiliates census below capacity

Tertiary facility overloaded

Proactive Model

Balance Bed Capacity Across

System

“Keep it within our system, but do not overload the tertiary care center”

MSJMC

SNMH WMH

MTMC

MGH MSJMC

TeleICU Case Study (One Year Comparison)

CY 2013 CY 2014

# of ICU Beds 6 6

Severe Sepsis & Shock Mortality

45% 19.4%

Ventilator Day ALOS 2.8 1.4

ICU Contribution Margin Increase

NA $868,255

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Transfers (One Year Comparison)

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2013 Transfers Out from Woodland Memorial Hospital* • Total Transfers 213

– ED Transfers 142 – ICU Transfers 28

*Source: AMAP & Teletracker; transitioned from AMAP to Teletracker software 2014 Transfers Out from Woodland Memorial Hospital** • Total Transfers 139

– ED Transfers 87 – ICU Transfers 25

**Source: Teletracker

TELEMENTAL HEALTH

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Last night I had a young man and his

father come into Methodist ED as the 19

yr old son was beginning to experience

active symptoms of his schizophrenia in

the last week and beginning to

decompensate because of it

I spoke to Dr. Nie (the psychiatrist) on the line, presented the patient case to

her and then had her speak to the patient using the telephone headset for

his privacy.

Within an hour, the pt had the

medication change, avoided a 5150, a

potential lengthy hospital stay and was

able to return to his home with father.

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Joint Commission Standard Patient flow through the emergency department

Requirements

Standards LD.04.03.11 and PC.01.01.01 are revised standards that

address an increased focus on the importance of patient flow in

hospitals.

EP 6. This element of performance went into effect January 1, 2014:

The hospital measures and sets goals for mitigating and managing the

boarding of patients who come through the emergency department.

Note: Boarding is the practice of holding patients in the emergency

department or another temporary location after the decision to admit or

transfer has been made. The hospital should set its goals with attention

to patient acuity and best practice; it is recommended that boarding

time frames not exceed 4 hours in the interest of patient safety

and quality of care.

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Mark Twain Medical Center Family Clinic

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Geriatric House Call Telemedicine

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The Telehome Kit

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Bluetooth

BP & Weight

Remote Patient Monitoring

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Patient @ Home Health Coach

Home Monitoring/Triage

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Chronic Care Management (CCM)

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Medicare will pay for chronic care management (CCM) services – non- face-to-face services to Medicare beneficiaries who have multiple, significant, chronic conditions (two or more) – effective January 2015.

Chronic Care Management (CCM)

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Chronic care management services include regular development and revision of a plan of care, communication with other treating health professionals, and medication management.

Chronic Care Management (CCM)

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• For the first quarter the payment rate is $40.39 for CCM that can be billed up to once per month per qualified patient.

• CCM services are to be reported with CPT 99490.

Billing Requirements

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• CCM services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient

• Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensating, or functional decline

Billing Requirements

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• Comprehensive care plan established, implemented, revised, or monitored.

• The CCM and non-face-to-face portion of the Transitional Care Management services provided by clinical staff incident to the services of a practitioner may be furnished under the general supervision of a physician or other practitioner.

Billing Requirements

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• Use a Certified EHR

• Maintain an electronic care plan

• Ensure beneficiary access to care

• Facilitate transitions of care

• Coordinate Care

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THANK YOU!!