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How IT is Driving Changes in Community-Based Healthcare

April 25, 2014
by John DeGaspari
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A broad set of IT initiatives is aimed at bringing better healthcare to the most vulnerable patient populations

How is IT being used to transform healthcare delivery at the community level? At the annual meeting of the New York State Chapter of HIMSS, on April 23 in New York City, which was attended by Healthcare Informatics, Mary Ann Christopher, MSN, R.N., president and CEO of the Visiting Nurse Service of New York (VNSNY), gave an insightful presentation of IT-driven initiatives, which she said are crucial to transforming care delivery in her organization.

Christopher said that VNSNY, as the nation’s largest not-for-profit community-based healthcare system in the nation, occupies a unique place as it meets challenges inherent in healthcare delivery. It is both a payer and a provider organization, giving it “access to upstream dollars that allows it to innovate and deliver care in unique ways,” she told an audience of several hundred. It encompasses 50,000 providers, an inter-professional team of physician, nurses, rehab therapists, social workers, pastoral care, home health aides, and strong staff in IT, who deliver care to 70,000 patients in their communities. Information flow and continuity is critical to ensuring good care, she said.

“We are in a place in healthcare delivery that is cataclysmic, with the passage of the Affordable Care Act (ACA),” with both opportunities and challenges with the 30 million Americans having access to health insurance and care, Christopher said. “There are opportunities to come together as a health system that we didn’t have before.” Delivering care in a silo environment focused on discrete events and episodes is no longer acceptable. “Much of our intervention has been on the tertiary level of care, less on health promotion and disease prevention,” she said.

Christopher sees opportunities embedded in the financial pressures brought on by the ACA. “Value-based purchasing means we need to come together in more intentional ways to bring together the healthcare delivery system in ways that are aligned, both financially and in terms of their quality outcomes of patients and populations,” she said. Under the new healthcare scenario, caregivers need to consider what is happening to patients in the primary physician’s office; acute care, post-acute and sub-acute care settings; home and hospice care, as well as where patients live, she said. The challenge is transforming healthcare in a way that reaches all of those environments.

Consolidation among provider organizations and physician practices—either through acquisitions or virtually—is offering the opportunity to avert patient safety issues, as well as to get the cost structure in place to deal with declining reimbursements, she said. At the same time, policymakers are increasingly cognizant of the healthcare needs of marginalized people. Meeting that imperative means focusing on the needs of the most vulnerable populations, particularly the dual-eligible, who fall outside traditional treatment modalities in terms of quality outcomes, she said.

Technology as an enabler of better care

In Christopher’s view, the only way to achieve those goals is to rely on the greater application of technology. She said that the healthcare industry has a “burning platform” to come together in ways that engage people where they live and put the patient and the community at the center of care. “More and more we see a system where we are called to function inter-professionally, where those who have clinical informatics expertise are as critical as the physicians and nurse in that team of care,” she said.

She said VNSNY has embraced its role as a virtual integrator, putting the information in the hands of the providers and VNSNY staff to make better decisions. She expressed a vision that information technology will enable better care. Among her examples: more treatment in place rather than moving a patient to an ED; less isolation from frailty as patients use web-based apps to engage them and participate in round tables with other patients; less diagnostic uncertainty by using home-based tests, with results that can be transmitted to providers in real time; and texting to provide motivational cueing to patients.

For example, VNSNY is using texting to provide motivational cueing to teenage mothers in its Nurse Family Partnership program. “They are not likely to pick up the phone when the visiting nurse comes, but they will respond to texting and cueing, and that’s a modality that we are using increasingly,” Christopher said.

In another initiative, VNSNY is using predictive analytics in its Outcome and Assessment Information Set (OASIS), a federally mandated tool to assess patients for home care. Using predictive models, it is able to identify, based on characteristics of those patients, what other services they might need beyond a traditional home care, she said. “For instance, we know that based on certain diagnostic characteristics, there are frailty indices. We are able to extrapolate that data and able to predict that that patient will benefit from an intensive rehab program to avert falls,” she said.

The OASIS assessment also predicts patients who would be more appropriately managed within a palliative care environment of hospice rather than traditional home care episode that is focused on acute intervention and then discharge. “This is an important set of analytics to make sure we are providing the appropriate care for the patient at the time they need it,” she said.

Christopher noted that VNSNY Center for Home Care Policy and Research has culled data to determine what other episodes might occur, creating alerts to the staff as they deliver care. “Our research center has culled through tens of thousands of patient records, and determined, for instance, that any medication change with a patient under our care potentially triggers a fall, which always triggers a re-hospitalization,” she said.

Predictive analytics are also used in VNSNY’s health plan to assess patients for receiving managed long-term care services. From that analysis it is able to identify the interventions that should be used to care for and coordinate the care for those patients. “It tells us, based on that risk acuity adjustment and that chronic disease burden, how much face-to-face intervention we need, what kind of telephonic intervention we should be using, should it be telehealth or should it be electronic,” she said. In a health scenario that no longer reimburses for the amount of face-time, it is critical for provider organizations to select the appropriate means to communicate with patients, she said.

Using technology to engage patients

The organization is also using technology to optimize patient and member engagement. Its goal is “to get patient and caregivers more comfortable and more literate with how the disease path physiology is impacted by the behaviors that they demonstrate on its hourly or daily basis,” she said. To do that, it has integrated telehealth significantly across the enterprise. 

For example, it is using biometrics with congestive heart failure (CHF) and diabetic patients who, using an application in the home, measure relevant physical data that is transmitted to a central station in real time. The data are used as cues for the provider to give guidance to the patient. “We have found that by using this with a community hospital, to reduce length of stay by 0.8 days for patients with the highest level of acuity of CHF and also to reduce that 30-day re-hospitalization below the national numbers,” she said.

In a separate application, it has used biometric technology to measure data on 410 diabetic patients, with the result that 80 percent of the patients have achieved better hemoglobin A1C control. Christopher added that VNSNY’s research has shown that those improvements have occurred because telehealth has raised the patients’ awareness of the link between their behavior and health risks, and they have modified their behavior for better outcomes.

Interactive voice response has proven to be another effective technology for its frailest patients. It is using interactive voice with members in its Medicare Advantage Health Plan, 85 percent of which are dual eligible, so are patients with the highest disease burden. The goal is to “Interrupt that cycle of non-medication adherence, one of the biggest factors of first 30-day all-cause readmission in the nation,” she said. These technologies have helped to reduce costs because people can be prompted through technological interventions.

Using a solution (supplied by Remedia LLC, Amherst, Mass.), it runs all of the pharmaceutical medications plans of care for its patients to screen for anything that would be inconsistent with best in class practice, and then drive the changes in that medication plan. It has implemented another solution (supplied by Eliza Corp., Danvers, Mass.) to deliver medication of voice alerts to patients about when they should be refilling their meds; if they have not, the patients’ case managers outreach to them to understand what is happening. 

Through VNSNY’s special needs program for 5,000 patients with AIDS and HIV, We also have a special needs program through we care for about 5,000 people with hiv and aids, VNSNY has started a text-messaging initiative (using a technology from New York-based RipRoad), to send patients reminders of medication refills and follow-up appointments with specialists. “Our goal is to help with the management of the disease and also, to reduce unnecessary reliance with EDs,” Christopher said.

New IT platform for care coordination

VNSNY is migrating to a new IT platform (GuidingCare, supplied by Altruista Health, Reston, Va.) that will bring together on a single screen clinical data that care coordinators use to manage the care, services and benefits around that particular patient, but also the claims data the person will have access to, as well as incoming and outbound customer service incoming calls.

She said the system will provide opportunities for patients to access the system any time on any device. “Our goal being that they will be able to control their own health, they will be able to indicate to the care coordinator, what their goal is for them themselves. They will be able to establish with the care coordinator a dashboard that is specific to them, which monitors their disease progress across industry standards in terms of metrics and benchmarks,” she said. She added that the portals VNSNY is implementing are user friendly and include visual cueing to promote better understanding and enhance health literacy.

At same time, it is moving to a new technology platform on the provider side to reduce the minimum data set at intake. This will help to ensure that that initial assessment will use predictive analytics for risk stratification that will then hardwire what the services within VNSNY should be, she said.

It also plans to centralize and automate the scheduling using evidence based guidelines. “We have estimated that this will take out $40 million in cost out of our system, important given the federal and state reimbursement reductions that have occurred within the provider and plan space over last two or three years,” she said.

Searching for health ‘hot spots’

VNSNY has also implemented a program to look at the characteristics of patients accessing the healthcare delivery system within certain neighborhood geographies. It identified the social determinants of health as they impacted the health of the population, such as immunization status; morbidity statistics in terms of diabetes, cardiovascular disease; and issues of crime, alcohol and substance abuse. Using that model and geo-mapping the community, it has identified “hot spots” that require a unique level of intervention, and deployed community wellness coaches, nurses and social workers, working with community-based coalitions in the area to address those needs.

“This is a program that is being followed by the Centers of Medicare and Medicaid Services, the Institute for Healthcare Improvement and the New York State Department of Health. Early results have shown that we are already impacting the number of folks accessing the emergency departments for ambulatory care and sensitive conditions, for which they are better served by primary care access,” Christopher said.



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