Welcome to our Success Story Page
An important part of the Central Oregon Telehealth Network process is sharing results to demonstrate the value of the project and perhaps encourage others to try remote monitoring or to assure them that Telehealth can, indeed, provide solutions to healthcare challenges.
With that in mind, we're sharing notes from providers who are seeing the successes of the program daily. These stories demonstrate a range of advantages to Telehealth, ranging from shortened hospital stays, quicker detection of problems, managing multiple chronic conditions in the home and many more.
We also share the opportunities we see as the program matures.
Take a look at the Success and Opportunity Stories below and see the value of the project.
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Expansion Opportunity Eyed
Positive Responses from Providers
Referral Opportunities
OCHIN Learning Forum
Opportunities
Plans to expand outside the Mosaic organization are being
met with receptive leadership from the St. Charles Medical organization. The team is meeting to determine funds and
how to move forward with the expansion as a part of the grant in the coming weeks. This will position both a near term and long
term stability plan for the program.
Positive Responses from Providers
The providers have a renewed interest and Becky contributes
that to the new workflow because of the use of the RPM encounter. It is more directly a part of what the
providers are seeing every day in the EHR.
They respond to those encounters and are seeing the benefit of being
able to route an encounter to a pharmacist for a medication review or being
able to adjust medications. Those are
just two of the examples of the providers realizing the value RPM brings to
them as they care for their patients.
Referral Opportunities
Becky had a recent meeting with the Mosaic Bridges team and
she believes additional referrals will continue from that program to help some
of Mosaic’s patients who need it the most.
OCHIN Learning Forum
Becky reported that Brandon, Michael, and herself presented at the 2016 OCHIN Learning Forum. Michael started it off with an overview, Brandon provided details around the Ideal Life/Epic interface, and Becky ended the discussion talking about the difference in care and patient stories on how much RPM and the team have helped them deal with their Chronic Disease. One key educational moment realized was when the attendees recognized RPM is not just about triage but providing the patients with the ability to take care of their chronic disease on their own.
The new Chronic Disease Management billing codes for 2016 continue to be discussed bi-weekly because of uncertainty about the requirements, primarily the charging of patients for RPM. Charging patients is a challenge for the team because we are trying to offer this service free to patients. The team will continue to work on the possibility of using these billing codes to recoup a portion of the costs.
Successes
Andy is officially a board member of the Telehealth Alliance of Oregon (TAO). For more information about TAO, visit their website here. Congratulations Andy.
Successes
Becky has done a great job, along with the other per diem RN’s supporting the Mosaic RPM program. The new workflow adjusted for the interface is successful, Becky has continued to support the testing and plan for the future of RPM at Mosaic through the use of the interface.
Becky, Dr. Gratton and Andy met with St. Charles administrators for both Madras and Prineville Hospitals. They asked lots of questions and the dialogue went well. Dr. Gratton was at a leadership meeting with the CEO of Madras/Prineville hospitals. Word has gotten to them and they are excited about the program and how to sign up. Excitement is in place so they want to do it, now trying to figure out how to do it.
The RCCHC/InScope team are supporting Andy with defining the engagement – specifically language for a MOU, as well as data demonstrating the success from hospital discharges which is a primary goal of this expansion.
Patients are graduating. Quality conversations are ongoing to ensure that action is being taken for those who have completed the program. The focus on patients ensures those who need discharged are also following the inventory management procedure to allow the equipment to be refurbished and available for other teams.
Through September 2015, the average time a patient is on the program is 84 days.
Successes
Successes
Opportunities
Opportunities
New per diem nurse hired for rural clinics to assist as back-up when primary RN is unavailable. This will ensure program continuity and reduce workload on primary RN. We continue to look for opportunities to support the local healthcare community as well as provide patients in rural areas with the monitoring care they need. To this end, we are researching possible partnerships with healthcare providers outside the Mosaic Medical arena.
Recently, a primary care provider came to ask if we could monitor a patient who lives in another town. The patient recently had a stroke: he cannot drive at this time, and does not have a way to monitor his blood pressure at home. We were able to send him home with remote monitoring equipment yesterday. We gave the patient and his son instructions on using the equipment in the office so they could start monitoring when they got home. This gives the provider and the family some peace of mind, knowing he is being monitored closely with the new blood pressure medication and stroke diagnosis. This is not the first patient that we have sent home immediately from the office with Telehealth equipment. This equipment is easy to set up and user friendly so patients are able to basically plug in and get started.
She started using her oxygen 24/7 instead of just at night and has been able to maintain oxygen saturation levels within normal limits. She reported feeling more energy within days of being on the oxygen 24/7. This patient also was able to monitor her weight more closely. She lost a total of 8 pounds in 4 months.
In addition, she had to use a walker in her house because of pain she experienced from her waist to her ankles. We connected her with physical therapy and, with the strength training and exercises, she no longer has to use the walker.
The patient maintained her enthusiasm throughout the 4 months on the program and was delighted with her own success.
Linda Hatch, FNP referred a patient to the Telehealth program to monitor his high blood pressure. The patient lives 8 miles out of town and works 1-½ hours out of town. He had to come into the clinic for frequent blood pressure checks due to the severity of his high blood pressure. However, his busy schedule made it difficult to come to the clinic as often as necessary. His blood pressure was not responding to the initial medications prescribed. We installed the monitoring equipment in his home, and he was able to conveniently check his readings daily. With the readings coming into our office, his provider was able to make medication adjustments without having to take time out of his busy schedule to come into the office. It took some time ,but with close monitoring and frequent contact with his provider, his blood pressure is now within normal limits
Successes
The defined Scope Of Work for the Epic interface has been completed. Pricing and details are agreed to and the Mosaic team, specifically Jen, will be meeting and managing the scope of the project along the interface project schedule.
Opportunities
Email exchanges have occurred and call scheduled to discuss the additional billing codes. Torey (RCCHC) and Becky (Mosaic) are working to schedule a meeting to help make inroads with the billing available on 01/01/16. Andy is also interested in how RCCHC handles hospital billing.
Successes
The RCCHC/InScope team are supporting Andy with defining the engagement – specifically language for a MOU, as well as data demonstrating the success from hospital discharges which is a primary goal of this expansion.
Opportunities
JIRA New Chronic Disease Management 2 New Codes could start billing – JIRA Medicare enrollment will be effective on Jan 1, 2016. FQHC’s can start billing – NACHC is training. Workflows to determine how to identify patients that can be billing – make that part of keeping it funded. Kim will send email with an intro with Mosaic Revenue on our end
Successes
Patients are graduating. Quality conversations are ongoing to ensure that action is being taken for those who have completed the program. The focus on patients ensures those who need discharged are also following the inventory management procedure to allow the equipment to be refurbished and available for other teams.
Through September 2015, the average time a patient is on the program is 84 days.
Opportunities
Grant budgeting to account for the hours used by Jen to manage the interface activities and definition of the workflow/requirements.
Successes
Jessica has been working to refine the inventory management processes to ensure the workflow is efficient and supports the needs of each of the clinics.
Opportunities
Andy is preparing to meet with the ancillary service director for a meeting in Mid-November with the target launch in Madras rather than Prineville. Andy will let the COTN team know what support he may need in preparation for this meeting.
Andy is also preparing to speak at the Oregon Rural Health Conference at the end of the month.
Opportunities
Planning for the launch of referrals later this Fall.
Successes
Linda, RCCHC, was able to support Becky with inclusion/exclusion and graduation criteria vs discharge for noncompliance.
Successes
Ongoing active patients in the program during the resource transition is very positive and is a testament to the processes being used by the Mosaic team.
Opportunities
Andy is still working with key decision-makers and his management team to work with St. Charles for expansion.
Opportunities
Annual Rural Health Clinic Conference – next week. Dr. Gratton, Paul and Andy will be presenting a group study on diabetes. Innovative care models to assist with access and providing details on the components. 75-100 participants for that session
The grant budget is being analyzed for potential carry over budget to be reallocated to items such as tablets or patient education material while ensuring the resources are in place to meet the grant goals.
Successes
Andy received updated data last week and all measurements continue to trend positively.
Andy received updated data last week and all measurements continue to trend positively.
Successes
Testing of the Epic/Ideal Life interface is nearing completion and all indicators point to the go live date of March 1, 2016. This interface again allows the nurse and physician to work within Epic and all remote patient monitoring readings will exist also. The coordination and tracking of RPM encounters will be simplified.
Testing of the Epic/Ideal Life interface is nearing completion and all indicators point to the go live date of March 1, 2016. This interface again allows the nurse and physician to work within Epic and all remote patient monitoring readings will exist also. The coordination and tracking of RPM encounters will be simplified.
Successes
Aimee has been making visits to the two newest sites, Redmond and Madras, based partly on feedback provided during an informal team interview. We have a newly trained RNCC in Redmond who is fully onboard and excited about the program. We have a .3 employee who is assisting with the equipment cleaning and reset. This is a great benefit.
Building and testing OCHIN inerface is progressing. We are looking to enroll active patient information into the system for testing purposes on or about 8/17/15.
Opportunities
Andy Eck is continuing to pursue opportunities available to expand the program.
Specifically targeting the St. Charles Medical system. Andy has provided items to the executive for consideration and will be following-up once we have a better handle on the training manual, ideal life interface, etc.
Aimee has been making visits to the two newest sites, Redmond and Madras, based partly on feedback provided during an informal team interview. We have a newly trained RNCC in Redmond who is fully onboard and excited about the program. We have a .3 employee who is assisting with the equipment cleaning and reset. This is a great benefit.
Building and testing OCHIN inerface is progressing. We are looking to enroll active patient information into the system for testing purposes on or about 8/17/15.
Andy Eck is continuing to pursue opportunities available to expand the program.
Specifically targeting the St. Charles Medical system. Andy has provided items to the executive for consideration and will be following-up once we have a better handle on the training manual, ideal life interface, etc.
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Update
Andy Eck is still working closely with St. Charles Medical System to explore expansion of the program. Networking through this channel and the recent regional meetings has made state level agencies more aware of what is happening in their own "back yard", so to speak. Wonderful awareness!
Successes
80 patients enrolled in the program as of 6/4/2015 and referrals are increasing! Andy is meeting with ancillary Service Director for medical clinics to determine whether or not the RPM program can be expanded in year three to St. Charles Medical.
Thanks to Aimee, all non-compliant patients and their providers have been contacted. The patients have either come into compliance (actively participating) or the equipment has been recovered.
Celebrations!!
New per diem nurse has been trained by Aimee; this will assist with workload overflow and vacation coverage.
OPPORTUNITIES
Andy Eck (Regional Director of Operations, Prineville) is making progress in coordinating with the CCO board regarding expansion of the RPM program outside Mosaic during year three.
SUCCESSES
Andy Eck (Regional Director of Operations, Prineville) has been asked to attend the upcoming Oregon Health Authority conference in June. This governing body for Medicare want to know more details about our program, so Andy will give a mini presentation and lead a forum regarding the program. The networking that this conference, the one in Seattle recently and others is wonderful.
Catching Up: Successes and Celebrations!
Patient participation grew from 67 patients in early December to 85 patients in mid-March for a total of 220-225 since the start of the program. Interpreters needed for certain demographics, this continues to be successfully managed as of December 18, 2014.
Stroke Patient Monitoring
Yes, the Equipment is Portable
We have a patient who went on vacation 120 miles away for the month of July. She took her equipment with her and is using it daily and we are receiving her readings. This is proof that this program is flexible enough to meet the needs of even the most active patients’ lifestyles.
Hospital Referrals Add to Program
Our medical director also works in the hospital. She is able to refer patients to us that are being discharged from the hospital. Today she came to us and explained that she is discharging a patient from the ICU that needs his HR monitored closely due to his diagnosis and recent medication changes. We are going to his house this afternoon to set the Telehealth equipment up for him.
Patients Graduate from Program
We have recently had patients graduate from the program after completing their six months on the program. It seems like just yesterday we were at their house doing the installation. We are amazed how time flies.
Telehealth Workflow Improves
The Telehealth process is now all in our Electronic Health Record (EHR) from admission to discharge. This allows us to track patients more efficiently. The only piece missing is the interface of our equipment and the EHR.
Patient Learns To Counter Chronic Changes
It was time to discuss the graduation option or process with a patient that has been on the program since November of 2013. She explained that she has found that the Telehealth program is helping her to stay accountable for her actions. She currently uses a scale, blood pressure monitor and an oxygen saturation monitor. The patient expressed that when her blood pressure or weight is elevated, she reflects on what she has done recently or the day before. She makes the necessary changes to her diet to help reduce her weight and blood pressure. When her oxygen saturation is low she remembers to breathe deeply and to wear her oxygen if she forgets. This patient is scheduled to have gastric bypass surgery in July 2014. She wants to stay on the program at least for a few months after her surgery. With the possibility of weight loss the patient understands that there may be a need to make medication changes and she recognizes the benefits of taking daily readings to manage her health.
Patient Learns Relaxation Techniques
A patient reported that she is using the relaxation techniques we discussed to help lower her blood pressure. She initially would be busy, fidgety and sit with her legs crossed before taking her blood pressure. After reminding her frequently how to relax prior to a blood pressure reading with deep breathing and peaceful thoughts, her readings have been within normal limits. She commented on the phone that she figured out how to get a “normal,” blood pressure reading. She is using relaxation techniques. This type of biofeedback has proven to the patient how important it is to try to stay calm and relaxed to maintain a blood pressure healthy for her body and mind.
Multiple Benefits
One of our patients was placed on the program for a history of low oxygen saturation readings in the office. She was also monitored for blood pressure, weight and diabetes. She was on the program for 4 months. In that 4 months we were able to identify that her lethargy during the day was related to the low oxygen saturation she has throughout the day time hours.
She started using her oxygen 24/7 instead of just at night and has been able to maintain oxygen saturation levels within normal limits. She reported feeling more energy within days of being on the oxygen 24/7. This patient also was able to monitor her weight more closely. She lost a total of 8 pounds in 4 months.
In addition, she had to use a walker in her house because of pain she experienced from her waist to her ankles. We connected her with physical therapy and, with the strength training and exercises, she no longer has to use the walker.
The patient maintained her enthusiasm throughout the 4 months on the program and was delighted with her own success.
Decreasing Health Care Costs
Dr. Gratton has been able to identify a key area where Telehealth plays a major role in decreasing hospital costs. She was able to discharge two patients from the hospital earlier than they usually would have been if not for Telehealth.
For example, one patient was hospitalized for pneumonia. After a few days in the hospital the patient was tired of the not-so-good food and constant interruption of her sleep; however, she still needed oxygen saturation monitoring. Dr. Gratton had the Telehealth team meet the patient at her home upon discharge. She was sent home with oxygen therapy. We installed the Telehealth equipment and monitored her oxygen saturation along with her blood pressure. With close monitoring and frequent contact with the family and Dr. Gratton, the patient was able to titrate her oxygen and eventually come off of the oxygen therapy. She recovered in the comfort of her own home.
Saving Patients' Time
Medication Adherence
Medication adherence is often an issue for patients. We know that some patients do not call in their refills in a timely manner or they simply cannot afford the medications.
With the use of the Telehealth program, we are able to monitor blood pressures, receive alerts, and be in frequent contact with the patient. This allows us to help them get their refills in a timely manner. Without the Telehealth readings, some patients just wait until their next office visit to ask for a refill. The longer a patient has uncontrolled blood pressure, more damage can be done to their body which creates further health care costs. Identifying this specific need for the patient in a timely manner decreases the chances of health complications.
Telehealth Saves Transport, Catches Health Issues Early
Telehealth monitoring allows us to identify abnormal readings and be in close contact with the patients. We have had the opportunity to see an abnormal reading, receive alerts, call the patient and collect data from the patient specific to their Telehealth readings. One patient triggered an alert for a low blood pressure. We called him and he described feeling weak, dizzy and tingling in his peripheral extremities. He had a recent blood pressure medication change. I advised him to have his wife drive him to the ER for evaluation. He was treated and released that same day with a change in his medications. I believe the Telehealth readings were helpful in alerting us prior to the patient passing out or “crashing.” This prevented a costly ambulance ride to the hospital.
Early Detection
The oxygen saturation monitoring aspect of the Telehealth program has been helpful in identifying patients who need sleep studies. Our referral rate for sleep studies has increased. This has led to earlier detection of sleep apnea thus reducing health risks and healthcare costs.
Increase in Patient Contact
Telehealth monitoring has given us the opportunity to be in more frequent contact with our patients and the ability to recognize their needs in a timelier manner. This had enabled us to make more referrals and obtain equipment that the patient may have needed. Meeting the patients’ needs leads to better health care and patient satisfaction.
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