Stephanie R. Bruce, MD
Medical House Call Program
Medstar Washington Hospital Center
Washington, DC
©AAHCM
 None
 Questions:
questions@aahcm.org





Mr H. 91 years old
H/o CAD, MI, known 80%
lesion in LAD
Non-CABG candidate
CHF EF 25 %
Mild anxiety about symptoms
“Providing after hours, urgent or emergency
care is a serious business; patients accessing
it are usually doing so at their most
frightened and vulnerable, and we have a
duty of care to ensure that the system is as
seamless and uncomplicated to navigate as
possible.”
-- Dr. Clare Gerada, RCGP Chair of Council
ED Patients
1/3 Do not
need
emergency
services
15%

Frail, older patients can be harmed by
ED/hospital
◦ Adverse event
◦ Functional decline

We can provide high intensity care at home
◦ Hospital at home
◦ VA experience

Effectiveness of 24/7 care and monitoring

Models
◦ Telephone
◦ VA: CC/HT
◦ Telehealth

Experience in one House calls practice

Lessons learned/discussion


Urgent access a tenet of patient-centered
medical home (PCMH)
“Medical home runs”


Urgent access a tenet of patient-centered
medical home (PCMH)
“Medical home runs”
◦ 4 common aspects of high performing practices
AM Milstein, E. Gilbertson. Health Affairs 2009; 28(5):1317-26


Urgent access a tenet of patient-centered
medical home (PCMH)
“Medical home runs”
◦ 4 common aspects of high performing practices:
◦ Longer visits, interim support, 24/7 urgent care
AM Milstein, E. Gilbertson. Health Affairs 2009; 28(5):1317-26
Protocol phone triage
Care
coordination/HT
Mixed model



Supported by access to EHR
Supported by protocols
VPA: FL, IN, KY, MI, MO,OH, TX, VA
Data
Results
Cochrane review 2009
- Phone triage decreases need for
visit without increasing ED use
NHS (National Health Service)
-- safe
-- may reduce ED use
-- reduces cost (usually through
decreasing doctor visit)
Telephone consultation and triage: effects on health care use and patient satisfaction (Review) i
Copyright © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.
Care coordination with Health Technologies
1995:
2.9 M vets
53,200 beds
30M otpt visits
2007:
5.3 M vets
18,199 beds
50M otpt visits

Key elements
◦ Individualized selection of technology
◦ Combined with a clinical plan


Cost: est $1600 per pt/per year
“Savings”
◦ 19% reduction in hospitalizations
◦ 25% reduction in hospital days

Not designed for urgencies/emergencies


86% satisfaction
“I’m here by myself, yet I feel like
I have somebody watching over my
condition on a daily basis.”
Site
Intervention
Outcome
Cost/Savings comment
Partners
Healthcare
CHF hospital
f/u
51%
reduction in
readmission
net savings:
$8,155 per
patient
Centura
Health
All
admissions
62%
reduction in
readmission
Savings
about $1500
per patient
CMS pilot
(1700pts)
Disease
specific (DM,
COPD, CHF)
Claims
billing
Savings of 7- Cost about
15% pppy
$120/mth
Increased
patient
independence
A. Broderick and D. Lindeman, Scaling Telehealth Programs: Lessons from Early Adopters, The Commonwealth Fund, January 2013
B. Integrated Telehealth And Care Management Program For Medicare Beneficiaries With Chronic Disease Linked To Savings
Laurence C. Baker et al Health AffairsSeptember 2011 30:91689-1697
©AAHCM
Called 911
Sent by us
• ‘forgot’
• Aide/other called
• Panic
• Medically
necessary
• Not enough info
Sent from
another
MD/faciility
©AAHCM



What data will be received
When
By whom?
©AAHCM
 Improved
patient experience
 Decreased 911 calls
 Decreased urgent calls to NP/MD
 Transitioned to hospice
 Died in 2013 at home


Technology gets lost
New learning
◦ “911 is ingrained”



The technology is just a tool
Access to wireless
The art of telephone triage



Grants/hospital systems?
ACO’s, private insurers?
Medicare?
©AAHCM


24/7 and urgent care is right for our
patients
Ways to provide
◦ As “simple” as the phone
◦ As complex as tele-video and remote ICU

Future?
©AAHCM
Thank you
QUESTIONS: questions@aahcm.org
Stephanie R. Bruce, MD
Medstar Washington Hospital Center,
Washington, DC
Stephanie.r.bruce@medstar.net
202-877-0570
©AAHCM
©AAHCM











9 states and the District of Columbia have laws
mandating the coverage and reimbursement for
telemedicine-provided services under their Medicaid
programs:
California
Colorado
Kentucky
Maryland
Minnesota
Mississippi
Nebraska
Texas
Vermont
District of Columbia


Levison D. Medicare Payments for Ambulance Transports. Washington, DC: 2007.
Hearld, LR, Alexander JA. Patient-Centered Care and Emergency Department Utilization: A Path
Analysis of the Mediating Effects of Care Coordination and Delays in Care. Medical Care
Research and Review. 2012;69(560).

Weaver MD, Moore CG, Patterson PD, Yealy DC. Medical necessity in emergency medical
services transports. American Journal of Medical Quality. 2012;27(3):250-255.

Huibers L, Giesen P, Wensing M, Grol R. Out-of-hours care in western countries: assessment of
different organizational models. BMC Health Services Research. 2009;9:105. PubMed PMID:
19549325. Pubmed Central PMCID: 2717955.


After-Hours Care In The United Kingdom, Denmark, And The Netherlands: New Models Grol R,
Giesen P, vanUden C. doi: 10.1377/hlthaff.25.6.1733 Health Aff November 2006 vol. 25 no. 6
1733-1737
Primary Care Collaborative: The Outcomes of Implementing Patient-Centered Medical
Home Interventions: A Review of the Evidence on Quality, Access and Costs from Recent
Prospective Evaluation Studies, August 2009 Prepared byKevin Grumbach, MD, Thomas
Bodenheimer, MD MPH and Paul Grundy MD, MPH


Murray E, Burns J, See Tai S, Lai R, Nazareth I. Interactive health communication applications
for people with chronic disease. Cochrane Database Syst Rev. 2005;4:CD004274. [PubMed]
Integrated Telehealth And Care Management Program For Medicare Beneficiaries With Chronic
Disease Linked To Savings Laurence C. Baker et al Health AffairsSeptember 2011 30:91689-
1697
Health Buddy®
iCare
Desktop


Work list is
Color coded
for risk
stratification
Red flags
triage
patients who
need further
investigation
and early
intervention
•Web access
•Real-time video conferencing
•Digital photography capabilities
•Customized question/answer interaction
•Personalizable advice messages for patients
•Deliver schedules and reminders for measurements, questions, or
medication
•Graph display of results to identify trends, and
•Important vital sign and schedule alerts
•Medical peripherals

Reinforcement
◦ Technology
◦ “call us first”




Your first “success’ will be your best friend
Creative staffing
Protocols for phone triage
Value…
Site
Outcomes
Washington:
• 29% fewer ED visits
• 11% fewer hospitalizations
for ambulatory care-sensitive
conditions
• Net cost savings trend
North Carolina:
• 52% fewer visits to
specialists
• 70% fewer visits
to the ER
North Dakota:
• 6% lower hospital
admissions
• 24% fewer ED visits
• 30% lower ED use among
patients with chronic disease
Group Health of
Washington(Seattle, WA)
2009, 2010
Blue Quality
Physician’s Program
(BCBSNC) 2011
BCBS of North Dakota
MediQHome Quality
Program 2012
4. B.D. Steiner et al, Community Care of North Carolina: Improving care through community health networks. Ann Fam Med 2008;6:
361-367. and v Mercer. Executive Summary, 2008 Community Care of North Carolina Evaluation. Available at
http://www.communitycarenc.com/PDFDocs/Mercer%20ABD%20Report%20SFY08.pdf.
5. BCBSA: Patient-Centered Medical Home Snapshots.
Default in the past:
911-> ED (15% of ED
patients arrive by
ambulance)
15-34% est Medicare pts
do not need ED care
Why?
Litigation
Lack of data
No eyes on the
patient
Is there a better way?
Called 911
Sent by us
• ‘forgot’
• Aide/other called
• Medically
necessary
• Not enough info
Sent from
another
MD/faciility
DOWN 17%
• Total Medicare cost
• ED visits
(.003)
(.001)
Down 9%
Down 10%
• Hospitalizations
(.001)
Exceptional individualized caring for chronic illness

Use “extraordinary means” to prevent crises
“Ambulatory ICU”

Actively coordinate carefully selected specialists,
hospital care

view to behavior/environment (SW, aides, home)
Exceptional individualized caring for chronic illness
Use “extraordinary means” to prevent crises
“Ambulatory ICU”
Longer visits, interim support, 24/7 urgent care


Actively coordinate carefully selected specialists,
hospital care

view to behavior/environment (SW, aides, home)
AM Milstein, E. Gilbertson. Health Affairs 2009; 28(5):1317-26
Exceptional individualized caring for chronic illness

Use “extraordinary means” to prevent crises
“Ambulatory ICU”

Longer visits, interim support, 24/7 urgent care

Actively coordinate carefully selected specialists,
hospital care

view to behavior/environment (SW, aides, home)
AM Milstein, E. Gilbertson. Health Affairs 2009; 28(5):1317-26
1995:
2.9 M Vets
53,200 beds
30M op visits
2007:
5.3M Vets
18,199 beds
50M op visits
©AAHCM
ED Patients
1/3 Do not
need
emergency
services
15%