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What are the objectives of the program?
Improved health outcomes, Reduced readmissions, Reduced utilization of post-acute care, Reduced transitions from post-acute care/long-term care, Reduced avoidable utilization, Reduced spending
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Please provide a brief description of the program:
Lorien and UMUCH collaborated on a telemedicine program that allows for remote visualization of patients, plus continuous vitals monitoring, Point of Care Testing and medications (at Lorien) that are the same as at the UMUCH ED. The goal is to reduce Acute care transfers, 30 day readmissions, and ED visits.
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What is the primary source of funding for the program?
Started with a 30K MHCC grant and continues with UMUCH operational funds.
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Is this program operated as part of HSCRC's Care Redesign Amendment?
No
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Which Center for Medicare and Medicaid Innovation (CMMI) category does (or would) the program fall under? Choose the best match.
Episode-based Payment Initiatives
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What are the major components of the program?
Care coordination/management, Patient assessment tools, Protocols/agreements with care partners, Telehealth/connected patient technologies, CRISP tools (e.g., Encounter Notification Service)
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What types of organizations participate in the program?
Hospital/health system, Skilled nursing facility, Rehabilitation center
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Which population(s) does the program target?
Medicare/older adults, Medicaid, Dual eligibles (Medicare-Medicaid enrollees), Frail/disabled
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How many patients have participated in the program to date?
The systems has been used more than 500 times since inception at Lorien Bel Air or the Lorien Riverside locations
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In what Maryland jurisdictions do participating patients reside?
Baltimore, Cecil, Harford
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Briefly describe the staffing resources required to operate the program:
A pool of Providers at the hospital to receive calls from the SNF for patients that are decompensating. Typically 1 person is assigned to respond to the calls during each day shift and 1 person has a call responsibility at night or on weekends.
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Briefly describe the key initial steps to implementation:
Leadership from SNF and Acute Hospitals is critically important. There will be missteps during the learning process. This cant let doubt enter the minds of the front line team. Shared development of protocols, patient criteria, is important. Credentialing providers at the SNF location There are malpractice and compliance items that must be resolved Technology needs to be reliable, but is not the most critical element of success- rather it is the availability and willingness of the hospital provider to answer the call.
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Are incentive payments to health care providers part of the program?
False
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Does the innovation program qualify as a CMS Advanced Alternative Payment Model (APM)?
Yes
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What are/were the expected results in improved outcomes, population health, and cost savings?
The first year of the program showed a 34% reduction in 30 day readmissions. As we expanded, this success moderated a bit. We have migrated to a different provider coverage model in CY 18 and are seeing results similar to year #1.
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Have expected results for improving outcomes and population health been met?
Yes, expected results were achieved
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Please briefly explain your answer to Question 25, and describe any results for improved population health achieved to date:
Yes, expected results were achieved
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Please briefly explain your answer to Question 27, and describe any cost savings results achieved to date:
Cost savings under the GBR can be generated by avoided admissions and days. The variable cost savings can fund the investment in the program moving forward. For Medicare, the savings is more likely to come from avoid ambulance transfer payments, as the GBR limited some of the charge savings at the acute care level.
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How to learn more (e.g., website URL)
https://youtu.be/r4P_Edrrvqo
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Please provide URLs to any published evidence (e.g., peer-reviewed literature, white papers, etc.)
http://mhcc.maryland.gov/mhcc/pages/hit/hit/documents/Telehealth_Brief_FINAL.pdf