Adviser LeadingAge New York Summer 2015 July 2015

St. Mary’s Heathcare System for Children Jonah Cardillo, director of institutional gifts Q. Please provide a brief description of your BIP innovation grant project. Jonah: In the summer of 2014, St. Mary’s was awarded a Balancing Incentive Program (BIP) innovation grant to launch a proof of concept telehealth project aimed at lowering avoidable hospital use among children with highly complex medical conditions enrolled in our certified home health agency. In October 2014, we launched the program – a nurse-driven telemonitoring initiative designed to enroll up to 500 medically complex children most at-risk for admission or readmission to hospitals, skilled nursing facilities or other more institutional settings. Those enrolled continued to receive skilled nursing and rehabilitation home care visits and case management as mandated by physician orders; as an adjunct service, parents or caregivers began to receive regular automated calls from an Interactive Voice Response (IVR) system administered by St. Mary’s skilled nursing telehealth team. Automated IVR calls request very basic information from a child’s caregiver. Five automated templates are tailored to monitor patients with asthma, non-asthma respiratory conditions, and seizure disorders, as well as those who are at risk for dehydration, or who are otherwise at risk for hospitalization. Calls solicit yes or no responses from caregivers who are asked a series of questions on their child’s medication adherence, occurrences of major medical events such as seizures or falls, and changes in condition. Responses to each automated call takes 2-3 minutes to gather, as opposed to other similar programs in which clerical staff spent nearly 30 minutes to make a similar call. 37 Based on these calls, reports are generated automatically, flagging responses that indicate the need for follow-up. RN Telehealth Nurse Managers monitor alerts and make follow-up calls to further assess flagged responses. If an urgent need is identified, the Telehealth Nurse Manager will coordinate with the child’s assigned home care nurse to make a follow-up visit, thus facilitating a preventative intervention days and maybe even weeks earlier than previously possible. that takes place between St. Mary’s and its home care patients. If additional care, education or guidance is needed between visits, we now have a means of identifying that need and facilitating support. Our telehealth care managers are skilled nurses, and are therefore equipped to apply a great deal of clinical expertise and experience as they manage incoming alerts. As such, this project advances the following objectives: IVR enables our staff to track occurrences of lapses in medication adherence, seizures, emergency room visits and other major medical events more quickly and more accurately. Because skilled nursing visits may take place as infrequently as once every 60 days, these calls provide the opportunity to touch base several times between visits. Our telehealth nursing staff can therefore identify children who need care between visits, and quickly intervene before an issue develops into a major health concern. Prevention among this vulnerable population is key, and our IVR helps us keep New York City’s sickest kids healthier. • An increase in medication adherence Since launching in October, we have built an active census of about 450 enrollees: • More than 11,000 IVR questions answered to date • Some 1,100 alerts generated and responded to • 88 percent of participants answered at least one template sent to them Q. What were the goals and objectives of the project? Jonah: The overarching objective is to • A reduction in avoidable hospital use among our patients • An increase in patient and family satisfaction Q. Overall, would you say that you met the goals and objectives? Please explain. Jonah: We are currently working with our telehealth vendor to track a vast amount of data generated by the automated IVR system, and with a consulting firm with expertise in data science to aggregate and analyze this data as we assess project outcomes. Initial data and anecdotal evidence suggests that we are on track to achieve a meaningful impact across all three of the above stated objectives. In the fall, we expect to release a white paper with a more robust analysis of program outcomes. Q. Specifically, what worked? And what didn’t work? Jonah: Parents are very satisfied with the project – they feel that these additional touch points are helping to keep their children healthy and that makes them feel more secure. Needless to say, parents and children are very happy when we can help them avoid a increase the amount of communication Adviser a publication of LeadingAge New York | Summer 2015 (Continued on page 38)

Adviser LeadingAge New York Summer 2015 July 2015 | Page 38