- A home health agency serving Medicaid recipients in western New York is using an mHealth platform to improve care coordination for it most fragile patients.
And for Raul Vazquez, MD, chief executive officer of the Greater Buffalo United Accountable Healthcare Network (GBUAHN), the new remote patient monitoring service will be important not only for the care it provides, but also for the numbers it produces.
“We’re creating a medical neighborhood,” he says. “We’re going to need quality metrics to make sure that we can manage this population.”
GBUAHN sits at the crossroads of today’s connected health landscape. Established under the Affordable Care Act of 2010, the home health program coordinates care for Medicaid recipients with chronic health conditions or who are at risk of developing them. The agency is also working to develop value-based agreements with local payers – agreements that include bundled care plans, which take into consideration concepts like social determinants of health.
To Vazquez, that jumble of key healthcare phrases means the agency needs to manage care for patients at home, before they become sick enough to need costly healthcare services, including hospital visits that may or may not be reimbursed.
“The Medicaid market is very costly,” Vazquez points out. “We need to manage those lives to reduce those costs.”
In 2013, GBUAHN launched a new program in which it dispatched patient health navigators (PHNs) to the homes of patients most frequently in need of healthcare services. Much like the community paramedicine programs popping up across the country these days, these PHNs assess each patient’s home life and work with healthcare providers to improve care management. That might include offering health and wellness advice, helping with medication management or even coordinating transportation for medical appointments.
Earlier this month the agency partnered with Tyto Care to equip some of its 96 PHNs with mHealth kits, which enable the navigators to collect vital signs and connect via a video telehealth portal to care providers. The connected care platform not only gives these patients a link with their doctors in between visits, but gives providers a chance to treat the patients at home for colds, infections and other nagging health issues that, left unchecked, might end up in a trip to the hospital.
“Now our PHNs have the ability to assist physicians remotely utilizing the Tyto devices,” Vazquez said in a press release announcing the partnership. “Many of our members have transportation, child care and other concerns, and this telehealth system makes it convenient and comfortable for patients to see their doctors.”
Just as important, Vazquez says, these PHNS can now collect important health data in the home, relaying it in real time back to care providers. That data goes into the patient’s electronic health record, giving providers a more complete patient history to work with.
And as GBUAHN moves forward with value-based care contracts, that data will help Vazquez and his colleagues prove the value of a remote patient monitoring program to payers – both private and public – who might still be on the fence about the value of telemedicine. Payer acceptance, in turn, opens the door to more programs out of the home rather than the healthcare facility, and more services that focus on improving health and wellness rather than reacting to a health emergency.
“There’s just so many things that we can check,” says Vazquez, noting the program serves roughly 7,500 people in and around Buffalo. “It’s like having them come into the doctor’s office for an exam.”