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Expanding Telemedicine to Medical Homes for Comprehensive Care Delivery for Persons with Hemostatic disorders: A pilot study of the American Thrombosis and Hemostasis Network (ATHN)/National Hemophilia Program Coordinating Center (NHPCC) Abstr. No. ISTH15ABS-2041 Vitamin K Antagonist II Roshni Kulkarni* 1, Rebecca A. Malouin1, Colleen Vallad-Hix2, Laura Carlson1, Marcia Bird1, Diane Aschman3, Ann Forsberg3, Zachary Trost1, Robert Greenhoe2 1Michigan State University, East Lansing MI, 2Portage Health Pediatrics, Upper Great Lakes Family Health Center , Hancock, 3American Thrombosis and Hemostasis Network, Illinois, INTRODUCTION &OBJECTIVES Results: Demographics and types of disorders • Telemedicine (TM) is the delivery of health services through HIPAA secure synchronous videoconferencing to patients in remote sites with limited access to specialist services. • Telemedicine can also be used to delivery cost effective diagnostic and comprehensive services for management and monitoring of patients with hemostatic disorders. • Our goals were to provide increase access to family-centered and culturally competent specialty care and to • Increase the number of patients with bleeding/blood disorders that are timely and accurately diagnosed and referred for specialty care Objectives • To assess feasibility of telemedicine between specialists and medical home for children with hemostatic disorders • To assess the cost of telemedicine visits versus traditional visits from the societal perspective • To assess the acceptability by patients, families, primary care physicians, primary care staff, specialist physicians, and specialist staff • To assess resource, referral, support assistance and patient confidentiality of medical and mental health services Telemedicine Clinics: Houghton MI Time period June 2014- May 2015 No. of patients Telemedicine visits Age range No. of Clinics 13 15 2 weeks -17 years 1 per month No of patients seen/clinic Videoconferenci ng system Challenges • Patient no shows • Technology challenges: • Portage network upgraded, firewalls blocking telemedicine • New laptop computers not set up with email to send telemedicine link • Clinic cancellations – due to meetings or lack of patients • Inability to do platelet function testing (platelet aggregation) and specialized coagulation tests in Upper Peninsula www.POSTERPRESENTATIONS.com Epistaxis/possible Ehlers Danlos 5/2 Von Willebrand disease (VWD) 2 Cervical lymphadenopathy Spherocytosis Iron deficiency anemia/ hemoglobinopathy (Thalassemia) 1 1 1 Vidyo Family members tested/counseled Family Parents and sibs and uncle Family Family 1 Patient and Father 3/1 Mother and siblings 1 Sickle cell trait Parents Results: Costs • TM site was the Medical Home/primary care physician (PCP) pediatrician’s office at the Upper Great Lakes Family Health Center in Hancock/Houghton, MI, located ~500 miles from Michigan State University Center for Bleeding and Clotting Disorders (MSUCBCD) • Types of comprehensive team services provided were recorded. • Personnel, equipment type and as well as the cost savings of travel by the care team were recorded. Cost savings were analyzed. • Synchronous HIPAA regulated bidirectional videoconferencing technologies, Vidyo TM (web based), was utilized in all phases • Written photo releases with permission to utilize them for education were obtained TEMPLATE AND PRINTING BY: No Hereditary Hemorrhagic Telangiectasia Menorrhagia, anemia, abnormal coagulation profile, thrombophilia 1-3 METHODS Clinic Location Types of Disorders Acceptability and Lessons Learned Demographic Parameters Portage Clinic Patient Costs Patient to attend clinic at MSUDriving costs (Driving, meals and lodging) Time lost from work, round trip (RT) hours @ $33/hr wage Average distance that 33.4 (2.4 -42.3 ) miles patients travelled Distance patients lived 30-50 miles : 4 Visits from local center. N13 10-15 miles : 4 Visits patients with 15 visits <10 miles : 7 Visits Distance for Patients to MSU (RT) 960 -1000 miles RT (460-504 miles OW) Commercial airline ticket cost $1142 to $1184 Driving time 9 hrs OW or 18 hrs RT Time lost from work 20 hrs ( 9 hrs travel time OW) Patient seen at HTC Total Costs with driving MSU, If patient flies ( $1184 airline costs + East travel time = 16 hours @$33/hr = Lansing 528 Meals and Lodging $175 /night Total Costs with flying Physician cost saving $3850 Patient seen locally at Portage clinic Portage Clinic $615 20 hours x$33=$660 $1275 $1712 $175 $1887 Patient to attend clinic at local facility $18.7 (Driving) Time lost from work (RT) @$33/hour 3 hrs x$33= wage $99 Total costs attending local clinic $117 Outreach Nurse/ Coordinator Roles Outreach Nurse Role::Gathered referral information, including labs & pertinent history and labs from outreach location; Reviewed patient information with hematologist, ordered necessary testing desired prior to visit During Telemedicine visit: Provided nursing assessments and family education Post TM clinic follow up: Coordinated patient and family testing, medications, education, implementation of plan of care Documented patient care and data entry to ensure that both clinics have visit documentation. Updated contact information Coordinator Role: Coordinated with Portage, MSU staff, and physicians, and IT department regarding dates and times for monthly telemedicine clinics. Assisted with grants and site visits • Families and clinic staff found telemedicine to be an acceptable form a care, especially as it is becoming common among other specialties in rural areas • In most cases families preferred telemedicine as their trusted healthcare provider was close by and they did not need to travel • Lessons learned from staff • Staff were accustomed to protocols and desired a telemedicine protocol for hematology consults • Tools to provide families with information about what to expect from the consult would be helpful • Planned visits are necessary due to scheduling in a busy pediatric practices • Lesson learned from patients • Written information about the purpose of and expectations during and following the telemedicine consults are needed • Having the primary care physician in the room to explain what the hematologist is recommending might be helpful • Having many team members on the video on consultant side is confusing - fewer is preferred Social Work (SW) Role and Perspectives • Facilitated services such as education programs, mental health support programs among patients, family members, MSUCBCD and PCP • Provided bleeding disorder education in specialty care, insurance and patient assistance programs to PCP and staff • Built a rapport with patient and family members and assured all participants of confidentiality, which was integral to success • Researched and offered alternatives for parent/child, in-home, early intervention, special education and social work services not available to patients in rural area • Assisted families in overcoming barriers due to low economic status, unemployment, learning disabilities and transportation through CBCD, local resources and Helping Hands • Provided post-telemedicine contacts for on-going HTC communication and referrals to bleeding disorder state and national recreational, educational activities and support services CONCLUSIONS • TM allows care delivery by specialists for diagnosis and monitoring and follow up of remote patients. Critical social worker and nursing evaluation and interventions can be accomplished via TM. • Successful care delivery is possible at Medical Home using telemedicine • There is significant cost and time savings for the patients, physician and health care facilities. • Besides patient satisfaction and education of patients and providers, TM allows state of the art specialized care to be provided to remote patients. References Whitten P et al. Applied Clinical Informatics 2010;1:132. Grosse SD et al. Medical Care. 2009;47:594 Study supported by ATHN NHPCC grant; Project Number: ATHN2014NHPCC-1; Funding source: HRSA#UC8MC2409 through ATHN