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ONC Pilot Challenge:
Total Population Health Management Delivery Model for Care Coordination in Underserved Communities
Innovator: Vital Care Telehealth Services Host: Dominican Sisters Family Health Service
Priority Areas Care Coordination
• Increase healthcare access • Improve delivery of care • Enhance quality of care • Community engagement
• Reduce hospital re-‐‑admissions • Lower healthcare costs • Improve post-‐‑acute care • Coordinate quality care
Underserved Communities
• Identify need • Community workers • Community-‐‑based
engagement
Access Quality Affordable Care
• Care based on risk stratification level o Preventative care
o Transitional care
o Chronic disease management
• Remote patient monitoring
• Care Coordination • Wellness and
Prevention
Purpose
Assisted Telehealth
Nurse Review
Wellness Coaching
Clinical Feedback
Vital Signs
Ques.ons
Social Support
Engagement
Educa.on
Hospitals
Physicians
Nurses
Social Workers
Case Managers
Tablet Applica.on
Cloud Hos.ng
Care Coordina.on
Monitoring
Management
Patients Providers
Care Communication and Connectivity
Level 1 Level 2 Care Coordination and Monitoring
Community Based Model
• Monthly Monitoring • Stable chronic
disease participants
• Weekly Monitoring • High clinical/behavioral
risk participants
Benefits Check and Assessment Assisted Telehealth Monitoring
Clinical Coordination of Care Trend Analysis and Interventions
Community partner buy-‐‑in formed early and will be integral partners in weekly project management and program evaluation meetings
Strategic partnership combining health IT and clinical care delivery to bring an interoperable total population care for care continuum
Health connectivity established for 400 participants with outcomes documented and reported to ONC
Pilot to demonstrate an innovative total population care model to serve a vulnerable and underserved population that can be replicated nationwide
Summary
Thank you
Christopher GaurVital Care Telehealth Services
[email protected] | www.myvics.com
Dr. Louis L. HarrisDominican Sisters Family Health Service
[email protected] | www.dsfhs.org
