"Emerging Trends in Health Care"



good afternoon and welcome to this the spring 2015 it really is spring honestly the spring 2015 presidential lecture series my name is Diane call I have the privilege of serving as the president of Queensborough Community College and I welcome each and every one of you to our college campus today into this event which was essentially established about 15 years ago by my predecessor and the focus for the spring lecture it really does feature our own faculty and we have a wonderful array from whom to select and we are exceedingly grateful to our presidential lecture committee for its work to identify a very hard decision among all of our faculty who might present a lecture for the spring so I'd like to thank the members of the presidential lecture committee dr. Seuss on Karimi from chemistry himself a presidential lecturer dr. Karen Steele dr. Amy traver and dr. mark van Ellis and I thank them for their work and again I welcome you to this lecture emerging trends in health care a very interesting topic for this time professor mary ann rosa is with our nursing department she's a gerrant illogical nurse practitioner and a consultant for North Shore Long Island Jewish Health System and she serves on a task force charged with decreasing readmissions and improving health outcomes something we all aspire to no doubt in 2000 professor Rosa was inducted into the nursing center of excellence of Liu for her work in community health care and we were very very happy that she was able to join our faculty a number of years ago along the way professor Rosa developed a heart failure community disease management health program and another community health program to manage diabetes at Queensboro and we pride ourselves on the quality the excellence of our nursing program our nursing faculty and our students who are outstanding at bro professor Rosa implemented telehealth into our nursing program a very rigorous program to begin with and she assisted with the incorporation of this concept at several other CUNY schools patient centered care using technology as part of a health management system is really at the forefront of our efforts to design health management programs to increase life expectancy while decreasing the costs which obviously are everyone's concerns I'm very anxious to hear her discussion of emerging health trends particularly in light of the fact that we have an ongoing conversation about healthcare in this country and the use of technology professor Rosa please join us thank you on it and privilege to be here with all of you this afternoon and I would just like to thank president qual and the presidential election committee for this opportunity I will be discussing emerging trends in healthcare so I will focus on an aging America and the increase in chronic illnesses and the impact that has had on our health system I will then focus on some national initiatives and advances in technology that have decreased cost and have improved healthcare outcomes so because we have an aging population we see more chronic illnesses and when we see more chronic illnesses we see people in the community with increased healthcare needs and then we happen to see more hospitalizations and more Hospital days so frequent hospitalizations make patients weaker they may have been able to self manage their illness before hospitalization but when someone is hospitalized they can have new impairments and new disabilities and that could be in some of that basic need like nutrition and sleep and activity also when patients are discharged from the hospital very often they have some degree of cognitive impairment and that can interfere with their self-care ability they mean find it hard to get organized or they may be a little confused over the treatment and they're your f—ing patients are also on multiple medications which is another factor that can impact on their self-care ability the older someone is and the longer the hospital stay the more at-risk they are for a readmission and the cycle of frequent hospitalizations makes patients frail and vulnerable so demographic changes have created an urgent need across our country and here's some statistics for you and she was that by 2030 one in five Americans will be an older adult an older adult is anybody over the age of 65 and that will be about 72 million people by 2050 the number of people is expected to double what it was in 2010 for the older population for the 85 plus group that is expected to triple and this is happening because people are living longer and we also have aging baby boomers and those are people born between 1945 and 1964 so the baby boomers they really have impacted across our country at every aspect of their lifespan so we've seen different things occur throughout the years we've seen sales of baby food rise commercial baby food we've seen construction of schools and housing rise but the biggest impact has been on our nation's public health and social services and healthcare system and our health care system is forced to address the needs of an aging population so years ago the leading indicators for or the health indicators for death were infections and acute illnesses like tuberculosis and while we still may see some of those illnesses today we don't see it as much because of the advances in medical treatment but what has replaced those illnesses as the leading causes of death have been chronic illnesses like heart disease and diabetes chronic lung conditions and cancer half of all older adults have one or more chronic health problem one in four adults have more than one chronic illness in fact patients with diabetes 10% of those patients have just diabetes the other 90% have other comorbidities in addition to the diabetes and when patients have multiple chronic illnesses this increases the need for specialists and treatments and medications and medications for one illness that are good for one illness might adversely affect another illness they may also be at risk for redundant tests and possibly avoidable hospitalizations so now longevity increases our risk for chronic illnesses genetics may play a role about half of American adults have at least one major risk factor for heart attack or stroke and that would be hypertension or high cholesterol or being a current smoker about 90% of Americans consume too much sodium or salt and this increases the risk of high blood pressure which is a risk factor for heart disease heart failure stroke a third of all Americans have obesity and obesity also contributes to these chronic illnesses obesity in fact is one of the strongest risk factors for hypertension so while getting older and genetics we cannot modify we can modify our lifestyle which also can contribute to nakooma says so if you look at the plate size years ago it used to be a nine inch plate and today it's a twelve inch plate so what does that mean more calories and more food more saturated fat possibly I encourage you to use a nine inch plate it'll look like you have more food as well years ago popcorn we used to be satisfied a little container today we get a tub of popcorn Extra Butter so we're piling on again saturated fat and calories coffee years ago we were satisfied with a small cup of coffee but now we get extra large and we top it with extra toppings like whipped cream and again that could be eight times the amount of calories that were consuming now while this is not a healthy choice if you look at years ago the same meal was about 400 calories but now with the super science phenomenon that same meal is about 1400 calories that's almost the total amount that we should have for 24 hours almost and what's wrong with this picture now in all seriousness these people could have joint problems and they could be going to do water aerobics which is fine right but it kind of just highlights the sedentary nature of our society so chronic illnesses and diseases are defined by the World Health Organization as illnesses that are permanent leave some form of disability and require training specific training by the patient and also require a period of observation and supervision from a healthcare team and when patients have chronic illnesses they may not be feeling well so it makes it harder to self manage the illnesses and so learning is hot a working is harder they may even experience diminished functionality or decreased quality of life it could interfere in their activities of daily living and then we can see an increase in institutionalized days whether that be in a hospital or a skilled nursing facility so interventions really should begin early in life our younger population will be old someday and also in our younger population type-2 diabetes is an epidemic among a younger population so intervention should really begin earlier and communities are pivotal in creating environments that help people to make healthy choices and live a healthy lifestyle which not only includes healthy eating but activity and it's very important to keep people functional so when patients are coming out of the hospital a lot of times we're focused on therapy and medications and treatments but we don't want to forget about keeping functional and active evidence tells us that the more functional we keep patients after a hospitalization the less likely they are to go back so chronic illnesses not only impact the activities of people and how well they feel but it also impacts on cost right so more than two-thirds of all healthcare costs are for treating chronic illnesses and in our older population ninety five percent for chronic illnesses so for people over 65 it costs three to five times higher than the care for people younger than 65 so we see this shift from acute care to chronic care because of the rise in chronic illnesses and individuals are discharged from the hospitals quicker and sicker so the needs increase in the community so self management becomes very important and this starts in the hospital and it has to start in the hospital but there are some obstacles patients may not be feeling well the environment may not be conducive to learning so it has to continue in the community and there's some advantages to that the patient is in their own environment where they feel comfortable they feel and and we uncover positive as well as negative factors that may impact on their self-care ability so we have to look at the hospitalization rates nationally 30-day readmission rates from patients that are discharged from the hospital are about 18 to 23 percent and this is for the age group 65 and older with chronic illnesses it was about 25% for many years and over the last several years it's comes down a little bit the 15 day readmission rate is about 13% so this is telling us that when patients come out of the hospital they are frail and they do have needs that need to be met this also increased costs for Medicare the Institute of Medicine says that this is possibly an indicator of poor care or missed opportunities to better coordinate care when we see frequent hospitalizations like that one study in the New England Journal of Medicine says that 76% of these rehospitalizations are preventable about 30% for our older adults are due to non adherence so this further highlights the importance of these self-management programs and evidence tells us that with intensive management we can decrease these avoidable readmissions so one national initiative that's going on right now is the hospital readmission reduction program and Medicare is authorized to give decreased reimbursement to hospitals that have frequent readmissions within 30 days now this started with the diagnosis of heart failure heart attack pneumonia and several other diagnoses have been now included in that and it's all cause so if a patient comes out of the hospital and they had heart failure but they get rehospitalization assess the hospital still gets penalized so this has a ripple effect on the community hospitals want to align themselves with community-based agencies or health care agencies that are going to help them keep patients well and keep them out of the hospital I like this article that was written by a toll Gawande he's a Harvard graduate he's a surgeon and an author and he wrote the article the bell curve and what he talks about is that some hospitals do very well some hospitals don't do so well and some hospitals cluster around the middle and this is what creates the bell curve so he goes on to tell the story about a young girl named Annie and she had cystic fibrosis and cystic fibrosis is an illness where the secretions in the body thicken so it can clog Airways in the lungs and it can clog the digestive tract and she was being seen at a hospital that wasn't doing so well with their clinical outcomes for cystic fibrosis and the physicians there decided to be transparent with Annie and her parents and tell them we're not doing very well with our clinical outcomes and they gave them the name of the hospital that was number one in the care of cystic fibrosis but they also went on to tell them that we are going to do whatever we can to improve those clinical outcomes so Annie and her parents felt comfortable staying with them because they were so transparent with them and today our hospitals he spoke about this in 2004 and today our hospitals are very transparent and we can get this information at medicare.gov and we can get report cards on how well nursing facilities are doing hospitals are doing home care agencies are doing he also went on to say well hospitals get paid for performing better and again this is in 2004 but that's exactly what's happening now and I'll talk about that so the staff at this hospital that was not doing very well with the clinical outcomes for cystic fibrosis went over to visit the hospital that was and they expected to find some new treatment or new medication that they were giving to their patients and they thought maybe that's why the outcomes was so much better but when they went there they were surprised because they were adhering to the same standards of care and the same guidelines that the hospital what was different is that the physicians were spending more time with the patients and they were asking questions like how are we feeling should felt you know feeling short of helping you what can we do to make you feel better what makes it hard for you to follow the treatment plan so they were making it patient-centered they were using the skills of motivational interviewing which is a skillful way of counseling – you know facilitate these productive conversations to keep it patient-centered and that's very much a part of all the programs today so the point is that knowledge alone and guidelines alone while they're very important and we do have to adhere to best practices and standards of care it's not the only thing there's much more than that so chronic illnesses doesn't have to mean that someone will become debilitated getting older doesn't have to mean that someone will be disabled with care proper care a lot of complications and associated conditions can be delayed or prevented so self-management programs disease management programs they're at the forefront of helping people manage their illnesses so they help patients transition from the hospital to the community but they also help patients that are already in the community so they want to help patients not only when they're ill and not feeling well but when they're healthy and they want to help patients stay healthy and empower patients the HEDIS measures that stands for healthcare effectiveness data and information set that's a set of measures that many healthcare plans use a lot of disease management programs use and what that is it helps agencies and to make sure that they're adhering to the standards of care so for example if a patient had heart failure they would look at such things well are they on the right medications did they have an injection fraction done which is a measurement of how well the heart is functioning if they had diabetes are they getting the proper annual screening did they have an a1c done which is a blood test that measures the glucose over a longer period of time in fact now community-based organizations will not get reimbursed unless they have an a1c documented every three to six months so disease health management Stan Bernard consultant to the Department of Health and Human Services and the heart failure Society of America defines disease management as a set of measures to improve clinical outcomes and decrease cost but Stan Bernard went on to say why do we call it disease management why can't we call it comprehensive health management I agree the word is more positive so when I first developed the heart failure program I had a patient come up to me and said why do you call it the heart failure program why can't you call it the hot success program and I thought that was such a great idea so I changed all the names to the hot success program but I got in trouble because I was confusing patients so the hospital called it one thing we were calling it another so I did have to change the names back but years later today they do use more positive terms so you hear such programs as a diabetes wellness program the heart healthy program so we do see positive terms being used because again we want to focus on when patients are healthy and keeping them healthy as well there are some national programs going on to promote health we have the healthy brain initiative and that came about by the CDC because of the increase in Alzheimer's disease and cognitive impairments and what that does is it helps health care facilities promote cognitive health and it also looks into the community to help people that have cognitive impairments and help their families a million hearts that was started in 2011 by CMS and the CDC and that is an initiative to prevent a million heart attacks and strokes and they do that in ways by smoke-free environments decreasing the amount of salt and food eliminating trans fat healthy people 2020 another set of national objectives this is done every 10 years and it's a set of objectives again to promote health and it focuses on maybe illnesses that we see that are more prevalent and in 2010 we did see some positive outcomes however we still need some more work with decreasing health disparities and decreasing obesity and I'd like to also highlight some healthy initiatives that are going on at CUNY and Queensboro to promote a healthy environment tobacco free environment the promotion of healthy eating there's wellness festivals there's screenings so if you work here or go to school here I encourage you to take part in these programs health literacy is another national initiative and this is defined as not only patients being able to find that information and understand that information but also to process that information to make appropriate health decisions and many people nine out of 10 older adults have trouble carrying out information following information because it's not easy to understand it's often not written from the patient's point of view and when this happens they have difficulty then managing their illnesses if you look at this study show me how many pills you would take in one day patients with low literacy 71 percent said yes I understand but only 38 CEN were able to demonstrate understanding so this just highlights the importance of making sure information is understandable to patients now the instructions on this label or I take two tablets by mount twice daily sometimes patients feel they took one in the morning and one in the evening and they feel they took their two tablets for the for the day when it's really two tablets twice a day so this national initiative is not only looking at the skills of the patient but is also focusing on the skills of the healthcare professional and what the professionals and the organizations are doing to have this information user-friendly for the patient and understandable for the patient so each organization has to have a health literacy plan and each organization has a committee so if the hell team develops any material it has to go through that committee so that they can approve this material healthy people 2020 is tracking health literacy improvement and the CDC also has online resources some other national initiatives going on right now one has to do with ICD coding so coding identifies an illness it's a set of numbers and letters that identify illnesses procedures and it gives us information it gives us information on statistics on illnesses that are more prevalent in certain areas it also gives information to health companies insurance companies for reimbursement so right now we use icd-9 coding but what the United States is the only industrialized country to still use icd-9 but we're changing over to icd-10 by October of this year so now the codes are about three to five characters it will change to three to seven characters and we have now 16,000 codes we will have 70,000 codes so that we can be more specific with illnesses and it'll decrease any errors in any claims other initiatives that are going on one has to do with observation units so instead of patients getting we hospitalized they may be observed for a period of time in the hospital and this could be 24 to 48 hours but they're not admitted they're observed so if they have interdisciplinary teams in place and they're following specific protocols this may be very good for the patient because we don't have a hospitalization and we don't have the risk of the patient's becoming debilitated so it may be a good thing but the only time it can become worrisome is if the patient needs extended Rehab after that time period because they won't be reimbursed for that because they didn't have the three-day qualifying hospital stay so that could be an issue improvements in transitional care we're seeing that across the country and this is really important because we want patients to stay healthy we don't want to avoid those avoidable hospitalizations one of the first things is making sure patients are appropriate for discharge so we do have teams of people in the hospital that work on this we have discharge planners but one of the problems we've seen across the country is a breakdown in communication the breakdown in communication from the discharge plan are getting the information from maybe the hospital as to the community physician or the community homecare agency so there's initiatives across our country to improve that and any patient has a right to an appeal at discharge also because if patients are discharged too quick and not to the right setting of course that would increase and avoid the likelihood of an avoidable readmission the other thing about discharge planning that they're working on across the country and in some of our own area hospitals as medications medications is a leading cause of readmission with patients and they're finding that when patients go home sometimes there's a couple of days they may not feel very important prescriptions or it may be a weekend and they don't have access to fill those prescriptions so what the hospitals are looking at now is trying to give pain a 48-hour supply of medications or looking at their internal pharmacies to maybe fill prescriptions before a person leaves the hospital the other thing social workers are teaming up from community to work from hospital to community to identify pharmacies in the community that will pick up prescriptions and then deliver the medications to patients so patients don't miss out on very needed medications the other thing that they're working on is transportation after the patient leaves the hospital evidence tells us that if the patients don't see that healthcare provider within 7 days they are more likely to go back to the hospital so it's very important to have that continuity so they are working on that because insurance companies don't cover transportation not all insurance companies cover transportation so the trying to work on that as well so they can connect patients quicker to that healthcare providers in the community so as you can see it forces hospitals and community agencies to work together so that alone improves transitional care another national initiative going on has to do with the Affordable Care Act implementing different payment and delivery systems and one of them is accountable care organizations and that has to do with different providers connecting and working together to improve clinical outcomes patient-centered medical home models that's where a patient is assigned a care navigator or a care coordinator and that person follows the patient from hospital to community so it decreases any fragmented CAD that can occur because they can really catch anything that can be missed because of following the patient and they're a link between all the physicians from the hospital to the community so pay-for-performance this is what a toll Gawande was talking about and now our hospital is being rewarded for improving care instead of quantity so years ago it used to be fee-for-service and they would get rewarded for quantity but today they're getting rewarded for quality so I know there is some controversy with the Affordable Care Act today and I'm not sure where it will go moving forward but I hope some of the positive things that have come about remain another initiative the bundle payment for care improvement initiative this is an initiative that is based on episodic time periods and there's a lump sum given for a certain period of time and that could be 30 days 60 days 90 days and there's a couple different models of this one model gives a lump sum for community for hospital to community and again the hospital and community have to learn how to work together because they're getting one lump sum payment to keep the patient out of the hospital so they work across healthcare settings so preliminary findings have told us that we do see improved care and we do see decreased readmissions so technology does it save money or increase costs maybe a little bit of both but it really depends on the type how its utilized is it appropriate I'm going to focus on some of the types of technology that do improve clinical outcomes and decrease cost smart phone technology that's beneficial for clinicians and it's also beneficial for patients there's a lot of apps that are very helpful to all of us here in the nursing program we use unbound medicine and that connects us to drug guides and medical information there's an app called Fitbit you should all download it on your phones it helps us to keep on track with healthy eating and activity there's certain apps for patients that have chronic illnesses like diabetes to help with Cobb counting the only thing I would encourage is that if you're looking to download any apps just make sure it's accurate information and how would you know that an app is okay to use is for example if you had diabetes go to the American Diabetes Association and they recommend certain apps that are accurate electronic health records that has done a lot for our nation so far has decreased errors it's a means of communication it's improved clinical decision support electronic prescribing makes it easier for the providers for the patients patients have accessibility to some of their records but there has been some challenges with the electronic health records especially during the transition period of when institutions are transitioning from paper to computer that can be quite challenging and the challenge of adhering to best practices and privacy and making sure the information is accurate sometimes fields and in the computer can auto populate so it's up to the professional to make sure that that information is correct but I would also urge everyone to make sure if they have an electronic record popping up that it's correct for example you you have all your information on an electronic record you go into an emergency room all your medications pop up you want to make sure it's accurate though that you didn't go to someone that didn't enter it into that record because you don't want to get medications that maybe you shouldn't be getting the other challenge has been patients perceived sometimes the computer as a barrier to the provider patient relationship so that's a work in progress to not decrease that relationship not you know interfere with that patient provide a relationship because sometimes it may feel that way cardio MEMS this is for patients that have heart failure this was just FDA approved last year this device it's about size of a paperclip and it's placed in the pulmonary artery through the way of the femoral artery and it measures pressures in the lungs and what this does is unit sometimes patients with heart failure have fluid retention and shortness of breath but this will identify a problem before that occurs so before a patient would get the shortness of breath and the swelling this will tell us that something's wrong and then medications can be adjusted accordingly it has decreased Ramesh readmissions for heart failure by 37% and very few complications I know of two hospitals that are you doing this now North Shore Manhasset and also NYU and Manhattan are using the cardio mens with very good results this is a life vest this is a wearable defibrillator so sometimes patients have internal defibrillators if they're at risk for life-threatening arrhythmias but sometimes the the internal defibrillator can become infected or the waiting for the internal defibrillator so they may get a life vest instead temporarily maybe and this what this does is as electrodes placed on the chest and the heart is monitored continuously and if this if a heart if a life-threatening arrhythmia is detected this will shock the patient and it will shock them into a normal heart rhythm this is one twenty four hours it's just taken off to shower this is an LVAD this is a left ventricular assist device some patients with advanced heart failure may need this and this is surgically implanted into the abdomen and a driveline comes out and it's connected to a machine that helps to pump the heart and it's also it's implanted in the abdomen but it also connects to the heart to assist the heart and pumping and sometimes patients need this temporarily while they're waiting for a transplant or sometimes patients have a type of heart failure whether that they will recover but they need some help temporarily it's also being looked at for destination therapy because it does extend life and it also improves quality of life this is a gastric pacemaker similar to a cardiac pacemaker and it's done by a minimally invasive procedure and it Y is go to the stomach and it treats a condition called gastroparesis gastroparesis is a slowing down of the stomach from emptying into the small intestine and that happens because of illnesses such as diabetes and nervous system disorders so this gastric pacer can stimulate the stomach muscles and stimulate the nerves so that the stomach doesn't slow down okay and then it can decrease those manifestations that they get like nausea and vomiting and abdominal pain so it can really help patients to feel better this is continuous glucose monitoring so for patients that have diabetes that have glucose that may not be stable this may be an option and what this is it's a sensor that's inserted under the skin and it checks the glucose levels in tissue fluid and it can check it very frequently at 1 minute 5 minute intervals so it also can alert the patient that the levels are going too low or too high and it can be sent to the computer for tracking and analysis so the thing about this though it's tissue fluid so it's not as accurate as blood so if a high very high reading or cars or very low reading occurs patients are still encouraged to check it by the regular glucometer these are smart pill bottles if you can see here it's lighting up blue that reminds a patient to take their medication so this is very helpful for people that are forgetful and taking their medications if they miss a dose it will light up in red and it will also be okay it also gives information when the bottle was opened how many pills were taken out when the bottle was closed and this information can be sent to the patient to a family member to the clinicians providers and now they're also looking at smart pills themselves because even though the patient took the medication out of the bottle no guarantee that they actually took the medication so smart pills they have a sensor actually on the pills and when it comes in contact with gastric fluid it sends a code and it tells us that the patient took this medication took a specific dose of that medication now we get to telehealth and there's an explosion of telehealth across the country it is defined as the use of technology to deliver health care information or education at a distance the Affordable Care Act addresses telehealth as a means of delivering efficient and effective health care it affects global health it affects population health there's two types of telehealth and if you've ever spoken to your physician or your nurse over the phone or your if you're a clinician and you have a smoke spoke to a patient over the phone you've done telehealth it's been around for years but it's just act tech nology has changed through the years so we're able to do a lot more with it so there's two types of telehealth one is store-and-forward and that's where patients will take a set of vital signs they'll answer some questions and then that information gets sent over to the clinicians computer and then there's real-time communication where we can connect with the patient through video interaction so the patient sees the clinician and the clinician sees the patient as many studies that have been done through the years to show that telehealth has improved clinical outcomes and has decreased cost I was involved with a study in the late 90s early 2000s with lij and bass Stony Brook where we introduced the monitoring portion of telehealth and we saw that we did decrease readmissions and then soon after that implemented the video component of telehealth so that real-time video component of telehealth gives information when you need it when the patient needs it so if a patient doesn't feel well if they have chest pain they can call up and say I don't feel well and we can connect with that patient immediately and do an assessment and see how that patient is doing we can give education when the patient needs it it's encrypted to abide where HIPPA regulations and all we really need is a telephone line broadband connection Oh God and we see it all over we see it in offices we see it in institutions and it's fast-growing in-home care this is Mercy's virtual care center this is a hospital this is in Minnesota this is the first virtual care center to be developed in our country and this is a hospital but there are no patients there clinicians practitioners with computers doing telehealth and I'll give you some examples of what they're doing that so they go across about four or five states and they all of that hospitals are connected with them and from what I hear other hospitals are also contracting with them now too so they do some great things Easter Oak is one of them if a patient goes into a rural emergency room and there's no neurologist there they will connect with means of telehealth and that neurologist that they're connecting with will give the orders to reverse that stroke because there's a time factor when somebody has a stroke and treatment needs to be given right away east sitting this is another way they're using it so sometimes patients need one-on-one observation so what they could do with each setting is a watching the patient and if the patients say is you know if they see the patient getting out of that and the patient's not supposed to get out of bed they'll tell the patient don't get out of bed you're not supposed to get out of bed patient doesn't know where the voice is coming from but they get back into bed yeah II I see you Annie oh I see you we're beginning to see in our local health systems right here also in I believe in Nashua County I'm not sure about Queens but II ICU is when we have professionals sitting at the computers watching the patients that are on NICU they're not taking over for the doctors and nurses that are already in ICU they're supplementing for them they catch things earlier so they can identify early signs of sepsis early signs of anything that can caused a lot of trouble for that patient and have that patient deteriorate so they've been seeing great results with us we see telehealth also in mental health for supportive services for a consultative services so a patient can go to their primary care physician and they can get connected to a specialist through the use of telehealth in home care as I said it's fast-growing in-home care nurses use a therapist use it and we use it for clinical management to help the patient's self manage their illness so the advantages are that patients become more autonomous they feel in more control of their illness they're able to manage their illness better clinicians can also see more patients with the use of telehealth it improves quality of life we can also reduce or I'm sorry reach underserved areas so we can help decrease those healthcare disparities so patients do need to have some manual dexterity and some vision and hearing to be able to work the technology but if they have a caregiver that can help them they can probably still utilize the technology so this is a video patient station and this is what we have up in our nursing lab that our students have access to and this is what we see in some of our local health systems and it's very easy for the patient to use you see a camera here this camera can be taken off and a patient can show us medication bottles wounds and we can do a video interaction visit this is a stethoscope and with the supervision of the clinician patients will be instructed to place to set the scope appropriately so we can listen to lung sounds heart sounds abdominal sounds this right here this will show up on the screen this green button and it will ring like a phone and the patient just presses the green button and then there's a connection between the clinician and the patient these are some of the peripherals being used and today sort of wireless so years ago we saw with that you know they were connected with the boys but today it's all wireless this is a pulse oximeter this checks Potok sagine saturation and pulse we have a scale blue kimono blood pressure monitor and these are just some of them and these peripherals the patient's can utilize them take their vital signs and that information gets sent over to the clinician so we can see how a patient's doing on a daily basis and if a clinician is going to do a video interactive visit with that patient we encourage patients to do this before the visit so that will give information to the clinician and help guide the visit and this is just shows you this just shows you how patients are taking their blood pressure and the instructions that come up and it also narrates to the patient and if for some reason it's not streaming into the computer they can click on manual entry and put a manual entry in there here they can click on history and get a history of maybe their weights and they can look at their weights and see that they're gaining weight from day to day and what that does is it helps people to connect the dots and they see oh I'm gaining weight I ate more sodium yesterday and I see now what's happening that makes me retain fluid so it gives them a sense of control over what's going on and then here they click on daily sessions and that will bring them to the instructions for the vital signs and the series of questions that they will be asked so here we have a sample of some of the algorithms that we use and we download to the patient's computer so when they enter their computer all those questions will come up so if they have heart failure we may ask questions about how is your breathing how do you feel today if they have diabetes we may ask about signs and symptoms of hypo and hyper glycemia low or high blood glucose and this is the clinician at the computer and to listen to lung sounds or heart sounds or abdominals sounds there's a guide and the patient gets one in the clinician gets one so that they can guide them and what they'll say is put the stethoscope on number one or number two or number three and guides them with that and the sound is incredible you can hear very clear sounds and and hear lung sounds heart sounds and abdominal sounds so the components of atella health visit a quite comprehensive you can do a complete assessment and education help patients to manage their symptoms and problem-solve this is to provide a station he has the camera here the patient area can be made larger and this right here you can see part of the electronic health record and you can see where it's red and what that's showing the clinician is that the patient may be out of the norms for safety for their vital signs or how they answer the questions so if the clinician turns on the computer and has 20 patients the ones that are in red will be priority because those vital signs were out of the norm and that's preset by the clinician this shows that how good the the pictures are how clear they are and how they can be utilized so the camera is very good this is another company that is working with telehealth and they're working just with iPads so it makes it a little bit more mobile now so patients can be more mobile clinicians can go with their iPads and you can can connect almost anywhere the only thing is they don't have the stethoscope yet and I think they're working on that so that it can be a complete visit so some patients though may like the one that's on the base and some patients may like to be more mobile with an iPad so there are some legal and ethical issues we want to make sure that the technology doesn't replace quality care that is a supplement so we want to make sure that professionals focus on the patient and not the technology and used a technology as a medium to help patients manage their illnesses there are organizations that put out standards of care for telehealth so there are standards and guidelines of care for this as well I'm going to show you a quick video of how patients feel about using telehealth I don't know what we've done without it it has helped us so much with this machine and different things it helps it really improves me it helps me a lot it helps monitor their vital signs and helps monitor their health status and they answer some questions on the devices and all of that information is downloaded on a daily basis to a nurse who evaluates it and the hope is that if there's a problem it can be identified sooner so that the patient doesn't end up in the hospital or emergency room instead the nurse or their physician can intervene our theory was that if we were to to watch on a daily basis we could see negative trends occurring we can intervene with teaching with patient education turn those negative trends around thereby avoiding hospitalizations emergency room visits and keeping the person at home inside this website we set parameters or values for each measurement if the measurement is not within parameters it will come up in red we have surveys there are either information education assessment questions if we have a survey setup attached to a measurement then if that measurement is out of bounds it automatically sends that survey back and if so its bless she does because it was a hardship for us to get up and go out in the weather and everything and by taking my blood pressure here like I do it makes me more alert to eat right take my medicine and everything most of these people that had one two or three hospitalizations before we put the equipment in the home have maybe one or none you know within a year's time after having the equipment in the home and that's because they're getting intervention before they have to go to the hospital we have been able to assist persons staying in their homes successfully home is where they want to be home is where they should be allowed to be and home is where we're keeping them clients tell us that they feel now in power so it really can be a beneficial service not only for the patients and for the caregivers but for the health system as a whole seniors want to be home as long as possible telehealth allows that to happen the best thing that has ever happened to us and I really mean this from my heart you know today I wouldn't be for a Mac today if they put one for this right here helping us so in conclusion our health care system is doing a lot to improve clinical outcomes and decrease cost and when they do that we feel the benefits from that but also we need to take an active role in our own health it's never too late to start it's never too early to start and through an active partnership with a health care system individuals communities we can create a healthier nation and healthy people I would like to thank all of you for being here today and I'm open to any questions you may have hi professor I have a question regarding the telehealth is it covered by insurance companies the equipment and the visits and if so is there criteria for it that's a good question I'm sorry the which one is there covered by so telehealth it depends on where it is what site it's at and what discipline is using it so it is covered for like consultation through physicians nurse practitioners it is not covered in homecare though so home yeah homecare gets paid by an episodic payment and they decide how to best service the patient so they'll give the patient if they need it though so home cares will give it to patients if they need it if they're on homecare but it's not covered by insurance is on home Kemp yeah there aren't you know it some insurance companies also work with patients to though and I think at very low cost or maybe sometimes they even give it to patients you know because it will keep patients healthy and keep them out of a hospital so it really will depend on the particular insurance yeah care is a very important factor in rural areas because a lot of them don't have doctors for like 30 miles this would they can keep in contact with a doctor when they get sick it's gotta be very important very small rural areas and what do you what is your elaboration or not I'm sorry I didn't hear the last part of that what is your elaboration on that Oh in the rural areas it's very helpful in the rural areas because just like you said that they may have to go miles before they can get anywhere so we've seen great outcomes with that especially like with a stroke so some patients have a very small rural hospital and they don't have the resources at that hospital but they can connect by means of telehealth near a hospital their sole hope they might have to go to a doctor imaging what you got to get all of them you know yeah I don't know if you saw the commercials recently also they have televisions by doctors through iPads now as well yeah telehealth is really exploding across our country one question I have are they using telehealth more in rural settings or in the city or both or what's the intention both they're using it in all areas we see it here in Queens we see it in Long Island we see it in the rural areas so they're really using it not only for access to patients that that can't get to services but also to help patients self manage their illnesses so regardless if they're in a rural area or an urban area it's going to help patients with that clinical management that's a good question yes so they need a caregiver you need someone to help you with that otherwise it would be really hot because a patient may be able to or anybody may be able to get to the lower back but it wouldn't get to all the lobes of the lungs and we really want to know how all the lobes are doing so a caregiver is really needed for that yeah mm-hmm that's a good question I have a question but it's not related to telehealth when patients stay in the hospital for a very long period of time they end up picking up you know bacterial infections and in a setting where it appears to be completely pristine you know everybody wears gloves apron everything and yet the patient's get infected with some kind of bacteria which is totally are not related to you know what they came into the hospital in the first place hey I don't know the reason why be what can we do to eradicate this really major problem in hospitals I'm sorry what can we do to eradicate to get rid of this problem yeah well discharging patients quicker will is one thing and that's what they are trying to do is get the patients out of the hospital as soon as they can and for us you know just making sure health professionals are washing their hands in between patients and also we're washing our hands I mean that's one of the major factors is hand-washing yeah it's too wide the students who complete our nursing program pass the NCLEX that are an exam the state level at a higher rate than our senior college sisters including Hunter and it's because of the faculty such as Professor Rose have made my colleagues in the audience so I do apply and I think of the committee dr. van else a senior here and he's been long requesting that we really address this in this particular topic so thank you I think I enjoyed it I hope you did as well I invite you all to have a people bit of refreshment and then we will send you an invitation to our football series which features usually cutie bug remember proof defense eat on topics related to all the things that we do in our great University so thank you professor

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