“Emerging Trends in Health Care”

“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 and to 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. Sasan Karimi from chemistry, himself a Presidential Lecturer. Dr. Karen Steele, Dr. Amy Traver, and Dr. Mark Van Ells. 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 gerontological 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 Queensborough, and we pride ourselves on the quality, the excellence of our nursing program,
our nursing faculty, and our students who are outstanding. At Queensborough,
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 health care in this country and the use of technology. Professor Rosa, please join us. (audience applauds) – Thank you. I’m honored and privileged
to be here with all of you this afternoon, and I would just like to thank President Call and the Presidential Lecture
Committee for this opportunity. I will be discussing Emerging
Trends in Health Care. 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 health care 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 health care 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 their basic needs 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 may find it hard to get organized or they may be a little
confused over the treatment. And very often 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. 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 health care system. And our health care system is forced to address the needs
of an aging population. So years ago the leading
indicators for death, 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 chronic illnesses. So if you look at the plate size, years ago it used to be a nine inch plate and today it’s a 12 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 we’re 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 supersize 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? (audience laughs) 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 kinda 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 health care 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
harder, 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
our 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 wanna 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. So more than 2/3 of all health care costs are for treating chronic illnesses. And in our older population,
95% 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 in charge, 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%, 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 come 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 adult 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
diagnoses 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 rehospitalized, maybe for an infectious process, the hospital still gets penalized. So this has a ripple
effect on the community. Hospitals want to align themself 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 Atul 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 were 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 they were adhering to. What was different is that the physicians were spending more time with the patients. And they were asking questions like, how are we failing,
you know, failing 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, to 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 wanna 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 Health Care Effectiveness
Data and Information Set. That’s a set of measures that
many health care plans use, a lot of disease management programs use, and what that is, it helps agencies 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 ejection 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
heart success program? And I thought, that was such a great idea. So I changed all the names
to the heart 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. ‘Cause, 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 in 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 Queensborough 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% said yes, I understand. But only 38% 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 were take two tablets
by mouth 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 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 health care 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 health 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. 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 rehospitalized, 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 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 planner getting the information
from maybe the hospital to the community physician, or the community home care agency. So there’s initiatives across our country to improve that. And any patient has the right
to appeal a discharge also, because if patients are
discharged too quick and not to the right setting, of course that would
increase 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, is 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 fill 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 patients 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, well
from hospital to community, to identify pharmacies in the community that will pick up prescriptions and then deliver the
medications to a patient, 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 their health care
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 they’re trying to work on that as well so they can connect patients quicker to their health care
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 care that can occur because they can really catch anything that can be missed because
they’re 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 Atul 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 bundled 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 health care 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 carb 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. It 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 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 have all your information on an electronic record, you go into an emergency room, all your medications pop up. You wanna 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 perceive sometimes
the computer as a barrier to the provider/patient relationship. So that’s a work in progress, to not decrease that relationship, not interfere with that
patient/provider relationship, ’cause sometimes it may feel that way. CardioMEMS, this is for patients that have heart failure. This was just FDA approved last year. This device, it’s about
the size of a paper clip, 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, 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 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 in Manhattan are using the CardioMEMS
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 internal defibrillator can become infected or they’re waiting for the internal defibrillator, so they may get a Life Vest
instead, temporarily maybe. And this, what this does is there’s 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 worn 24 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 in pumping. And sometimes patients
need this temporarily while they’re waiting for a transplant. Or sometimes patients have
a type of heart failure 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 wires 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 one minute, five 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 occurs or a 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 in taking their medications. If they miss a dose it
will light up in red and it will also beep, 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 and took a specific
dose of that medication. (man speaking faintly) 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 if you’re a clinician and
you ever spoke to a patient over the phone, you’ve done Telehealth. It’s been around for years, but it’s just that technology 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. There’s 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 Bayer/Stonybrook 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
with HIPAA regulations. And all we really need
is a telephone line, broadband connection, air card. And we see it all over. We see it in offices, we
see it in institutions, and its 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 there. So they go across about
four or five states and they, all of their 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. E-stroke 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. E-sitting, this is another
way they’re using it. So sometimes patients need
one-on-one observation, so what they could do with E-sitting is they’re watching the patient. And if the patient, if
they see the patient getting out of bed 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. (audience laughs) – [Man] That’s amazing,
(speaking faintly). – E-ICU, and E-ICU, we’re beginning to see in our local health
systems right here also. In, I believe, in Nassau County, I’m not sure about Queens, but E-ICU is when we have professionals sitting at their computers
watching the patients that are in ICU. 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 cause a lot of
trouble for that patient and have that patient deteriorate. So they’ve been seeing
great results with this. 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 it, therapists use it and we use it for clinical management to help the patient
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
health care 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 the stethoscope 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 is all wireless,
so, years ago we saw with it, they were
connected with the wires, but today it’s all wireless. This is a pulse oximeter. This checks oxygen saturation and pulse. We have a scale, glucometer,
blood pressure monitor, and these are just some of them. And these peripherals, the
patients 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 hyperglycemia,
low or high blood glucose. And this is the clinician at the computer. And to listen to lung
sounds or heart sounds or abdominal sounds, there’s a guide, and the patient gets one
and 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 hear lung sounds, heart
sounds and abdominal sounds. So the components of a Telehealth visit are quite comprehensive. You can do a complete
assessment and education, help patients to manage their symptoms and problem solve. This is the provider station. Here’s 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 with safety for their vital signs or how
they answered 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 how good the pictures are, how clear they are and
how they can be utilized. So the camera’s 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 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 wanna make sure that the technology doesn’t replace quality care, that it’s a supplement. So we wanna make sure that professionals focus on the patient
and not the technology, and use the 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’d
have done without it. It has helped us so much. – [Aimee] 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 watch on a daily basis, we could see negative trends occurring, we could intervene with teaching, with patient education, turn
those negative trends around, thereby avoiding hospitalizations, emergency room visits and
keeping the person at home. – [Woman] 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. They are either information, education, assessment questions. If we have a survey set up
attached to a measurement, then if that measurement is out of bounds it automatically sends that survey back. – And its a blessing to us, 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 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
wanna be, home is where they should be allowed to be, and home is where we’re keeping ’em. – Clients tell us that
they feel now empowered. – 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. – This is the best thing
that has ever happened to us, and I really mean this from my heart. You know, today, I wouldn’t
be where I’m at today if it wasn’t for this
right here helpin’ 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. (audience applauds) – [Woman] Questions? – [Woman] 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 a criteria for it? – That’s a good question. I’m sorry? – [Woman] Which one is it covered by? – Which one is it 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 a physicians, nurse practitioners. It is not covered in home care though. So home care 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 home care, but
it’s not covered by insurances on home care. – [Woman] That’s terrible. So they don’t have it in New York yet, or, that’s a damn shame. – Yeah, they’re not,
some insurance companies also work with patients too though, and I think at very low cost or maybe sometimes they
even give it to patients, ’cause it will keep patients healthy and keep them out of the hospital. So it really will depend on
the particular insurance, yeah. – [Woman] Sorry. – [Man] That’s all right. I think health care is
a very important factor in rural areas because a lot of ’em don’t have doctors for like 30 miles. And this way they can keep in contact with a doctor when they get sick. It’s very important in
very small rural areas. And what do you, what is
your elaboration on that? – I’m sorry, I didn’t hear
the last part of that. – [Man] what is your elaboration on that. – Oh, in the rural areas? It’s very helpful in the rural areas ’cause 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 E-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. – [Man] Some people may not even be near a hospital, they’re so far away, it’s a rural area. But they might have to go to a doctor in an, where you gotta
get hold of ’em, you know? – Yeah, I don’t know if you
saw the commercials recently. Also they have televisits by doctors through iPads now as well. – [Man] Good, good. – Yeah, Telehealth is really
exploding across our country. – [Man] Good. – [Woman] Any questions? – [Man] One question I have, are they using Telehealth
more in rural settings or in the city, or both,
or what’s the intention? – Well 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 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 their clinical management. – [Woman] I just have
a practical question, which is, is it heavy? – [Woman] It’s a stupid question. – No stupid questions. – [Woman] How do you put the stethoscope to all those places? – That’s a good question, yeah. So they need a caregiver
to, you need someone to help you with that, otherwise
it would be really hard, because the patient may 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 wanna know
how all the lobes are doing. So a caregiver is really
needed for that, yeah. That’s a good question. – [Man] 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
bacterial infections. And in a setting where it appears to be completely pristine,
everybody wears gloves, apron, everything, and yet the patients get infected with some kind of bacteria which is totally not
related to what they came into the hospital in the first place. A, I don’t know the reason why. B, what can we do to eradicate this really major problem in hospitals? – I’m sorry just say the
last part of that question. – [Man] What can we do to eradicate, to get rid of this problem? – Too, yeah, well,
discharging patients quicker 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, 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. – Thank you Professor Rosa. I think, I’m really (speaking faintly) (audience applauds) – Thank you, thank you. – You may get a glimpse as to why the students who complete
our nursing program pass the NCLEX, that RN
exam, the state level, at a higher rate than our
senior college sisters, including Hunter, and
it’s because of faculty such as Professor Rosa,
and many of my colleagues in the audience. So, I do applaud, and
I thank the Committee, Dr. Van Ells, I see you’re here, and he’s been long requesting that we really address
this particular topic. So thank you, because I think, I enjoyed it and I hope you did as well. – [Audience] Hear, hear. – I invite you all to have
a brief bit of refreshment and then we will send you an invitation to our fall series which features usually a CUNY faculty member
who can speak on topics related to all the things that we do in our great university. So thank you, Professor Rosa. And thanks for coming out.
(audience applauds)

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