Winner presentation for ONC

1. ONC Pilot Challenge: Total Population Health Management Delivery Model
for Care Coordination in Underserved Communities
Innovator: Vital Care Telehealth Services
Host: Dominican Sisters Family Health Service

2. Priority Areas
Care Coordination
• Increase healthcare access
• Improve delivery of care
• Enhance quality of care
• Community engagement
• Reduce hospital re-­‐‑admissions
• Lower healthcare costs
• Improve post-­‐‑acute care
• Coordinate quality care
Underserved Communities

3. • Identify need
• Community workers
• Community-­‐‑based
engagement
Access
Quality
Affordable Care
• Care based on risk
stratification level
o Preventative
care
o Transitional
care
o Chronic disease
management
• Remote patient
monitoring
• Care Coordination
• Wellness and
Prevention
Purpose

4. Assisted
Telehealth
Nurse
Review
Wellness
Coaching
Clinical
Feedback
Vital
Signs
Ques.ons
Social
Support
Engagement
Educa.on
Hospitals
Physicians
Nurses
Social
Workers
Case
Managers
Tablet
Applica.on
Cloud
Hos.ng
Care
Coordina.on
Monitoring
Management
Patients
Providers

5. Care Communication
and Connectivity
Level 1
Level 2
Care Coordination
and Monitoring
Community Based Model
• Monthly Monitoring
• Stable chronic
disease participants
• Weekly Monitoring
• High clinical/behavioral
risk participants
Benefits Check and Assessment
Assisted Telehealth Monitoring
Clinical Coordination of Care
Trend Analysis and Interventions

6. Community partner buy-­‐‑in formed early and will be integral partners in
weekly project management and program evaluation meetings
Strategic partnership combining health IT and clinical care delivery to bring
an interoperable total population care for care continuum
Health connectivity established for 400 participants with outcomes
documented and reported to ONC
Pilot to demonstrate an innovative total population care model to serve a
vulnerable and underserved population that can be replicated nationwide
Summary

7. Thank you
Christopher Gaur
Vital Care Telehealth Services
Chris@myvics.com | www.myvics.com
Dr. Louis L. Harris
Dominican Sisters Family Health Service
LHarris@dsfhs.org | www.dsfhs.org