ICCC at the National Level

Chronic Care Delivery Network

The ICCC has been a leader in the proposal of the Telehealth and HIT Enabled Chronic Care Delivery Network (CCDN), which was submitted to the Senate Finance Committee to be included in federal health care reform proposals. The primary objective of the proposed Network is to reduce unnecessary and avoidable hospitalization and ER visits and related costs for high-cost Medicare beneficiaries with certain chronic conditions. The Telehealth and HIT Enabled Chronic Care Delivery Network model is composed of four key modular elements:

  1. Chronic disease registry populated by Medicare claims data.
  2. Care Coordination staffing infrastructure, training, and performance management.
  3. Home telehealth technology for monitoring large populations efficiently.
  4. Care oversight by the beneficiary's treating physician.

The four component operational model allows each of the elements to be configured at a regional or potentially local level. In other words, beneficiaries will be able to receive care through local previously established provider relationships. These providers may elect to use existing care coordinator resources (home health or office staff, for example), but will be required to undergo training and performance monitoring under a centralized network management structure. Additionally, disease registry and telehealth technologies will need to meet a prescribed standard, including HIPAA and interoperability compliance, and qualify as meeting HHS requirements for "Meaningful Use". Finally, and importantly, a central management structure will be in place to coordinate all contracting, training, performance monitoring and quality improvement functions of the Network.

Inova Health System Heart Failure Program

The Iowa Chronic Care Consortium recently served as the developmental consultant to the Heart & Vascular Institute of the Inova Health System in northern Virginia for implementation of a heart failure care coordination program based on the model that ICCC used in its CHF demonstration projects in Iowa. Based on the business plan developed by ICCC, Inova made the decision to implement the program, called the Inova HeartLink Tel-Assurance Program, to all six hospitals within their system.

Inova's flagship hospital, Inova Fairfax, is nationally known for its quality in cardiovascular care. The program is supported entirely by Inova, which believes that the cost savings will more than cover the program expenses. The program is coordinated by the cardiac rehab department at each hospital. Early results of the program are producing strong trends in reduced hospitalizations.

The care coordination program is a combination of telehealth monitoring, as developed by Pharos Innovations, LLC, and supportive follow-up through the staff of the cardiac rehab programs at Inova.

Academy Medical Systems Webinar Series

Three ICCC staff members developed and are delivering, in concert with Karen Lui, BSN, a six-week seminar series in the fall of 2010 titled "Retooling, Reframing and Redefining Cardiopulmonary Rehabilitation." This series challenges existing cardiopulmonary rehabilitation programs to transform their programs and align with hospital leadership to reduce avoidable hospitalizations and ER utilization for patients with chronic conditions. It delivers information and action steps for leveraging cardiopulmonary rehabilitation services in chronic care and management. As healthcare reform continues to change the landscape of where and how care is delivered, this program provides information about how cardiopulmonary rehabilitation departments and professionals can participate in improving the health status of individuals with multiple chronic conditions post-hospitalization.