The Guthrie Clinic

RURAL HEALTH CARE SERVICES OUTREACH GRANT PROGRAM - PROJECT ABSTRACT FOR CONNECTEDCARE FOR SENIORS PROJECT PROPOSED PROJECT: AS THE FIRST HOSPITAL ESTABLISHED IN THE TWIN TIERS REGION OF NORTHERN PENNSYLVANIA AND UPSTATE NEW YORK, GUTHRIE ROBERT PACKER HOSPITAL (RPH) UNDERSTANDS THE DISTINCT CHALLENGES RURAL COMMUNITIES FACE IN ACCESSING HEALTH CARE AND STANDS IN THE GAP, WORKING TIRELESSLY TO ENSURE THAT HIGH-QUALITY CARE IS AVAILABLE CLOSE TO HOME. THE CONNECTEDCARE FOR SENIORS PROJECT AIMS TO IMPROVE CHRONIC DISEASE MANAGEMENT IN ELDERLY POPULATIONS BY ADDRESSING BOTH CLINICAL AND SOCIAL DETERMINANTS OF HEALTH. UTILIZING INNOVATIVE REMOTE PATIENT MONITORING (RPM) TECHNOLOGY AND COMPANION SOLUTIONS, THE PROGRAM WILL FOCUS ON REDUCING EMERGENCY DEPARTMENT (ED) UTILIZATION, HOSPITAL READMISSIONS, AND LENGTH OF STAY WHILE IMPROVING PATIENT SATISFACTION AND QUALITY OF LIFE WITHIN THEIR RURAL COMMUNITY. THIS PROJECT WILL BE A SPECIAL TRACK PROJECT WITH A FOCUS ON HEART DISEASE (CHF) AND CHRONIC LOWER RESPIRATORY DISEASE (COPD). THE PRIMARY POPULATION SERVED BY THIS PROGRAM INCLUDES ISOLATED ELDERLY INDIVIDUALS (AGES 65 AND OLDER) RESIDING IN THE RURAL REGIONS SURROUNDING GUTHRIE RPH, PARTICULARLY IN BRADFORD COUNTY, SULLIVAN COUNTY, AND TIOGA COUNTY, PENNSYLVANIA. THE PARTNERS FOR THIS PROJECT WILL BE GUTHRIE ROBERT PACKER HOSPITAL: ENTITY: RURAL HEALTHCARE FACILITY; GREATER VALLEY EMS: RURAL EMERGENCY SERVICES; AND THE B/S/S/T AREA AGENCY ON AGING. EVIDENCE BASED MODELS: THE CONNECTEDCARE FOR SENIORS PROJECT WILL UTILIZE 3 KEY EVIDENCE-BASED MODELS. THOSE INCLUDE REMOTE PATIENT MONITORING (RPM) WHICH WILL MONITOR PATIENTS IN THE SETTING OF THEIR OWN HOME, LONELINESS INTERVENTION THROUGH ELLIQ (A VOICE ACTIVATED DEVICE) FOR ELDERLY PATIENTS WITH COMORBID DISEASES, AND MOBILE INTEGRATED HEALTH (MIH), ALSO KNOWN AS PARAMEDICINE. GOALS AND OBJECTIVES: THE GOALS AND OBJECTIVES OF THIS PROJECT ARE TO INCREASE ACCESS AND ENGAGEMENT, WHILE IMPROVING HEALTH OUTCOMES FOR ELDERLY PATIENTS EXPERIENCING CHF AND COPD IN THIS RURAL COMMUNITY. THIS WILL BE DONE THROUGH CONNECTING WITH PATIENTS IN THEIR HOME THROUGH REMOTE PATIENT MONITORING (RPM), CREATING A VIRTUAL RELATIONSHIP BETWEEN THE ELDERLY PATIENT AND ELLIQ (A VOICE ACTIVATED DEVICE), CONNECTING PATIENTS WITH COMMUNITY PARTNERS THAT WILL COME PROVIDE CARE TO PATIENTS IN THEIR HOME (GREATER VALLEY EMS) AND CONNECTING ELDERLY PATIENTS WITH COMMUNITY PARTNERS SUCH AS B/S/S/T AREA AGENCY ON AGING TO ADDRESS THEIR SOCIAL DETERMINANTS OF HEALTH THAT ARE IMPACTING THE PATIENTS ABILITY TO RECEIVE CARE SUCH AS TRANSPORTATION. KEY OBJECTIVES OF THE PROJECT WILL BE REDUCING EMERGENCY DEPARTMENT UTILIZATION, REDUCING READMISSION RATES, DECREASING LENGTH OF STAY (LOS), IMPROVING THE PATIENT'S QUALITY OF LIFE, AND ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH THAT ARE IMPACTING THIS RURAL COMMUNITY'S ABILITY TO RECEIVE PRIMARY CARE AND PREVENTATIVE CARE SERVICES. THE EXPECTED OUTCOMES OF THIS PROJECT ARE: REDUCTION IN ED VISITS FOR PARTICIPATING PATIENTS BY 20% WITHIN THE FIRST YEAR. 30% DECREASE IN 30-DAY READMISSION RATES. 10% REDUCTION IN HOSPITAL LENGTH OF STAY. PATIENT-REPORTED QUALITY OF LIFE AND SATISFACTION IMPROVEMENTS, MEASURED THROUGH SURVEYS. EXPERIENCE IN SERVING RURAL UNDERSERVED POPULATIONS GUTHRIE ROBERT PACKER HOSPITAL HAS EXPERIENCE SERVING THE RURAL ELDERLY POPULATION. OUR ORGANIZATIONAL EXPERTISE INCLUDES DEVELOPING AND IMPLEMENTING TELEHEALTH SERVICES, REMOTE PATIENT MONITORING, MOBILE HEALTH CLINICS AND OUTREACH PROGRAMS TAILORED TO MEET THE UNIQUE NEEDS OF RURAL COMMUNITIES. THESE EFFORTS AND INVESTMENTS IN TECHNOLOGY ENHANCE ACCESS TO CARE, ADDRESS TRANSPORTATION DIFFICULTIES AND IMPROVE QUALITY OF CARE OVERALL. FUNDING PREFERENCES: YES, GUTHRIE ROBERT PACKER HOSPITAL AND THIS PROJECT QUALIFY FOR A FUNDING PREFERENCE UNDER QUALIFICATION 3: FOCUS ON PRIMARY CARE, AND WELLNESS AND PREVENTION STRATEGIES.