Community Telemanagement Program (CTP)

Community Telemanagement Program (CTP) formerly called the Community Clinical Case Management (CCCM) is a community based model of care which offers holistic management of medically complex, chronically ill, high risk persons. These individuals often utilize multiple health system resources and require advanced health assessments and psychosocial support.

In this program, the advanced practice nurse maintains a relationship with the person after discharge from the hospital. The nurse makes both home and tele-monitoring visits with a focus on health assessment, disease prevention, ongoing monitoring and early interventions. CTP helps to prevent the escalation of a person's health status into a more serious condition, which can lead, to readmissions, high resource utilization and high cost.

Community Telemanagement Program:

• Is a program designed by Piedmont Hospital to coordinate meeting the needs of persons with chronic illnesses including multiple health problems, socioeconomic, spiritual and/or environmental concerns.
• Identifies the needs of individuals and coordinates their care, spanning all care sites and providers.
• Views health as the result of life-long choices and experiences that impact mind, body and spirit, taking into account the forces that shape a person's view of health - such as hopes, dreams, fears, customs and culture.
• Considers persons in our care to be accountable for how they view their health and the decisions they make to change it.

Services

Some of the services provided by the advanced practice nurses in the Community Telemanagement Program include:

• Ongoing clinical assessment and evaluation of a persons needs and response to care.
• Ongoing education of the person, family and significant others.
• Early intervention and continuous management of the person's health status.
• Collaboration with the physicians to provide coordinated care to the person and his or her family.
• Coordination of care with other healthcare services.
• Communication of the person's needs to appropriate healthcare providers.
• Contacting and linking persons to available community resources.
• Maximizing the self-care capabilities of persons and families receiving care.

Video Tele-monitoring

Without leaving the hospital, CTP staff can make personal visits to patients in their homes using state of the art voice and video combined with unique medical equipment. The result is a complete real time picture of the patients condition, concerns and lived experience. Patients are seen and heard. They can be evaluated visually and verbally, then in more detail with measurements that include heart, lung, and bowel sounds, blood pressure, pulse, weight and oxygen saturation.

As a supplement to in person home care visits, the tele-monitor system improves early detection and intervention for chronically ill, home bound, high risk patients. Emergency room and hospital visits can be reduced through the use of the tele-monitoring system.

Non-Video Tele-monitoring

Home Telemanagement is a method of providing care, monitoring and education to a patient at home using telecommunication technologies. An important new tool in the delivery of health care, home telemanagement improves patient quality of care and clinical outcomes, provider productivity and the financial efficiency of healthcare organizations

WebVMC's system involves the use of electronic communications to enable health care providers to capture and review vital sign measurements and/or assessment questions from remote locations without requiring an on-site visit. The information is captured through devices, placed in the home, which transmit information through an existing phone line back to a secure facility for review.