Visiting nurses and health coaches are attempting to decrease readmissions by checking the status of patients in their homes. In the process, these health care professionals are using a variety of monitoring technologies to keep recovering patients and the chronically ill stable and out of danger.
Franciscan Visiting Nurse Service, a home health unit of Indianapolis-based Franciscan Alliance, provides computer tablets to a third of its daily caseload of 1,000 homebound patients. The tablets— connected to gear that patients stand on, strap on and manipulate to check vital signs—relay the data to critical-care nurses who monitor the action. Since the program started, readmissions have declined to well below national averages, says Fred Cantor, manager of telehealth and patient coaching.
The Indiana Rural Health Association has utilized technology in a different way, creating the Indiana Statewide Rural Health Network, which gathers status reports from patients through electronic prompts and then feeds the information to their health coaches. A green/yellow/ red method of grading the current condition of patients stratifies the relative need for attention and concentrates scarce staff where it makes the biggest impact—namely on preventing trips to the ED, says Cody Mullen, network development coordinator for the remote monitoring program.
The program plans to have eight hospitals using health coaches and the patient self-reporting tool by the fall. At less than $10 per patient, per month, the reporting application can be extended to about 1,800 patients across the state under a $900,000 grant from the Health Resources and Services Administration, says Mullen.
The health care industry is inundated with commercial mobile health management applications professing to improve health and decrease cost, but many of them “haven’t been adopted on a wide scale and have not demonstrated, for the most part, to improve outcomes,” says David Lee Scher, M.D., a digital health technology consultant. “One large barrier is that most technologies are unproven, leading providers to be wary of adopting them.” But he notes, “Remote monitoring is an exception, because there are studies to show that it prevents readmissions and improves outcomes—and it doesn’t have to be fancy technology, either. Simple wireless weight scales and vital sign monitors with text messaging have proven useful.”
In one recent study, a rural facility in Flagstaff, Ariz., used a wireless remote monitoring program to facilitate patient and team co-management of heart failure patients, among the most expensive to care for if their conditions deteriorate. Average numbers of hospitalizations among participants declined from 3.3 in the six months prior to the monitoring to 1.9 in the six months after, and the average number of days hospitalized fell from 14.2 to 5.2, a 64 percent decrease, according to the study published in the March 2015 issue of Telemedicine and e-Health. Average total charges plummeted 72 percent, from $129,480 to $36,914.
An earlier study of heart failure monitoring concluded that remote patient monitoring “significantly reduced the risk of death, hospitalization for any cause, and hospitalization for HF” compared with in-person follow-up visits. The meta-analysis in a 2009 issue of the Journal of the American College of Cardiology reviewed 32 studies between 2000 and 2008.
Franciscan VNS has paired health coaching and remote monitoring to benefit the alliance’s two accountable care organizations, which pay a fee to supply the services at no cost to their patients, says Cantor. “It reduces the patient’s usage of the health care system and ultimately saves money in the long run,” he says. “For every patient they put into health coaching, we recognize reduced readmission rates, higher instances of following their primary medical doctor’s instructions, and an increased tendency to make all of their appointments.”
In 2014 the home care service’s HF readmission rate was 4.4 percent, compared with the national average of 23 percent computed by the Centers for Medicare and Medicaid Services. The rate for chronic obstructive pulmonary disease was 5.5 percent, against 17.6 nationally, and the readmission for cardiac patients was 3 percent, compared with the national average of 18.3 percent.
The Indiana Statewide Rural Health Network has completed training of health coaches, in partnership with the Iowa Chronic Care Consortium, at Logansport (Ind.) Memorial Hospital and Margaret Mary Health in Batesville, and training is under way at six additional hospitals, says Mullen. Instead of employing sophisticated vital-sign equipment, the system asks questions that patients regularly answer by either a texting exchange, logging onto a website, or speaking answers into a toll-free phone call. Those reports are routed to the health coaches for review and possible follow-up by phone or in person.
Logansport and Margaret Mary are two of nine original members of the National Rural ACO, established to gain a sufficient number of attributed lives to spread financial risk. The umbrella group participates in six ACOs around the country and had expanded to 31 members as of June. Indiana has nine participants in all.
The ability to prevent complications or intervene early has expanded the scope of home care beyond its usual focus on attending to homebound patients. Medicare covers that care, but not services to people who can get around, including those recently discharged from a hospital who could benefit, says Cantor. Health coaching is meant for people not eligible for Medicare coverage, and centers on engaging them in their recovery or understanding their chronic disease and how to keep it under control. Those are the top priorities of ACOs seeking to stratify their covered lives according to risk and concentrate on the riskiest.
“Remote monitoring is a great aspect, because people who check their daily vitals start to recognize the ties between behaviors, such as what they ate yesterday, and the readings they’re seeing today,” Cantor explains. They also get calls from a telehealth nurse when the measures are out of range. Several months into the program, patients have learned the behaviors that directly affect their vital signs each day and are motivated to change their ways.
The monitoring service also helps visiting nurses make the best use of their time-they don’t have to visit each home as often, because patients are being tracked from a central office. “Strategically, logistically we’re saving a lot of time and money and effort by being able to monitor them every day without actually going out there,” Cantor says.
It’s a way to provide “the tools to empower the patient to succeed but also not overburden the health coaches,” Mullen says. “They can’t call a patient every day and say, ‘How are you doing?’”
Next in the series: How remote monitoring works, and its role in cost-efficient care