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.
In a hospital, inpatient triage prioritizes the sickest patients, enabling health care professionals to focus their efforts on the patients who need care the most. Remote monitoring is helping home care services marshal their clinicians in much the same way, says Fred Cantor, manager of telehealth and patient coaching for Franciscan Visiting Nurse Service, a unit of Indianapolis-based Franciscan Alliance.
Where patients receiving inpatient care are separated by rooms or floors, homebound patients can be 60 to 90 minutes away from a home care office, says Cantor. Yet they are all under the watchful eyes of nurses monitoring daily readings of blood pressure, weight, blood oxygen and other data collected from instruments used by the patients.
A triage nurse works with the daily visit scheduler to deploy field staff where the need is greatest. Each staffer can only see so many patients in a day.
“There’s a finite amount of work we can get out of each person,” Cantor says. “By more efficiently utilizing their time, it makes us a thousand times better.”
Before telemonitoring, patients in the most need could not be identified until a nurse called or visited them.
“You really were blind, and you didn’t know they were the sickest patients because there are a lot of things that change between nurse visits,” Cantor explains. “You’d miss a drastic change in their health, and they’d end up back at the hospital. With telemonitoring, every time we keep somebody out of the hospital, we save a lot of money.”
Catching problems before they require hospitalization is likewise a central tenet of a remote reporting initiative being developed by the Indiana Rural Health Association called The Indiana Statewide Rural Health Network. Matching health coaches with patients recovering at home enables the network to monitor vital signs and minimize readmissions, says Cody Mullen, coordinator of the initiative.
The Indiana Statewide Rural Health Network has partnered with the Iowa Chronic Care Consortium to set up training for coaches and has engaged technology vendor Civic Health to use its tool for gathering, organizing and sharing incoming information with the health coaches, Mullen says. Patients are given three choices to communicate: texting answers to questions, calling a toll-free number and following prompts, or logging onto a web portal.
Patient feedback is drawn out by yes-or-no questions or prompts to type in values from gear that patients acquire on their own. When patients are unable to afford the proper equipment, the hospital foundation will work to get them the devices they need. Some examples of requested data include:
“The patient reports, the health coach receives it and then each of our facilities has different mechanisms for how they handle it,” Mullen notes. “Most mechanisms will have the health coach call the patient, because the health coach has a different type of relationship with the patient. A doctor-patient relationship is a great relationship, but a coach who presents as a peer or friend is more approachable and, as a result, more likely to gather meaningful information in a timely fashion.”
Within an hour of reporting, the information is in a chart and trended so that a coach can see and quickly identify a concern, says Mullen.
Results are color-coded according to relative need for action. If blood pressure is normal, and weight gain hasn’t approached a trigger level, the status will be colored green. A range of results calling for caution is colored yellow, which might merit a call to see if the patient has been taking prescribed medications and following the recommended diet. The final level is red, alerting that an adverse event could be imminent. The health coach can then decide either to contact a doctor or send the patient to the hospital.
“Ideally, we would catch it three or four days beforehand, before it gets to the emergency department, and be able to intervene in whatever way is best,” Mullen says.
Patients of Franciscan Visiting Nurse Service receive all the necessary measuring devices, which work with a base unit that records the results and sends them to a central monitoring location. The 489 units now in service, from Honeywell’s home care division, include 150 second-generation tablets that receive wireless signals from the weight scale, cuff and other precise instruments as part of the kit. The new tablets have a touchscreen and include audio and video prompts, says Cantor.
“The high-tech stuff can create a lot of anxiety when you talk about putting technology in [a patient’s] home,” he says. “But once you get it out and start showing it to them, it truly is one of the easiest things you’ll ever use, so we don’t get a lot of pushback there.”
Depending on care workload, Franciscan can have as many as 80 percent of the monitors mobilized. In August, with an average daily census of 200 patients, nurses called 65 of them in response to incoming information, or nearly one in three, Cantor reports. If the data identifies a significant change in status, a nurse can be dispatched the same day, and if an emergency is detected, the patient is sent straight to the emergency department.
On the other hand, a nurse with a high visit load might call in from the field to identify patients that are doing well and don’t require a visit until the next day. Monitoring is rarely used to push visits to another day, Cantor emphasizes, but cites that the opportunity exists if the need for increased efficiency arises. After all, Franciscan covers 30 counties in a radius of Indianapolis, from Peru and Wabash to the north, to Columbus in the south.
The Indiana Statewide Rural Health Network, which is in final stages of development, plans to be monitoring between 500 and 800 patients by year-end, at up to eight hospital-based organizations: Logansport Memorial Hospital; Margaret Mary Health, Batesville; Rush Memorial Hospital, Rushville; Henry County Hospital, New Castle; Pulaski Memorial Hospital, Winamac; Fayetteville Regional Hospital, Connersville; Gibson General Hospital, Princeton; and Decatur County Memorial Hospital, Greensburg.