Hospitals and health systems are increasingly implementing programs to monitor a patient's health at home to avoid unnecessary physician office visits, hospital admissions or trips to the emergency department. In addition to financial savings through reducing unneeded patient encounters, employing a remote monitoring program can also help a hospital avoid Medicare penalties for excessive readmissions and work to achieve population health goals outlined in the healthcare reform law and most accountable care agreements.
Below, three health systems with successful remote patient monitoring programs share their achievements and outline best practices for other providers.
Partners HealthCare
The Center for Connected Health in Boston is an incubator for technology-enabled care coordination programs for parent Partners HealthCare, testing the clinical benefits and calculating the potential return on investment of new initiatives to find the best programs to roll out across the system. "We've got about 50 people dedicated to moving care out of the physician's office or hospital and making it a continuous function in the patient's life," says Joseph Kvedar, MD, the Center's founder and director.
One of the Center's most successful programs is a heart failure telemonitoring program, Connected Cardiac Care. Launched in 2003 through a partnership with the system's home health service Partners HealthCare at Home, the program delivers monitoring equipment, including a scale and a blood pressure cuff, to patients' homes so daily vitals can be reported remotely. The patients also answer a series of questions every morning about their daily habits and overall health. At the height of the program's run with the Center, four nurses were remotely monitoring 250 patients.
If the vitals are unusual or the patient does not send any data, the patient will get a phone call from their telemonitoring nurse to find out why and determine if an intervention is necessary. The phone call "is a powerful stimulus" for the patient to comply with the daily monitoring routine, says Dr. Kvedar. "They know we're watching, they know we care, and that plays a real role in the success of the program."
Overall, the program saw a 50 percent drop in all-cause readmissions and had a significant positive effect on patient mortality, says Dr. Kvedar. The program has since been handed off to Partners at HealthCare at Home to implement on a larger scale, and Dr. Kvedar and his team are currently working on similar programs for diabetes and hypertension patients.
Despite what Dr. Kvedar sees as mixed opinions about the effectiveness of telehealth and remote patient monitoring, the programs at the Center for Connected Health have seen consistent success. "In evaluating why we've had such good success, we've found it does boil down to the patient knowing their doctor or another provider is watching their information," and by extension, watching out for them, says Dr. Kvedar.
Dr. Kvedar sees the financial temptation to outsource a program like this, but by doing so a hospital will undercut the clinician-patient relationship he sees as vital to the success of a remote monitoring program. "Patients take programs like these more seriously when they believe their doctor is involved and the program is part of their overall care plan," he says. "It makes a big difference."
In addition to keeping the remote monitoring program in-house, Dr. Kvedar also recommends keeping the nurse-to-patient ratio low. "The ratio we've found to work is about 80 to 100 patients per dedicated telemonitoring nurse for patients with acute illnesses," he says. "These nurses should also have a close working relationship with the patients' primary and referring doctors — it's no good to know [if the patient is experiencing trouble] if they can't do anything about it."
Essentia Health
The remote monitoring program for heart failure patients at Duluth, Minn.-based Essentia Health started back in 1998. Then, heart failure programs were associated with transplant programs. "They were focused on the transplant population not the overall heart failure population,” says Linda Wick, NP, RN, the program's manager. Begun with one physician, one nurse practitioner and one registered nurse, the program has since grown to include the efforts of 14 nurse practitioners and 14 registered nurses working across seven sites. Currently, the program helps manage the health of 2,300 total patients.
The impetus for the program was the low patient adherence to medication guidelines among heart failure patients when the program began. "Back in 1998, [medication adherence] was around 20 percent" for heart failure patients across the country, says Ms. Wick. "It's now 50 to 70 percent," in the general heart failure population, she says.
In contrast, Essentia's remote monitoring program has achieved a 98 percent medication adherence rate through close remote monitoring of patients' habits and follow-up contact from nurses. This increased adherence has led to an average overall readmission rate throughout the seven sites of between 5 and 10 percent. Among patients also using a special scale that sends the patients' vitals directly to nurses in Duluth, the readmission rate drops further, to 2 percent.
In addition, Essentia is an accountable care organization, and the population health and care coordination goals of the ACO align with the benefits of the remote monitoring program. But even in the fee-for-service world the program was created in, telemonitoring helped save the hospital money. "When we looked at the cost of caring for the population, even before the ACO, it cost the hospital money when people's conditions weren't managed," says Ms. Wick.
For other hospitals looking to begin a telemonitoring program, Ms. Wick emphasizes the importance of allowing strong patient-nurse relationships to develop. "Programs that use the skills nurses have are the ones that keep people out of the hospital," says Ms. Wick. "Even patients who are on the right medications have other issues that come up, like they can't really afford their medication, or they're by themselves and struggling or they're depressed, and nurses pick that up," and are able to intervene or refer the patient to appropriate treatment before the situation escalates, she says.
Ms. Wick also recommends ensuring patients know who to reach out to if they notice a problem themselves. "Often, patients are told which symptoms they should call about, but they don't know who to call," she says. Primary care physicians can be hard to reach, and calling the hospital floor that discharged the patient may not be able to quickly reach the referring physician. "Patients want to do the right thing and make the call," she says, "but sometimes we just don't give them the tools."
Centura Health
The remote patient monitoring program at Englewood, Colo.-based Centura Health at Home started almost nine years ago to help patients with chronic diseases manage their condition and help keep them out of the hospital and out of the emergency department. "We've learned so much since we've started, and it's allowed us to refine and tweak the program accordingly" to get the best results, says Erin Denholm, senior vice president of clinical transformation at Centura.
The program delivers monitoring equipment to high-risk patients' homes to allow the patients to record their vital signs and remotely upload the information to a telehealth station at a Centura hospital using a basic telephone line connection. The patients upload the information at least once per day, and a nurse tracks the reports for any red flags. If any of the readings fall outside set parameters, the nurse contacts a physician to decide on the best course of action.
Last year, the program included 3,200 patients, mostly those previously hospitalized for congestive heart failure. The readmission rate for congestive heart failure dropped to 1.7 percent with an all-cause readmission rate of 7.3 percent, says Ms. Denholm, significantly better than the national average of a 24 percent all-cause readmission rate among congestive heart failure patients.
The remote patient monitoring program at Centura "really helps with the in-the-moment management that can help prevent the downward spiraling that can quickly put frail or elderly patients in the ER," says Ms. Denholm. "With remote monitoring, we can catch [deterioration] quickly and keep these patients at an optimum level of wellness."
An additional benefit of the program has been improved socialization and reduced anxiety among the patient population. "The seniors feel like someone's looking out for them," says Ms. Denholm. Knowing a nurse will be in touch if their vitals are out of the ordinary reduces the patients' anxiety and the physiological symptoms that anxiety can manifest. Some patients have become so attached to their monitors and the feeling of security they provide as to give them names. "Nurses will hear, 'Oh, George doesn't like my blood pressure today,'" says Ms. Denholm.
To other hospitals looking to implement a similar program, Ms. Denholm recommends involving all stakeholders early on in the process to ensure their engagement. Having the hospital board, administration and physicians on board from the beginning will help to accelerate the adoption and implementation of a remote monitoring program, she says.
Ms. Denholm also recommends carefully selecting the monitoring equipment vendor to find the best equipment to achieve the program's goals. "When you go out to do product selection, be proactive, ask the questions you want answered to get the best fit for your program," she says. Telehealth or telemonitoring may have different definitions to different vendors, and clearly communicating needs and requirements will help lead to a successful launch of the remote monitoring program.
More Articles on Remote Patient Monitoring:
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Essentia Health's Remote Monitoring System Cut HF Readmissions to 2%