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Home monitoring cuts cardiac readmissions
Program gets patients to follow treatment plan
When Ocean Medical Center in Brick, NJ, and Meridian At Home care agency collaborated on a remote monitoring program for heart failure patients, the readmission rate for heart failure dropped from 14.93% before the program began to 4.84% in the first eight months of the pilot program.
The project received the first-ever Excellence in Quality Improvements Award from the New Jersey Hospital Association.
The program provides appropriate heart failure patients with remote monitoring devices on a temporary basis in an effort to get them in the habit of weighing themselves daily and calling the doctor when their symptoms indicate that they are experiencing exacerbations, says Sandra Elliott, director of consumer technology and service development at Meridian Health. A remote monitoring nurse case manager continues the education the patients received in the hospital and helps them understand what is causing their weight gain and how excess weight can impact their ability to breathe, she says. "Rapid weight gain in heart failure patients can signify water retention, which is a tell-tale sign that something is wrong with the operation of the heart," Elliott says. "This program offers great benefits to the patient. They can remain under the watchful eye of the hospital in the comfort of their own home, and the patient's health can be monitored and tracked in an extremely accurate and safe manner."
When administrators of the health system began analyzing the impact that healthcare reform would have on its hospitals, they determined that hospital readmissions are one area in which the health system is at risk for losing reimbursement. Ocean Medical Center was chosen for the pilot project because the hospital serves a large population of older retirees with chronic diseases and was experiencing a high rate of readmissions for heart failure, Elliott adds. When the heart failure readmissions prevention team reviewed the medical literature, it determined that many patients with heart failure who were readmitted were not comfortable in assessing their own symptoms, which led them to delay seeing their doctor until the symptoms were so severe that they ended up in the emergency department or were readmitted to the hospital. The team looked at available technology and explored ways to make it work financially.
"We wanted something that was easy to implement and low cost and that easily could be adapted at other hospitals in the system," she says. "I got involved because my role is to focus on everything outside the traditional health system walls to help people through technology to take care of themselves as best as possible."
Case managers at Ocean Medical Center assess their heart failure patients for eligibility in the program and work with the pilot project coordinator to educate the patients and their families about the program and enroll them. Patients who are eligible for the program must be cognitively capable of using the equipment, be able to manage at home without help, and have eyesight that enables them to read a scale. Patients who are in active treatment for other major diseases, such as cancer, are not appropriate for the program, Elliott says.
The nurse case manager in the hospital educates the patients about heart failure, the importance of monitoring their weight, ways to keep the condition under control, and signs and symptoms that indicate they should call their doctor. The nurse case manager at the home health agency continues the education after patients are enrolled in the program.
A home care agency nurse installs a comprehensive remote monitoring device in the homes of patients receiving home care. The device measures vital signs including weight and blood pressure and asks the patient questions about their health every day. Patients without home care services receive a wireless scale and a cell phone communicator, a special type of cell phone that is pre-programmed to transmit data to the home care agency computer system. They are signed up to an automatic calling system that places a call every day and asks patients key questions, such as their weight, any swelling, breathing problems, or other issues.
When patients submit answers that indicate they might be having an exacerbation, the telemonitoring nurse receives an alert. That nurse calls the patient and talks with them to find out what has been going on. "Many times, the patient just needs some additional education," Elliott says. "The nurse repeats the education the hospital case manager presented but often education at the right moment is more effective." For example, the nurse was able to identify that one patient's weight gain occurred when he ate rotisserie chicken from a particular market and wasn't aware of the high sodium content. "No booklet tells patients that rotisserie chicken has so much sodium it will adversely impact their condition," Elliott says. "The nurse takes advantage of the teachable moments."
When the remote monitoring nurse calls patients, she assesses the situation and often suggests that the patients call their physicians. The nurse might call the doctors' offices to alert the staff to expect the calls, but has the patients make the calls themselves so they'll become accustomed to taking charge of their own healthcare, Elliott says.
Patients who do not receive home care services stay in the remote monitoring program for a minimum of 30 days and have the option of continuing the monitoring for an additional 60 days at no charge. Patients who are receiving home care services are switched to the wireless scale and cell phone communicator monitor when their home care visits are completed.
The organization is analyzing whether making daily automated phone calls without providing the wireless scale and cell phone communication is as effective as the combination of the phone calls and the technology. The calls cost less than 10 cents a day, compared to $600 for the wireless scale and cell phone communicator, Elliott points out. "The purpose of this program is to get patients accustomed to monitoring their weight and symptoms so they know when to see the doctor and avoid emergency department visits and hospitalizations," she says. "It takes about three weeks of monitoring to change behavior. When we identify the most cost efficient ways to help patients avoid rehospitalization, we plan to roll the program out to other hospitals."