Like their colleagues in hospitals, home health nurses have an assigned list of patients to care for, to get information on, and to respond to condition changes or a revision in orders during the shift. Unlike in hospitals, home care patients are miles, maybe hours, from the nurse and one another. That complicates basic issues such as who needs attention first and most, how to stay informed and how to get help fast.

While always a challenge in the home care setting, these issues are becoming more pressing now that the handoff is so critical to keeping discharged patients in recovery instead of spiraling back into crisis and a return to the hospital. It calls for “a mechanism to allow timely information to be provided to the clinician to make the best possible judgment out in the field, and to be connected to the rest of the care team,” says Philip Chuang, chief strategy executive for Sutter Care at Home, serving 23 counties in Northern California.

A trio of information strategies is fast becoming the basis for an integrated approach to that mechanism, says Richard Brennan Jr., vice president of technology policy for the National Association for Home Care & Hospice. First is the use of electronic health records, second is technology that nurses take with them to homes and third are devices and software to monitor patient vitals in the home.

In home health, “care coordination is vital to the way the service delivery model works, and one clinician has to understand what the other one in front of him has done,” Brennan explains. For example, it’s helpful if the occupational therapist knew that a nurse earlier in the day had administered certain medications. That information can be shared through a mobile EHR link, first captured and sent from a mobile device.

It’s a far cry from the days of paper documentation and hit-or-miss phone calls, and nurses’ returning to the office to write reports and file them in a chart. Clinicians work from a care plan and if, for any reason, that plan needs to be changed — either at a physician’s request or a home care staffer’s request based on a visit — communicating those details via mobile devices enables action quicker, even in real time. On top of the set schedule, clinicians have to scramble to allow for new patients discharged well after the day has started, especially those “who clearly have a risk for rehospitalization,” says Chuang. “It’s essential that we get someone out there [see After They Leave].”

“The technology is the facilitator of speed,” he says. All the processes it facilitates were done before, but barriers of time and space hindered moving things along, sometimes delaying them until the next day. “Mobile technology has eliminated that speed barrier so that nurses can be effective in a timely fashion.”

Remotely monitoring patient conditions through in-home technology bolsters the objective of making every minute count for nurses’ time. On any given day, the home health service of Aspirus Network sees 40 to 70 patients somewhere in a 16-county area of northern Wisconsin and Michigan’s Upper Peninsula. In remote reaches, a nurse may have to drive 90 minutes to get to a patient, says JoAnn Borchardt, clinical director of Aspirus VNA Home Health. The agency can match its resources with the caseload by evaluating patient data coming in from monitors and prioritizing time and visit order.

For example, patients with congestive heart failure who are regularly flagged for gaining a pound or two daily will be seen by visiting nurses more often than someone maintaining stable weight, Borchardt says. Even after hospitalization, a CHF patient who had gained 20 or more pounds isn’t likely to have lost it all by discharge; continued monitoring is necessary to make sure the progress continues and weight doesn’t spike up again. Aspirus has posted stunning results in this area [see Staying in Touch].

Electronic, sensitive devices also are important because medical stats such as weight are tricky for patients to self-report and may not be reliable. A one- or two-pound gain is a trifle on a normal scale at home, and any margin of error throws off the accuracy and a correct pattern of reporting over time, says Borchardt. Sometimes patients will fib because they know the reading is not good and they don’t want to hear the clinician’s reaction, she adds. Inaccurate information confounds efforts to deploy nurses wisely.

After they leave

Many hospital discharges happen just before the weekend. The transition has to be managed expeditiously, but also without putting undue burden on a patient who’s been through a lot. Quick dispatch of a visit is crucial. Mobile devices figure prominently in that response, says Sutter’s Chuang.

“Studies have clearly shown that getting that initial visit within 24 hours of discharge is critical in keeping patients out of the hospital,” he says. “If we had to get a nurse into the office, work out a schedule, make a bunch of phone calls to get the information needed, the likelihood of being able to get out there late on a Friday afternoon or early Friday evening is low. You leave the patient at risk.”

The typical full-blown assessment is a two-hour session, and that’s not the object. A patient who’s tired and in pain doesn’t have the focus for it, so the idea is to get in and assess for safety, then come back the next day for the full evaluation and care plan. Patients get briefed on what meds to take, “red-flag” symptoms, what to do if they occur, and whom to call for help.

Mobile devices also transmit key information such as med lists to help the nurse understand what’s happening with the patient and provide education on taking drugs safely. “Asking a patient who has just been discharged from the hospital — who is probably exhausted, overwhelmed with the deluge of information that happens at discharge — to recount his list of medications is awfully difficult,” Chuang says.

Staying in touch

The 33-year-old man spent about a month in a Milwaukee hospital and then several days at Aspirus Wausau (Wis.) Hospital, running up a bill of more than $200,000 by the time he was enrolled in the Aspirus home health service a year ago. A virus had attacked his heart, giving him heart failure. He couldn’t do his job and lost it, along with his health insurance.

Fast-forward a year, during which time Aspirus found health coverage for him and put him on remote monitoring. “Through this monitoring and the ability to watch his weight and his blood pressure every single day, we have been able to medically manage this kid and not send him to a hospital,” says clinical director Borchardt. Actually, he spent one night in the hospital, but that was for kidney problems related to the need for heavy doses of diuretics — which are adjusted twice a week based on the readings coming back to clinicians.

The remote monitoring program, in operation nearly a decade, has piled up other evidence of preventive value. An early pilot offered discharged CHF patients a telemonitoring device: 58 percent accepted and the other 42 percent became a control group. Those feeding data back to Aspirus in addition to being followed by nurses had a readmission rate of 6.7 percent; for patients contacted by visiting nurses alone, it was 36.4 percent.