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About the series

As health care moves rapidly toward a value-based delivery model, a greater emphasis will be placed on care coordination. We must ensure that patients not only get the right care at the right time in the right setting, but also that every part of the delivery system is connected and understands that a patient's need will be critical going forward. Information technology will be instrumental in making sure that these connections take place and in providing clinicians with valuable new decision support tools.

H&HN, with the support of AT&T, has created this yearlong series called Connecting the Continuum to explore how hospitals and health systems are addressing the care continuum in their strategic and operational plans. Each month, we will examine such topics as health information exchange, mobile health and transitions of care. Follow the Connecting the Continuum series in our magazine and in our e-newletter H&HN Daily.

Monitoring the health of not-so-healthy people gets tricky once they leave the hospital or physician clinic and head home. The previous extent of home-based management included visits from nurses, phone calls and other labor-intensive activities. But those moves alone won't scale to the level of accountability now required to catch medical decline before it leads to emergency department trips, hospital admissions and readmissions. That's why Geisinger Health Plan and its staff of case managers use telemonitoring to supplement nurse efforts to reach patients discharged from Geisinger Health System hospitals in central Pennsylvania. It's a tool to better prioritize patient caseloads per manager that are "upward of 125 to 150 patients," says Doreen Salek, the health plan's director of population management operations.

It's also why Christus Health is discharging some patients with a software-stocked tablet that connects wirelessly with a weight scale, pulse oximeter and blood-pressure cuff. A home-health application takes patients through much the same set of questions and vital-sign recordings that a nurse would do in person, says Hank Fanberg, director of technology advocacy at the Irving, Texas-based health system.

Remote monitoring of patients using computerized devices extends the continuum of care to cover recently discharged patients at risk for readmission as well as people with such chronic conditions as heart failure who could go downhill in a hurry without a way to detect the first slip. These technological assists can be set up internally or contracted out to a monitoring firm. But the most crucial aspect isn't the gizmo but rather the clinical process around it, says David Lee Scher, M.D., a consultant on digital health technologies.

"You can't just give the hospital a remote monitoring system and expect them to run with it and be successful," Scher says. A good company will interact with the health system in advance, "getting physicians involved in creating and customizing algorithms that will determine what filtered information gets to providers and what gets done about it."

Geisinger developed two programs in conjunction with monitoring firm AMC Health using interactive voice response via phone: one program for post-discharge follow-up, another for heart-failure patients that adds a Bluetooth-enabled weight scale to the IVR-based monitoring. Case managers had been fanning out into patient homes since 2006 and understood the drivers of readmissions and ED trips, says Salek. Their input resulted in the dozen or so questions and the branching logic that proceeded from them. For the heart-failure program, a certain weight gain triggers an IVR call with a different set of scaled-down questions regarding signs and symptoms of complications.

Though patients don't see a human face, they get the message from Geisinger that "this tool that we're introducing into your everyday life is a direct communication line to your care team," Salek says. "So your case manager is going to get the information that's being collected through this call, or when you step on the scale." She says that's very comforting to the patient and can lead to phone calls to further discuss reasons for a particular prompted answer.

The remote-monitoring kit and clinical interaction that Christus Health has piloted since late 2012, geared to people in their 80s and living alone, also has put a lot of patients more at ease along with the purely medical benefits, says Fanberg. "Part of the positive reaction has been that they feel connected to the care team. It's not just, 'You're being discharged, you're going to go home, here's a bunch of printed material — if you have questions, call.' " Instead, the kit is introduced and sent home with explanations that messages will be sent to and from the tablet (see case study).

On the provider end, the logical display and routing of patient feedback has to be thought out efficiently. At Geisinger, any alert is fed into the information system in which case managers already are working, Salek says. "They are the conduit to work with the clinicians and doctors to say, 'Hey, this occurred, the patient is experiencing this, these are the suggestions,' and then the doctor signs off and orders whatever, or they bring the patient in for an appointment."

The importance of meshing monitoring with other information displays was underscored in June by the Center for Connected Health, a division of Boston-based Partners HealthCare, which detailed a means by which data collected at home were now being transmitted electronically and viewable through the Partners medical records system, making this data accessible within established clinical workflow.


Case study

Geisinger case managers get on the phone with patients within 24 to 48 hours of when they leave the hospital, and that's enough to assess whether the patient is a good candidate for telemonitoring as the next follow-up. It's a way to more efficiently determine if issues are surfacing that "normally cause a readmission or a bounce-back to the ED," Salek says.

The health system's ProvenHealth Navigator program, which uses case managers in medical-home outreach, already was reducing inpatient stays. A study published in 2010 showed a 36 percent reduction in readmissions and an 18 percent decline in admissions among the population followed home by case managers. But could they do better by being even more vigilant? A total of 875 Medicare patients enrolled in the combined case-management and remote monitoring program were compared with 2,420 patients being case-managed alone.

"On top of what we already accomplished with having a case manager, this tool for post-discharge IVR provided us another 20 percent reduction in readmissions in that population they case-managed," Salek says.

The results are significant, but so is the simplicity of the method, says consultant Scher. "Geisinger has proven that you don't need terribly sophisticated technology to have good outcomes."


Case study

Vital-sign readings are the foundation, but by no means all there is, to a tablet-based monitoring system in the homes of Christus Health patients.

An application on the tablet goes through a routine using voice prompts as patients use the wireless-enabled devices in the kit, asking them for a yes/no verification of the readings. The importance of wireless scales — along with cuffs and other means of taking readings — "is that when the patient steps on the scale, they don't have to write anything down," says Fanberg. "The result is automatically uploaded into the tablet."

Then the application asks such questions as: How is the patient feeling? Were the meds taken? Does he or she have any problems or want a video call with a member of the care team? If so, the tablet sends a message to the Christus monitoring unit, and "someone there will initiate a call to the patient over that same pathway, so the ability to do videoconferencing takes place within that one device," Fanberg says. It's a secure, two-way video phone call with a provider.