Technology helps case managers and nurses work more efficiently
Remote monitoring keeps at-risk patients safe
Healthcare organizations in a variety of settings are leveraging today's technology to increase the efficiency of case managers and nurses and for early intervention of patients who are experiencing exacerbation of their disease or other problems that might lead to an emergency department visit or hospitalization.
In a program developed by Geisinger Health Plan and Geisinger Clinic, with headquarters in Danville, PA, patients who received a combination of traditional case management and remote monitoring with interactive voice response technology, were 44% less likely to have 30-day readmissions than patients who received only case management interventions.
Heart failure patients who live in remote areas of Montana, make daily calls to a telemonitoring system at Billings (MT) Clinic heart failure program, and answer questions that alert the clinic's nurses when an intervention is indicated.
Bayada Home Health Care, a national home health agency with headquarters in Moorestown, NJ, and 51 offices across the country uses a combination of telemonitoring devices and telephone calls to supplement the work of its home health nurses in its disease management programs.
"Technology can help case managers work smarter and understand which patients need assistance by stratifying their workload and concentrating on patients who need their assistance the most," says Maria Lopes, MD, MS, chief medical officer for AMC Health, a telemonitoring technology company with headquarters in New York City.
When telehealth tools are a part of the daily work flow, case managers can track the clinical progress of their patients. "This proactive approach targets the most appropriate patients and yields clinically meaningful and actionable information which can then be used to more effectively triage their caseload. Telemonitoring is a beneficial enhancement to proven case management best practices and creates efficiency and improves effectiveness in the case management process," Lopes says.
Jo Rowland, BSN, MA, CHFN, program coordinator for the Billing Clinic heart failure clinic says that technology helps the nurses in the program monitor the conditions of high-risk patients, many of whom live in remote wilderness areas. Billings Clinic is an integrated healthcare system that includes a 272-bed hospital with a Level II trauma center, a 90-bed assisted living and rehabilitation center, and the region's largest multi-specialty group practice with more than 310 providers. The healthcare system serves patients in Montana, Wyoming, and the Western Dakotas. A large portion of the area served by the health system is wilderness with fewer than six people per square mile and counties that share a single physician. Many patients live long distances from the nearest primary care provider and winter storms and floods often make the roads impassable.
"Even though we try to coordinate care and keep tabs on our patients in outlying areas, there often are glitches because it's not always easy for patients to see their local physician or come into the clinic. With the telemonitoring system, patients get daily calls and we can tell from the patient's response to the questions when there is a problem, then call to get more information and decide what intervention is needed," Rowland says. (For details on Billings Clinic telemonitoring program, see related article, below.)
Eric Thul, MBA, division director with home health practice of Bayada Home Health Care says his organization's use of technology is still in the infancy stage and the company is looking for a balance between lower cost and high-touch solutions to help patients learn to self-manage their conditions and to optimize the time of the nurses and case managers.
"We continue to take a balanced and measured approach toward telehealth in an effort to understand which interventions and which types of services add value by increasing patient engagement and preventing hospitals admissions, he says. (For more on Bayada Home Health's use to technology, see related article below).
Doreen Salek, BS, RN, director of population management partners for Geisinger Health Plan reports that in a survey, more than 96% of Geisinger case managers said that the interactive voice response technology helps them work more efficiently, and more than 85% said the program helps keep their patients out of the emergency department.
Geisinger Health Plan case managers set up the interactive voice response program for appropriate patients who have been discharged from the hospital. The system makes outbound calls to the patients once a week for approximately four weeks, asks a series of questions about the patient's condition, and alerts the case managers if the patients' answers indicate they may be experiencing problems. (For details on the program see related article, below.)
"Technology is an efficient new way of extending the reach of case managers. Patients don't necessarily know when they are experiencing an exacerbation or problem," Salek says. The interactive voice response system allows them to identify early indicators of infection, exacerbation of chronic diseases, or anything else that looks like it might be problematic and intervene to keep the patient out of the hospital or the emergency department, according to Salek.
Technology supplements old case management Voice-response system monitors patients Case managers at Danville, PA-based Geisinger Health Plan who are embedded in primary care practices, and those who provide case management telephonically in the community, use a combination of traditional case management and interactive voice response technology to monitor the conditions of patients discharged from the hospital. A project conducted over a two-year period demonstrated that patients who received the combination of services were 44% less likely to be readmitted within 30 days than patients who received only case management. The interactive voice technology system is now used for appropriate patients in all Geisinger primary care practice sites, and at seven other practices that provide care for Geisinger Health Plan patients, and some Medicare fee-for-service patients managed by Geisinger Health Plan. "The interactive voice response system is a tool in the case manager's toolkit. It doesn't replace case management telephone calls and interventions. If the case manager determines that the patient needs a phone call every day from the case manager, that option is open," says Doreen Salek, BS, RN, director of population management partners for Geisinger Health Plan. The health plan's case managers are located in the clinic and work face-to-face and over the telephone with the patients and their family members. They typically are responsible for coordinating the care of 150 or more high-risk patients, most of whom have a combination of chronic illnesses. They also coordinate transitions from hospital to home. The case managers call patients who qualify for case management within 24 to 48 hours after they are discharged from the hospital, complete a comprehensive assessment of the patient's condition, conduct medication reconciliation, and determines the patients' needs and line up any support such as home health or assistance from community agencies. When patients are appropriate for the interactive voice response program, the case manager sets up the system to call the patients once a week for approximately four weeks, at a convenient time and day. Not every patient who has been hospitalized participates in the interactive voice response system. The case manager may determine that the patient needs personal phone calls at more frequent intervals. Patients who have hearing problems or who are not cognitively or physically able to participate are not included in the program. During the interactive voice response telephone calls, which typically last about three minutes, patients are asked a series of questions about their adherence to the discharge plan and symptoms that may indicate an exacerbation of problems. If a patient doesn't answer the call, it is tried again later. The system uses branching logic to ask additional questions based on the patient's response. Questions depend on the reason for the hospitalization and may include: Have you scheduled a follow-up appointment? Did you get your prescription for medication filled? Do you have a fever? Are you short of breath? Are you having pain? The interactive voice response system interfaces with Geisinger Health System's electronic medical record systems and issues an alert to the case management documentation system whenever the patient's answers indicate a problem. This notifies the case manager to call the patient to find out more information and determine if the patient needs to come in to the clinic. "The key to the success of the program is that it allows case managers to understand what is happening in the home after discharge and intervene when there are problems or gaps in care," Salek says. Jove Graham, PhD, comparative effectiveness researcher with the Geisinger Center for Health Research, adds that the interactive voice response calls are not a substitute for case management. "They enhance what the case managers are doing and make them aware of any problems in a timely manner. Case managers become aware of whether the patient has filled prescriptions, has a follow-up appointment with their primary care physician, and if he or she is experiencing signs and symptoms that may indicate a problem," he says. Patients in the program responded well, possibly because it's not over intrusive for patients to accept four phone calls over a four week period. Graham adds, "There was a very high compliance rate. Only 4% of patients failed to take all four weeks of calls," he says. |
Telemonitoring cuts readmits for HF patients Nurses coordinate care with community docs Just 15% of heart failure patients at risk for readmission who participated in a telemonitoring program at Billings (MT) Clinic's heart failure clinic, were readmitted to the hospital within 30 days, according to an analysis conducted by the clinic staff. Billings Clinic is an integrated healthcare system that includes a 272-bed hospital with a Level II trauma center, a 90-bed assisted living and rehabilitation center, and the region's largest multi-specialty group practice with more than 310 providers. The healthcare system serves patients in Montana, Wyoming, and the Western Dakotas. In the program, patients whose condition was stabilized and whom nurses contacted by telephone periodically had a 10% readmission rate within 30 days. The statistics compare to a 42% readmission rate for patients who were not in the clinic's heart failure program. The readmissions were for all causes, not just heart failure, says Diana Parker, BSN, MBA, director of cardiovascular services for the Billings Clinic. The clinic is managed by the health system's cardiology department and is staffed by registered nurses with expertise in heart failure. The nurses use telemonitoring for patients with the highest risk of readmissions. Stable patients are followed routinely in the cardiology clinic and by telephone by the heart failure nurses who call them periodically to check on their condition. Jo Rowland, BSN, MA, CHFN, program coordinator for the Billing Clinic heart failure clinic, attributes the success of the program to using specially trained heart failure nurses, patient and caregiver training about heart failure, signs that indicate an exacerbation, and the need for following the treatment plan, and ready access to clinicians trained in treating heart failure. The clinic sees patients who are referred to the heart failure program by cardiology within a week. The heart failure clinic conducts a sleep disorder breathing screening on all patients and has standing orders for an outpatient pulmonary consultation if indicated. Patients are screened for depression and undergo a six-minute walking test to assess their functional capacity. Those patients who live a long way from Billings typically are referred to their primary care physician for follow up. Patients who live in proximity to the clinic come in for assessment every two weeks until their condition is stabilized, then see the nurse practitioner, physician assistant or cardiologist every three months. Very stable patients come into the clinic twice a year. Every patient sees his or her cardiologist annually. "The nursing team at the clinic uses a nurse case management model to educate and monitor the conditions of these patients." Rowland says. A nurse from the heart failure clinic is assigned to the hospital and reviews the census every day to determine which patients have heart failure, either as an admitting diagnosis or comorbidity, and educates patients on their condition, the importance of follow up care and following their treatment plan. When patients are appropriate for telemonitoring, the heart patient nurse who is assigned to the hospital goes over the instructions, gives them written materials, and calls them the day after discharge. If the patient does not have a scale at home, the clinic provides one. Every day, patients dial into a toll-free number which connects them to a web server that asks six questions. The patients enter their weight each day and answer six questions such as do you have more swelling today? Are you short of breath? Do you feel lightheaded? Answers are recorded by pressing 1 for yes and 2 for no on a touchtone phone. The computer program separates answers into clinical and non-clinical variances. If patients' weight fluctuates three pounds or more in a day or if they say yes to any of the questions about symptoms, the nurse calls the patient to get more information and determines what kind of intervention is needed. "Many times, we do rescue therapy over the telephone. We do a lot of counseling about diet and medication adherence. Sometimes patients get worse because they took over the counter medication for a cold, or ate foods with a lot of sodium," Rowland says. The nurses enter their progress notes in the clinic's electronic record which is available for providers who are affiliated with Billings Clinic can access. The clinic's cardiology and internal medicine departments developed diuretic protocols and electrolyte protocols so nurses can manage patients' medication over the telephone if the symptoms indicate. "When the patients call in, we can check their conditions and treat them every day if their medications need adjusting," Rowland says. Rowland says that when patients do not respond to diuretic protocols, the heart failure nurse, by protocol, recommends that the patient see his or her local provider. Sometimes in outlying areas, follow-up is difficult. For instance, one patient was a rancher who, following a major spring flood, was taking a boat to see his cows. "There was no way he was going into town to get labs or see a provider. This happens sometimes and we just do the best we can," she says. The nurses work closely with primary care providers in the outlying community to coordinate care for the patients. "We make an effort to have a good working relationship with the outlying community physicians. They're the ones who see the patients frequently and can provide information we can't get over the telephone. We also coordinate with many other services such as home health agencies, hospice services, ventricular assist device and cardiac transplant teams, as well as specialists such as nephrologists and pulmonologists," she says. Parker reports that the clinic is planning to expand the home telemonitoring system in which all capable heart failure patients will call in periodically and answer the same questions as people who call in every day. "We want to check on patients after they are stable. We realize that stable patients can become unstable and we feel like it's valuable to assess them periodically," Parker says. |
Home health organization balances technology, touch Remote monitoring, EMR part of program Bayada Home Health Care, with headquarters in Moorestown, NJ, uses an automated voice response service that calls high-risk patients with chronic diseases at intervals selected by their home health nurses. The service asks questions designed to identify any problems the patients might be having and any exacerbation of their conditions. The program targets patients with chronic obstructive pulmonary disorder, heart failure, diabetes, and hypertension, but can monitor patients with any condition if their physicians order the service. The system alerts a case manager in the office by email, and by a flag on the computer screen. The case manager decides what intervention is needed depending on the situation, and may call the patient's doctor or send out a nurse. When physicians request it, the agency uses digital weight scales and blood pressure monitors in patients' homes in conjunction with the regular visits from home care nurses. The devices, typically in the home for 60 days, assist in allowing patients to self-report their vital signs through an automated voice response system which telehealth nurses who monitor up to seven days a week. Using the data, the home health nurses determine if the patient is experiencing an exacerbation and the telehealth nurse works with the local Bayada branch case manager and physician to determine what steps to take. "We have a variety of options available to provide the best care and monitoring of our patients. We're still analyzing the various types of services to determine the best balance between live calls and technology," says Eric Thul, MBA, division director with home health practice. The company's most recent adaption of technology has been to replace a paper record system with a fully functional electronic medical record in 2011. Nurses, therapists, social workers, and home health aides take electronic tablets with them as they visit patients, and complete the vast majority of their documentation in the home. "It created efficiencies in terms of back office processing but we also found that it increases the amount of documentation that happens in the home, cutting down on the amount of time the nurses spend writing out their treatment notes after hours, and improves the quality of the documentation as well," he says. The process allows nurses to easily review what's been going on with their patients over time and to track the results of their interventions, he says. The organization is rolling out a physician portal that allows physicians to log in to review and sign orders orders and to see their patients' basic health status online. |
Healthcare organizations in a variety of settings are leveraging today's technology to increase the efficiency of case managers and nurses and for early intervention of patients who are experiencing exacerbation of their disease or other problems that might lead to an emergency department visit or hospitalization.
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