Remote monitoring cuts costs for chronically ill
Remote monitoring cuts costs for chronically ill
Project extends the reach of health care providers
Following the success of a program that provides remote monitoring of chronically ill patients in poverty-stricken rural areas, Roanoke Chowan Community Health Center in Ahoskie, NC, is replicating the program at six other community health centers in North Carolina.
The program monitors vital signs and other data as determined by the patient's primary care physician using remote monitoring devices placed in the patients' homes. Nurses review the data daily and intervene.
In the original pilot project, hospitalizations decreased by 38%, total charges for health care were reduced by 70%, and hospital bed days dropped by 50% among the 65 patients for whom the health center could obtain data, says Bonnie Perry Britton, MSN, RN, telehealth clinical network director/development director for the health center.
"We don't have an affiliation with a hospital so we can't get emergency department data. We can get data from our local hospital, but if the patient went to another hospital, we had no way to obtain the data," Britton says.
"We do know that one of the main reasons for the decrease in cost is that if patients went to the emergency room and were hospitalized, their length of stay was shorter," she says.
The three-year pilot project was conducted with a grant from the North Carolina Health and Wellness Trust Fund Commission, which utilizes the state's share of the national tobacco settlement to fund programs that promote preventive health.
Medicare beneficiaries represented the largest number of patients in the pilot program , followed by indigent patients and Medicaid patients.
The health center rotated the monitors every six to seven months.
The new program, which started July 1, will monitor about 400 Medicaid patients with cardiovascular disease over a three-year period, leaving the monitors in place for about six months at a time.
"North Carolina Medicaid is our partner in this program to supply financial data on all health care expenditures, including emergency department visits, hospitalizations, and primary care provider visits," Britton says.
The program will be replicated at Green County Health Care, Kinston Community Health Center, Tri-County Community Health Center, Rural Health Group, Cabarrus Community Health Center, and Bertie Rural Health Group.
The telehealth program was instrumental in improving the health of residents of three rural counties that are among the poorest in the state, Britton adds.
The center is a federally qualified health center serving four counties in northeast North Carolina, an area that leads the state in heart disease, diabetes, and childhood obesity.
The median family income in the counties served by Roanoke Chowan Community Health Center is $21,000 a year, and 21% of the population is uninsured.
"We have only a 41% high school completion rate, which means that people grow up and go right into poverty. It's a vicious cycle," she says.
"The center provides primary care and mental health services as well as operating a program that provides medication and supplies for indigent patients and conducting outreach into the community to screen residents for hypertension, cardiovascular disease, and HIV," Britton says.
"One of the obstacles we have to overcome is that patients have difficulty accessing care for a number of reasons. There is only one public transportation system in the area, and many residents have to pay someone to drive them to see the doctor. For the poorest families, that can be a challenge and a problem," Britton says.
The North Carolina Health and Wellness Trust purchased 25 in-home monitors for the pilot project to monitor patients with cardiovascular disease, diabetes, and hypertension.
Primary care physicians identify patients who are eligible for the telemonitoring program, develop a plan of care, and determine what parameters to use for the biometric data that will be monitored.
The information is faxed to a nurse case manager, who gets the patient's consent to participate, goes to the patient's home, installs the unit, and teaches the patient to use it.
Patients use the device daily Monday through Friday to collect whatever data the physician determines are appropriate and answer a series of questions.
For instance, the machine will ask if the patient is short of breath. If the patient says no, it shifts to another question. If yes, the patient answers a series of questions developed by the primary care physician and the telehealth team.
The telehealth nurse checks the server regularly, and if there is an alert indicating that the patient is having problems, she contacts the patient immediately to verify what is going on. She may ask the patient what he has eaten that day, whether he's taken his medications, or other questions that will help her determine what interventions the patient needs.
The nurse educates the patients on diet, medication compliance, or whatever else may have triggered the alert and notifies the physician if she feels more interventions are needed or if the physician may need to change the patient's medication.
The physician reviews the situation and may ask the patient to come in for a visit, or may send a change of medication to the patient's pharmacy.
"In our experience, this has increased medication compliance because the patients don't have to come into the office for the doctor to adjust their medication. They don't have to travel from home, possibly paying as much as $30 for transportation, then pay for the office visit as well. Many patients will skip their medication when they run out or not see the doctor when they don't feel well simply because they can't afford it," she says.
Britton attributes the success of the pilot to the fact that, unlike the majority of telemonitoring projects, the program is driven by the primary care provider.
"The physicians designed the protocols that the telemonitoring nurses use. They determined which data to track for each patient and which questions to ask. Nobody knows the patient better than their primary care provider," she says.
Many telehealth projects follow patients for only 60 days, according to Britton.
"Our average is six to seven months, during which time patients receive daily reminders. The nurses develop a close relationship with their patients, who often say that the nurse is the first person who has cared enough to help them manage their disease," she says.
When patients monitor their vital signs on a daily basis using the telemonitoring equipment, it keeps them aware of their disease and what they need to keep it under control, Britton points out.
"Our program is not just about vital signs. The telemonitoring equipment asks the patients questions designed to give us insight into the patient's daily routine and the social setting. Our nurses have the information they need to help the patient manage their disease and to get them tied into other resources and programs that can assist them," she says.
The first telehealth monitors in the second phase of the program were installed in August and will be redeployed to other patients at the end of January.
The health center is working with East Carolina University and Wake Forest University to analyze data from the program.
The health center chose a different vendor for the telemonitoring equipment for the second phase of the program because it needed equipment that would enable it to quickly manage the volume of data that will be gathered by the new program, Britton says.
"Our new vendor's products seamlessly integrate the information gathered from patients, their electronic medical records, and Medicaid, giving us easy access to data," Britton says.
Roanoke Chowan Community Health Center created a telehealth manual for the new program and is handling the installation and training on the monitors.
Roanoke Chowan nurses are conducting the initial assessment of all patients in the new program and will monitor all of the patients in the new program. When interventions are needed, they will be conducted by nurses and physicians at the individual health centers who are familiar with the patients.
"Based on anecdotal information and the data we were able to access in the pilot project, we expect the program will show significant reduction in charges and total Medicaid expenditures among the patients in the program. Remote monitoring is an extremely cost-effective way to extend the reach of rural health care workers and improve public health," Britton says.
(For more information, contact: Bonnie Perry Britton, MSN, RN, telehealth clinical network director, Roanoke Chowan Community Health Center. e-mail: [email protected].)
Following the success of a program that provides remote monitoring of chronically ill patients in poverty-stricken rural areas, Roanoke Chowan Community Health Center in Ahoskie, NC, is replicating the program at six other community health centers in North Carolina.Subscribe Now for Access
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