Remote monitoring leverages CMs' resources

Data determine who needs immediate attention

Every morning, a group of congestive heart failure (CHF) patients steps on a scale at home, then answers a series of questions asked by a device attached to their telephone.

The scales prompt patients by voice and on a digital monitor about shortness of breath, dizziness, swelling of the ankles, and other symptoms of heart failure.

The information is transmitted to their case manager at Montefiore Medical Center's Care Management Organization (CMO) in Yonkers, NY, which contracts with five regional HMOs to manage the care of more than 115,000 patients.

If the results indicate problems, such as rapid weight gain, the nurse contacts the patient immediately. The goal of the remote monitoring program is to manage the patient's conditions to keep small issues from becoming bigger.

"Medical expense in the [remotely monitored] group is currently trending at a rate that is 18% lower than the rest of the population managed under risk. This is mainly due to a reduction in hospitalization utilization," says Ann Meara, RN, director of medical management at the CMO.

"We have a financial risk associated with managing this group of patients. We are getting capitation revenue, and we are choosing to spend it on telemonitoring so we can identify episodes of decompensation much earlier and prevent hospitalization," she says.

Of the 200 patients in the CHF disease management program, about 130 have received a remote monitoring device.

Some patients have been using the remote monitoring equipment for more than three years.

"It's had a tremendous impact on patient outcomes," Meara says.

Telemonitoring allows care managers to manage the care of patients very intensely, while maximizing the resources of the organization, she points out.

"It's all about leveraging resources when you have a large number of people to be managed. It helps us identify the patients who are doing worse today than yesterday or a week ago and who may need some more interventions," she says.

For instance, one care manager could be monitoring the care of 150 patients but couldn't possibly know which ones needed intervention on a given day without calling them.

With remote monitoring, the nurse gets information on the weight and answers eight to 10 symptom-related questions and can zero in on the people who need a phone call.

"When she gets a list of people who weighed in and answered the questions, she knows who to call right away. If the patient's condition doesn't look good, she can call right away and connect them to the doctor or the emergency department or put an emergency plan in place and tell the patient to take extra Lasix," Meara says.

By the time the case managers come in each morning, many of the patients have weighed in and answered the questions. The nurse reviews the data and determines who needs a call.

The system generates reports of patients who haven't weighed in for two days, which prompts a phone call from the nurse.

"The patients have a sense that there is a partnership between them and the case manager. Standing on a scale and writing their weight on a piece of paper doesn't engage people, but with this program, they know if certain things happen, their case manager will call them," Meara says.

When a patient enrolls in the program, a care manager conducts an assessment, collecting clinical information as well as information about the patient's perception of the disease, the caregiver situation, and any psychosocial issues.

The equipment is delivered direct from the manufacturer with instructions on how to set it up. The patients have had no trouble setting up the equipment on their own, Meara adds.

The device asks questions about symptoms and compliance, such as "Are you more short of breath?" "Are your feet swollen?" and "Do you have a three-day supply of medication on hand?"

"The parameters for weight and other issues are customized for each patient. Three pounds in one patient may not be a crisis but for another, it's a major issue," she says.

The case managers work closely with the physicians in the network, alerting them when the data indicate that the patient is having problems.

"The physicians like the program because it cuts down on extraneous phone calls from patients. The nurse can intervene in some instances and that patient doesn't always have to come into the office," Meara says.

The CMO started out offering the remote monitoring device only to people with Stage 3 or 4 CHF, Meara says. "Over the course of time, the people using the scales did so much better that we began offering it to everyone. The cost of the equipment is minimal in comparison to hospitalization," she says.

The CMO is exploring ways to use a similar remote monitoring device for diabetes patients and patients with other chronic conditions.

"We see remote monitoring equipment as a tool to leverage our resources. We have a huge diabetic population that needs to be managed. Many are young and work during the day. They could upload glucometer reading and answer the questions at night," Meara says.

Instead of using a discrete clinical marker such as weight for other at-risk patients, the monitor may just ask a series of question on a regular basis, she points out.

For instance, the device might ask: Do you have medication on hand? Did you take your medication today? Were you able to exercise?

"This would allow the case manager to keep tabs on the condition of all patients who qualify for our case management programs without having to call all the time," Meara says.

The program is to the hospital's advantage as well, she points out. "Our hospital operates at close to 100% capacity almost all of the time. Heart failure accounts for a very high number of admissions, and these admissions are frequently avoidable with early recognition of worsening symptoms and initiation of treatment. It's a win-win situation," Meara says.