Faced with the need to provide follow-up care for its Native American patients, many of whom lack electricity or running water, the telehealth department at Northern Arizona Healthcare’s Flagstaff Medical Center developed a remote patient monitoring program and worked with the care management staff to implement the program.

“Between 35% and 40% of our high-risk patients identify as Native Americans and most of them live on the Navajo reservation. It was critical for us to develop a process to help them follow their treatment plans and avoid readmissions,” says Lisa Brugh, MS, BSN, RN, ACM, system director of case management for Northern Arizona Healthcare. Telehealth follow-up is available to all at-risk patients.

Some Navajo patients live in traditional Navajo hogans — small mud-covered huts with no electricity or running water. They don’t have 911 service or home health services. Public health nurses on the reservation visit the patients, but it may take as long as two weeks to arrange a visit, Brugh says.

Outpatient RN care managers visit patients in the hospital and clinics, teach them how to use the home monitoring equipment, and begin to develop a relationship with the patients. Depending on the clinical condition to be monitored, patients may be given a scale, pulse oximeter, blood pressure cuff, or thermometer.

“When the program started patients were also given a cellphone, but we find now that most patients or family members have a cellphone,” says Gigi Sorenson, RN, MSN, director of Community Connected Care and Telehealth.

“The equipment we provide is specific to patient needs and what they are willing to have in their home. Some feel threatened by technology, but the patients who agree to monitoring say they feel safe and supported,” Sorenson says.

The remote monitoring equipment transmits the clinical data into the hospital’s telemedicine care management program. It is scanned into the patient’s electronic medical record. An outpatient RN care manager reviews the data, then contacts the patient to discuss the results along with any symptoms the patient is experiencing. The nurse also reviews the patient’s discharge instructions and medication regime.

If any of the data are out of normal range, the care manager discusses follow-up options with the patient and collaborates with the care manager, primary care provider, or other clinician at the patient’s medical home to monitor the patients and to intervene before they end up back in the hospital.

Many of the Navajo patients live in remote areas with poor cellphone service, which means they have to walk down the road or drive to an area with better service and transmit the data to the telehealth computer. Some older patients rely on their children to visit and assist them in using the equipment. “It’s not an ideal situation, but for the most part, we are able to connect with patients,” Brugh says.

Spotty connections are another problem, Brugh says. If the patients can’t transmit their clinical data, they keep a written log.

“One challenge is that 40% of patients who live on the reservation don’t have electricity or running water in their homes. They rely on wind power and cellphone service,” Sorenson says.

Most clinics, schools, and Navajo chapter houses have Wi-Fi, Sorenson says. The hospital provides the patients with chargers they can plug into a vehicle for another source of energy.

Flagstaff Medical Center’s Meds In Hand program provides prescribed medications to high-risk patients before they are discharged from the hospital.

The inpatient team arranges for the health system’s outpatient pharmacy or the Indian Health Clinic to fill patients’ prescriptions while they are still in the hospital. “It’s critical for patients who don’t have easy access to a pharmacy to leave with their medications in hand,” Brugh says.