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Daily monitoring reduces admissions, costs
Device allows patients to submit data from home
A home monitoring program for patients with complex chronic conditions has reduced hospitalizations by as much as 50% to 80%, according to Charles Hart, vice president of Cardiocom, a Minneapolis-based company that works with managed care companies, hospitals, and medical groups at risk for cost of care to manage complex patients.
The company home monitoring system won the 2002 "Best Enabling Tool for Disease Management" from the Disease Management Association of America.
Congestive heart failure (CHF) management is the company’s primary focus but the home monitoring system can be used to effectively and efficiently manage any patient with complex chronic diseases, says Ed Kramper, MD, medical director at Cardiocom.
Many of the patients being monitored have congestive heart failure with comorbidities. However, the company provides monitoring services for any complex or at-risk patient, including those with diabetes, chronic obstructive pulmonary disease, hypertension, and even high-risk obstetrical patients.
"Studies have shown that daily monitoring is a cost-effective way to improve patient health and reduce costly hospitalizations. Clients who have contracted for these services have reported that they see a positive return on investment," says Kramper.
The company conducted a study of 1,026 CHF patients from nine independent, managed care, and hospital-based facilities.
During the year of the study, the patients experienced an average of only 234 hospital admissions.
The Cardiocom staff works with clients to identify patients who are at highest risk — those most likely to need health care services and those whose costs are highest.
"We identify patients who will benefit from monitoring through diagnoses, admissions, total cost of care, and quality of life issues," Kramper says.
The company does an intake assessment on each patient to validate that they will benefit from the monitoring and sign them up for the program.
"We call the patient and let them know that the program will enhance quality of care at no cost to them. They’re very agreeable about participating," he says.
Patients who are identified for the program receive a home monitoring device that connects to an electrical outlet and a telephone line.
They are asked to use the device each day and answer a series of questions that vary from day to day and depend on the patient’s health status and diagnosis.
The patient answers 10 or 12 subjective questions, such as, are you having trouble sleeping lying down? Are you short of breath? Are your ankles swelling? Are you able to exercise?
"We chose yes or no responses, rather than multiple choice, because they work better with an older population. The questions are visually displayed and spoken as well. We have Braille keypads for people whose eyesight is failing," Hart says.
The device monitors whatever the physician decides, including weight, blood sugar, blood pressure, peak flow and/or oxygen saturation.
The information goes over the telephone line to a disease manager who may be at the health plan, a hospital, or in Cardiocom’s call center, depending on the client’s wishes.
A disease manager typically monitors 200-250 people. In most cases, only 10%-15% of the people they are monitoring don’t meet criteria for health and have to be contacted.
"The disease managers use very concise management software that can determine if the patient is in trouble or not, based upon criteria given to the system by the treating physician. If a person is starting to get into trouble, the case manager is alerted to contact the patient to find out what is going on and then send information to the physician for action," he says.
When the disease manager is alerted, he or she gets in touch with the patient and puts together a one-page exception report that is faxed or e-mailed to the physician offices. The report shows 21 days of weight measurement in graph configuration and 21 days of reported symptoms in bullet points along with the nurse’s notes.
Depending on what the physician wants, the report may list all the current medications prescribed for the patient.
In most cases, the physician has the nurse call the patient and tell him or her what medications to adjust.
Daily monitoring of CHF patients is essential to managing a disease that can quickly exacerbate, Kramper points out.
"When I admit patients to the hospital with congestive heart failure, their weight has gone up 35-40 pounds in 10 days and it’s all fluid. That’s why daily monitoring is so effective. It doesn’t allow the weight to get out of control," he says.
If the patient doesn’t use the device and no report comes in, the nurse calls to make sure nothing is wrong.
In the case of one patient with diabetes and CHF, the device saved her life.
The woman was homebound and completed her monitoring at 9 a.m. like clockwork. When her report didn’t come in, the case manager called the house with no answer, and then called 911. When the police broke into the house, they found the woman lying on the floor in a diabetic coma.
Cardiocom allows patients to sign up for the program and pay for it themselves if they wish, an arrangement that works well for people with chronic diseases who live alone.
For instance, Kramper’s mother, who lives in rural Nebraska, has been on the device since February 2002.
"She doesn’t have congestive heart failure, diabetes, or other chronic condition but she is overweight and has severe arthritis. She has problems with weight gain and hates to bother the doctor. The family looked at the situation and determined that daily monitoring was the only way she could continue to live alone," Kramper says.
She was hospitalized three times for a total of 31 days before she was placed on the Cardiocom device in February 2002. Since then, she hasn’t had a single emergency department visit or hospital admission.