Remote monitoring keeps CHF in check
Remote monitoring keeps CHF in check
Two programs find it aids compliance, cuts costs
Automated patient-monitoring systems may be the low-cost solution to the costly problem of congestive heart failure (CHF) management. Nearly 5 million Americans suffer from CHF, bringing an estimated price tag of more than $20.2 billion annually in emergency room visits, hospital admissions, and disease-related complications, according to 1998 statistics released by the American Heart Association in Dallas. Now, health plans are finding that automated patient monitoring systems boost patient compliance with CHF treatment plans and drive those costs down.
Two disease management companies, San Francisco-based LifeMasters and Greenwood, IN-based TeleHealth Systems, recently reported significant cost reductions for managed care patients enrolled in personal-computer-based monitoring systems. A group of CHF patients enrolled in the LifeMasters Supported SelfCare program experienced an overall cost reduction of 25.3%, even after adjusting for the cost of the LifeMasters program. A similar group of patients using the TeleHealth Heart Success program had a more than 60% reduction in readmission rates. (See boxes at right and on p. 41 for more data.)
Working with a net
"I have a heart-failure patient who I monitor daily with the assistance of the LifeMasters program," says Richard J. Moore, MD, a San Francisco internist. "Prior to enrollment in the TeleHealth program one year ago, this patient experienced three emergency hospitalizations in a 12-month period. Now, I can oversee this patient daily — not just during occasional office visits. The patient has become an active participant in his own well-being and has not been hospitalized since his enrollment."
"The TeleHealth system gives our patients a safety net. We can now contact them proactively on a regular basis to monitor and assess their symptoms and medication issues," says Susan Baseman, RN, MS, CNS, administrative director of disease management for Crozer-Keystone Health Systems in Springfield, PA. "We track and trend their data over time. If we notice a new symptom or a weight gain, we can respond proactively. It’s human nature for chronically ill patients to underplay the significance of early symptom changes. The system allows us to intervene before a full-blown problem leads to an emergency room visit or an admission."
Both telemonitoring systems provide electronic visits to CHF patients in their homes using a question algorithm to monitor progress. The questions are specific to CHF and cover key indicators for CHF management such as fluctuations in weight. The systems are connected to a computer-based reporting system monitored by a nurse. The nurse can be paged by the patient or caregiver during any call. (See flowchart, inserted in this issue, for a description of a typical telephone call for TeleHealth patients.)
If there are noticeable changes in a patient’s daily record, a nurse contacts the patient for information verification. The nurse reports changes in health status to the patient’s personal physician by telephone, fax, or e-mail. In addition, Heart Success sends physicians monthly status reports on all patients enrolled in the program.
"Physicians were skeptical at first," says Baseman. "They thought they might be losing control over their patients. Now they realize they are still in control; we’re just providing them with additional information and alerting them when it’s time to become more involved in a patient’s care."
Getting an education
LifeMasters patients receive coaching and encouragement through regular telephone calls and e-mail messages from a LifeMasters nurse. TeleHealth Heart Success patients also receive scheduled home health visits.
"There are three levels of care in the Heart Success program," notes Baseman, explaining that Crozer-Keystone developed the Heart Success program and partnered with TeleHealth to enhance the program’s care plans and provide a cost-effective patient monitoring component. "Each level has a different number of home health visits, duration, and intensity of multidisciplinary services. Home health nurses trained in CHF care educate patients in their home about the use of the system. Nurses also make sure there are no technical glitches and that patients are comfortable with the technology."
The LifeMasters program begins with a CHF education class. If patients are unable to attend scheduled classes, clinical nurses trainers educate the patient at home, says Sandra J. Feaster, RN, MS, MBA, director of special projects for LifeMasters.
"We provide patients with a digital scale and show them how to use it. We teach patients the basics of their condition in a two-hour training class. We don’t want to overload them," she says, adding that trainers also explain the use of the monitoring system.
In addition, each LifeMasters patient works with a primary nurse who provides weekly education calls, which cover different aspects of CHF management such as nutrition, exercise, and medications. "Nurses gauge how much information a patient can tolerate and how much information they need and individualize the education accordingly."
The LifeMasters program includes a 52-week care map with specific education and monitoring goals for the nurse to follow. "We adjust the intensity of the program every quarter. They graduate from the program after one year. At that point, we work with the patient’s physician to determine how frequently the patient should collect and report data," says Feaster. "CHF is a progressive disease. Patients get worse. We adjust our interactions to keep patients as healthy as we can for as long as we can."
Building a caseload
Each LifeMasters nurse manages a caseload of about 75 patients. Nurses use pagers to send patients medication and exercise reminders. "They also use pagers to send messages such as birthday greetings," she says. "It allows personalized contact in a very time-efficient way. Technol ogy gives nurses more time with patients and less paperwork."
The Heart Success program provides six weeks of monitoring for most patients with the duration adjusted according to need. The program has been in place for more than two years at Crozer-Keystone. "We’re starting to get some repeaters who have had CHF exacerbations and come back into the system, but they don’t need the entire Heart Success program, which includes a CHF education component, again. For those patients, we abbreviate the program, and the CHF nurse looks at the specific issues that lead the patient back to the hospital and institutes appropriate interventions," Baseman says.
LifeMasters is currently piloting an Internet intervention group. Patients in the Internet pilot have a personal Web site where they enter their vital signs such as blood pressure, heart rate, and weight into the computer on a daily basis. Patient confidentiality is secured through the use of passwords and encryption.
Seniors use the Internet
The personal Web site also provides patients with educational information and news stories related to their condition. Internet chat rooms give patients additional support by offering interaction with health care professionals and other CHF patients.
"We believe that connected patients are more empowered to take an active role in improving their own health," explains Christobel E. Selecky, president and chief executive officer of LifeMasters. "The Internet study will provide further evidence that technology enables physicians and managed care organizations to reduce health care costs while providing greater quality of care."
LifeMasters first beta tested the program to determine whether seniors could be comfortable with the Internet and the necessary technology. "Seniors found the technology simple enough for their use," says Les Cordes, MD, medical director of the Physicians Medical Group of Santa Cruz (CA), whose patients are participating in the Internet pilot.
"The Web-based technology allows seniors hands-on management of their clinical condition. It becomes the patient’s own self management and education tool. The patient determines the educational level. And if patients don’t make scheduled calls, a nurse makes a direct telephone call. This is a high-cost clinical diagnosis for us. CHF is the No. 1 reason for hospital admissions in our senior population," explains Cordes. "We welcome this tool for reducing medical costs and hospitalizations. It’s a natural for us to try this program."
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