How Telehealth Provides the Bridge Between Patients and Healthcare Providers

In an environment where the desired end-result from both patients and healthcare providers is increased communication and continued medical oversight with patients after they are discharged from the hospital (or healthcare specialist), one key element of the solution is telehealth.

Telehealth solutions are the perfect companion to integrated healthcare delivery networks and ACOs because they have the same overarching goal: making healthcare delivery more efficient (i.e. bringing the right level of care to the patient at the right time) to reduce readmissions while simultaneously increasing quality of patient care.

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VNA Staff and Cardiologists Demonstrate Strategic Telehealth Deployment

A Heart & Vascular Program, by VNA staff and hospital cardiologists, established monitoring protocols & standards for all patients treated for CHF, including those who did not qualify for telemonitoring under Medicare guidelines. CHF readmission rates were reduced, demonstrating highly successful outcomes for participants.

In addition to improving outcomes, patients in the new Heart & Vascular program realized much more than simply a ticket out of the hospital. Through daily engagement with Honeywell’s telemonitoring solution, patients are encouraged to develop healthier habits.

Overall, the program has resulted in long-term sustainable changes to patient health while enabling patients to stay out of the hospital and enjoy the benefits of better health and well-being.

With the support of LifeStream, organizations like VNA of Rockford and Rockford Memorial Hospital, are developing solutions that address the needs of targeted patient groups.

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Disease Management Through Telehealth

THE NEED

“Our executive leadership realized that we needed to do population health in a more cost effective way. They wanted to get out ahead of the curve to succeed under value based care,” said Josi DeHaven, RN, manager of ambulatory care coordination at the Goshen, Indiana-based community hospital.

The idea of establishing a new telehealth program with chronic disease patients began to emerge. The fact that the hospital’s telehealth equipment – which was being used in home health – was old and too expensive to maintain pushed the idea of purchasing new equipment to the front-burner. The organization began to look for a telehealth solution that could support both its existing home health program as well as chronic disease and population health initiatives that could be administered by Goshen Health’s Accountable Care Organization (ACO).

THE SOLUTION

After reviewing proposals from several vendors, leaders chose to purchase 70 units (Resideo’s Genesis Touch) that collect and then transmit biometric data to the LifeStream, Resideo’s remote patient monitoring software that provides a single consolidated view of patient information enabling care providers to make informed, data-driven decisions. The devices also enable patients to conduct real-time online visits with caregivers through the videoconferencing function. With these units, the hospital can support its existing home health programs, as well as emerging chronic care and population health initiatives that are being administered via the ACO.

After identifying COPD patients as its initial patient population, clinicians developed a disease management program that could be administered through the telehealth equipment. The program consists of an initial home visit, daily remote vital signs monitoring and weekly videoconferencing. After fine-tuning the installation process and training the care coordinators on the use of the equipment, Goshen Health launched the initiative by enrolling 10 COPD patients in an eight week trial program.

During weekly video visits, ambulatory care coordinators in the ACO met with patients, counseled them about specific health challenges and provided education covering topics such as medication management, stress reduction and breathing techniques. In addition, if patients presented with specific problems, specialists such as physical therapists or dieticians were brought in to participate in the videoconferences as well.

THE BENEFIT

“There were several occasions when I was not feeling well and through the telehealth visits, the nurses were able to catch it early enough,” Jim said. “By reviewing my vital signs and observing me during the telehealth visits, nurses would establish that I needed a medication change. They would work with the doctor and made sure I got it – and that would get my symptoms back under control. So, I could stay at home, instead of in the hospital.”

Keeping patients like Jim out of the hospital is precisely what Goshen Health is aiming to do with its innovative telehealth program. A look at how the initiative came to be, its early success and its future direction sheds light on not only how telehealth can help individual patients like Jim but on how such programs could become an integral component of successful population health initiatives.

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Expanding a Telehealth Program to Serve More Patients

THE NEED

MultiCare is looking to reduce costs by offering high quality care in a more efficient manner as virtual visits will take the place of in home appointments. In fact, with this model in place, MultiCare expects to enable home health case managers to double their average case load, moving from 30 to about 70 patients. In addition, MultiCare is looking to improve care outcomes by offering patients the opportunity for clinicians and patients to routinely collaborate on clinical care issues by providing telemonitoring to interact with patients on a very personal level.

THE SOLUTION

To meet the needs of a large number of patients, MultiCare is offering a two-tiered telehealth program. “Tier one will be a full-blown program. These patients will have the telehealth monitor with all the peripheral devices in the home. They will get all of the intensive interventions that we can provide. We expect about 300 to 350 of the 500 patients will be enrolled in this tier one program,” said Kelly Gariando, RN, telehealth specialist at MultiCare

Instead of conducting telehealth sessions without any specific purpose, specific disease management questions are integrated at specific points in the telehealth process. For example, there are specific points in the care process when the telehealth nurses will ask cancer patients about pain control or diabetic patients about sugar levels.
To ensure that patients continue to adhere to their medication regimens, medication management is purposefully integrated into the telehealth nurses’ workflow. For example, the telehealth nurses focus on medication management on Tuesdays by asking a series of specific questions about the patients’ medication compliance. On Wednesdays, the nurses follow up to make sure the patients took action on any gaps that were identified the previous day. And, on Thursdays, the nurses work with the patients to ensure that they are prepared to stay in compliance with the medications over the weekend

THE RESULT

Now in its third year of using video technology the program is showing positive results in reducing 30-day readmission rates for both heart failure and COPD. For heart failure, the 30-day RPM readmission rates have never exceeded 5.1%, which compares favorably with national CHF 30-day readmission rates of 25%. In addition, when compared to all of MultiCare’s heart failure patients, the RPM patients experienced 30-day readmission rates of 3% and 4% compared to 22.38% and 18.70% respectively for the two reporting periods (2016 and January – June, 2017).

For COPD patients participating in the RPM program 30-day readmission rates have decreased steadily since the program was implemented – 10.7% in 2015, 6.0% in 2016, and 4.0% January-July, 2017. These readmission rates also compare favorably with national COPD hospital readmission rates of 20.2%.

Patient satisfaction is another area where hospital organizations can demonstrate improvements in care delivery which can also impact reimbursement levels. For all but one question, 93-97% of patients answered positively with an agree or strongly agree response. The highest rated questions (agree or strongly agree) were for reliability and ease of use of the equipment (97%) and whether the patient would use the equipment in the future (96%).

The impact of MultiCare’s RMD program has already resulted in improved patient care, enabling patients to stay in their homes and has increased the efficiency of care delivery by reducing the high cost of rehospitalization.

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