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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