Reducing Readmissions With Telehealth

Compiled by Jennifer Dennard

A remote patient monitoring program has helped Lee Memorial Health System avoid more than 1,200 hospital readmissions since 2010.

Lee Memorial Health System (LMHS) is a Florida-based integrated delivery network recognized as the fourthlargest public health system in the United States. The not-for-profit, 98-year-old organization employs 1,130 physicians who oversee 1 million patient encounters each year. It includes four acute-care hospitals, a children’s hospital and rehabilitation hospital, physician offices, a nursing home, and a homehealth agency. Cathy Brady, RN, clinical manager, Lifeline and Telehealth program manager at Lee Memorial Home Health, explains how the telehealth system is reducing readmissions using remote patient monitoring and other technologies.

Q: What telehealth solutions are currently in use at LMHS?

A: We’re using the Honeywell LifeStream remote monitoring system, which includes software that allows us to run standard reports, perform analytics, and track patient outcomes and caseloads. We also use devices that enable us to check heart rates, pulse oximetry, blood sugars, and blood pressure. We use weight scales where appropriate and have two tablets that act as monitors.

Q: When it comes to remote patient monitoring, how do you decide which patients will be monitored upon discharge?

A: When we started the program in 2010, we told our clinicians that we wanted to primarily monitor patients with congestive heart failure, pneumonia, and myocardial infarctions. Those were conditions that CMS was going to target as far as readmissions into the hospital. Our hospital homehealth field clinicians, however, did not refer patients to us as frequently as we initially expected.

Sometimes telehealth is a difficult thing for clinicians to buy into. You have to make sure they’re aware you’re not trying to take over care of their patient. Remote patient monitoring has to be done in conjunction with them, our homehealth nurses, and field clinicians. We weren’t getting the number of patients on telehealth that we felt we should have according to our patient census.

To remedy that, about a year ago we began to have our telehealth nurses review all the hospital admissions scheduled for the next day. If a nurse sees that a cardiac patient is coming in, that’s a no-brainer. They’re going to need the equipment. We’ve even moved beyond the three conditions I previously mentioned and now offer the equipment to anyone with a condition that could benefit from at-home monitoring, whether it’s a cardiac diagnosis, pulmonary diagnosis, or even a wound combined with a history of hypertension. There are reasons we wouldn’t implement the technology, such as if a patient is physically unable to use the equipment, a caregiver is not available, the house is infested, or there’s an unsafe environment with no good place to put the device.

Q: How do you plan to expand use of the equipment going forward?

A: We started with 50 remote patient monitors, and have since grown to 250, allowing us to monitor more than 9,000 patients since the start of the program. At present, we’re only using the telehealth equipment on homehealth patients. Currently, there is no reimbursement from Medicare or insurance companies. We’re absorbing the cost of the telehealth program right now because it ultimately saves the entire system money.

We do have patients who, once they are discharged and no longer meet Medicare requirements, want to continue using the equipment but aren’t quite sure how to do it on their own. They could still benefit from somebody monitoring their vital signs and explaining to them when it’s important to contact their physician. These types of patients often wind up back in the hospital because they don’t know what to do with the vital signs they get. They don’t know what they mean. We’re looking at options to offer these patients a way to pay privately so they can continue using the equipment.

We’ve had our remote patient monitoring technology for four years, and we are also looking at updating certain devices, such as the two tablets we currently have. Honeywell has updated what the tablets can do, and so I’d like to see how we could go beyond using them to take a simple vital sign and move toward using them in more innovative and cost-effective ways. We are in the process of developing a pilot program using 10 to 15 tablets in conjunction with our regular monitors. I’d like to put those to use with some of our more critical patients so that we can have face-to-face time with them daily. That will help us to develop a better rapport with them, and it will likely be a more effective way to provide education.

Q: What type of data do you collect, monitor, and/or disseminate via the remote patient monitoring and telehealth solution?

A: We keep up with readmission rates of patients by payer as well as by illness, such as congestive heart failure. Soon we’re also going to start tracking patients with chronic obstructive pulmonary disease or stroke.

We also keep up with the number of new telehealth patients and unduplicated telehealth patients that we serve each month. Unduplicated patients are those who are admitted, discharged, and readmitted to the telehealth program in a given month but are counted only as one patient. We also track “packets,” which are basically any types of information sent from the patient that a nurse may need to respond to. A packet could simply be someone’s vital signs, while an empty packet could be a lack of transmitted vital signs. An empty packet might prompt us to call the patient and find out what’s going on and why we didn’t get a set of vital signs transmitted on a given day.

Q: What types of readings would alert telehealth and field clinicians to take preventative action? What is the escalation procedure?

A: We have agency-specific vital sign parameters given to us by our medical director. Sometimes these may be passed on from a physician who has a specific set of parameters for an individual patient. We make contact with that patient anytime those vital signs are outside of those parameters.

We then check to see whether or not they’re having symptoms related to their abnormal vital signs. If they have high blood pressure, we call them and ask them what’s going on. Are they upset? Did they take their medicine? Did they go to an all-youcan- eat seafood buffet the night before? Those are the types of questions we ask to better gauge their condition. Depending on their response, we’ll ask them to retest later in the day or have them take a wait-and-see approach over the next 24 hours.

We usually look for what we call a trend or pattern. If we have to call them three days in a row, then we’re noticing a pattern. That’s when we move to other kinds of interventions, whether we decide to call the doctor and he gives us an order to increase a particular medicine, or we send a nurse to see the patient. If it’s something we can’t deal with, then of course we’ll send them to the ER, but that is our last-ditch effort.

Q: Can you explain the team-based approach LMHS has instituted for remote patient monitoring and why it is effective?

A: The field clinical manager is responsible for overseeing the care of the patient. This could be a nurse or a therapist. The telehealth case manager is the second set of eyes on the patient. If there is a problem with the patient, depending on the severity and how soon an intervention needs to take place, then the telehealth case manager will call or email the field case manager. If the situation requires immediate action and the telehealth case manager can’t get in touch with the field clinical manager, then the telehealth case manager will take control and handle the situation. The bottom line is that all of this depends on how quickly intervention is needed. An intervention may be as simple as having the patient drink extra fluids, elevate their legs if they have low blood pressure, and then retest 30 minutes to an hour later to see if their blood pressure improved. The telehealth case manager would do the intervention immediately, and then the field clinical manager would be alerted to the situation. Interventions could also include patient education, notifying the doctor of a patient’s condition, faxing vital sign trends to the doctor, collaborating with the field clinical manager, obtaining an order from the doctor for a new medication or medication adjustment, or sending a clinician to the home to assess the patient.

Q: How important to the process is benchmarking LMHS against other remote patient monitoring programs?

A: We visited a number of similar agencies when we started the program to get a feel for what worked and what didn’t. It gives you a good idea of what will be effective at your own facility. We discovered that it’s best to have staff dedicated to equipment installation rather than having clinicians install their own. One agency we visited struggled to get more than 20 monitors out to patients in the field. That’s a fairly low number, and we discovered the reason for it was that the clinicians were responsible for installing their own equipment. If they didn’t want to install the equipment, they didn’t tell the agency that patients needed telehealth.

We learned from those visits that you need to let clinicians be clinicians and not overtask anyone with duties that might stretch them too thin. It just ends up hurting your program and patients in the long run. Now we have two dedicated installers. We also learned that you need somebody within the agency like myself that has a strong desire to run and champion the program.

Q: What results have your organization and its patients realized as a result of its remote patient monitoring solution, specifically as it relates to reducing readmissions?

A: In order to prove our worth to the system, we knew from the beginning that we would need to keep up with what we call our “saves.” We documented what patients we kept out of the hospital, whether we notified the physician who gave them a new medication, sent a staff member to their house, or provided significant education.

As of the end of 2013, we have avoided 1,282 readmissions as a result of our telehealth program. It is really great, because when someone goes back into the hospital with congestive heart failure, you’re looking at a cost of somewhere between $3,500 and $9,600, maybe even $10,000. If you’re talking 1,282 patients, you’re talking a lot of money. That becomes a very significant number. Our CFO is definitely now a cheerleader for the program.

Q: What are your plans for continuing to expand and enhance your telehealth program?

A: We’d like to try tying our telehealth equipment and electronic medication dispenser together in some way to see if we can improve medication compliance. If we could somehow incorporate the activity of the medication dispenser with the remote monitoring, then we might be able to decrease medication mismanagement. Patients could potentially take their medicine more safely, instead of one older person trying to give it to their spouse and subsequently mixing up medicines. Medication mismanagement is a huge reason people are readmitted to the hospital. We could potentially partner with a vendor to do a pilot on something like that.

I’d also love to incorporate video so that we see the person we’re talking to when we call them. Perhaps we could see that bag of chips sitting on the side of their recliner and better determine if they’re eating right, especially if they’ve told us “I didn’t eat any salt yesterday!”

Q: What other strategies and best practices can you offer your colleagues who are thinking about doing something similar?

A: In addition to having dedicated equipment installers, I’d also recommend that you have a minimum number of clinicians available. When you have too many clinicians going into the home and seeing patients, then you miss out on continuity of care and education. We have divided our telehealth patients and field clinicians into north and south teams, which enables our nurses to predominantly work on one team. Being assigned to one particular area, rather than all of them on any given day, allows our nurses to develop better relationships with a smaller number of patients.

Before our team approach, we responded first to alerts on patients deemed critical, no matter their location. Now that we’ve broken it down by area, clinicians look at the alerts just on their team, which cuts down on how many they need to look at. It also ensures that the same person is acting on the trends or the problems. That’s a great thing for our patients because it provides a high level of comfort and reliability.