Improving Outcomes Through Remote Monitoring-Enabled Patient Engagement
By Nesim Bildirici
Posted on: March 20, 2013
Since the advent of healthcare reform and the recognition that our current healthcare delivery system is financially unsustainable, there has been a steady drumbeat of calls for greater patient engagement. This has been driven by the recognition that achieving long-term financial stability depends on the ability of the healthcare system to morph from its traditional role of treating acutely ill patients to an outcomes-based model focused on delaying or eliminating the onset of chronic diseases and their associated complications.
This means that for the growing population of Americans with chronic conditions (three out of four older adults have one chronic condition, more than half have two or more chronic conditions and 11 million live with five or more chronic conditions) their home-not the hospital-will become their healthcare "Mission Control." Their home is where they need to consistently and accurately monitor their health status, receive coaching to support healthy behaviors, and be notified when they need to see their physician before their condition worsens. Clearly, it's not feasible for a nurse to visit or personally interact with each patient daily, but a comprehensive telemonitoring program that automatically transmits key biometric, medication, and activity data; analyzes the data; generates alerts when an intervention is needed; and provides ongoing, customized support and problem solving, offers a scalable and affordable alternative.
Underpinning this fundamental change is the need to motivate and change behaviors of patients with chronic diseases such as heart failure, chronic obstructive pulmonary disease (COPD), asthma and diabetes, who account for 75% of the $1.7 trillion spent on healthcare annually. Post-discharge care is often spotty, and meaningful change will require empowering and engaging patients and their families and caregivers. For example:
- Nearly 18% of hospital patients are readmitted within 30 days of discharge and three out of four readmissions were probably preventable. Half of readmitted Medicare patients never received any follow-up care in the 30-days after their hospitalization. (New England Journal of Medicine, April 2, 2009, "Rehospitalizations among patients in the Medicare Fee-for-Service Program.)
- The Medicare Payment Advisory Commission (MedPAC) predicted that widespread use of remote patient monitoring to avoid unnecessary readmissions could help save the Medicare program $12 billion a year.
- About half of all patients do not take their pills as prescribed resulting in an estimated $290 billion a year in unnecessary emergency room visits, avoidable hospitalizations, additional physician visits and increased illnesses and death. (Health Affairs Blog, December 19, 2011.)
Changing the behavior of patients and physicians, and the hospitals' culture pose enormous challenges, but without far-reaching, systemic change there aren't enough resources - money, physicians, nurses, capacity, etc. - to meet the demands imposed on our nation's healthcare system. Hospitals must act quickly because they are about to confront a "perfect storm" of converging trends, mandates and market realities, including an aging population, newly insured Americans seeking care, a shortage of primary care providers and the shift from volume- to value-based reimbursement that will transform how they operate.
With bundled payments, shared risk, accountable care organizations (ACOs) and patient-centered medical homes (PCMHs), hospitals and physicians must find cost-effective tools such as remote monitoring to improve clinical outcomes and reduce costs.
Thirty-day readmissions, once a source of revenue, are quickly becoming a significant cost. Not only has the Centers for Medicare and Medicaid Services (CMS) stopped paying for readmissions for the same condition within 30 days of discharge, but in October 2012, CMS implemented a readmission penalty that cut overall Medicare reimbursement by up to 1% ($280 million) for 2,214 hospitals with high 30-day readmissions for heart failure, heart attack and pneumonia. The penalty will double to 2% in October 2013 and rise to 3%t in October 2014, when more conditions will be added.
Deploying a remote monitoring program to engage patients after they leave the hospital has helped improve clinical outcomes and decrease readmissions. The New England Healthcare Institute (NEHI) found that remote patient monitoring resulted in a 60% reduction in hospital admissions when compared to patients receiving standard care and a 50% reduction in hospital readmissions when compared to patients receiving traditional disease management programs without remote monitoring.
A remote monitoring program helped Geisinger Health Plan reduce the risk of all-cause 30-day readmissions by 44%, according to a study of 3,280 patients published in the January 2012 issue of Medical Care. Actual readmissions decreased by 19.5% according to the study.
A study in the November 21, 2012, issue of the Journal of Managed Care Medicine found that telemonitoring systems combined with case management helped Medicaid patients in the New York City Health and Hospitals Corporation (HHC) House Calls program reduce their glycosylated hemoglobin (HbA1c) levels by an average of 1.8%. A drop of 1% in HbA1c has been associated with a 35% drop in macrovascular endpoints, 18% fewer heart attacks and a 17% reduction in mortality. Patients received a blood glucose monitor and those with hypertension also received a blood pressure monitor. Readings were uploaded to a secure website, which alerted nurses when an intervention was needed. Nurses also called participants weekly to provide diabetes self-management education, support, coaching and reminders about treatment and medication adherence.
Although remote monitoring and the ability to transmit, analyze and respond to data are critical elements of a telemonitoring program, the most effective programs combine state-of-the-art technology with skilled case management: high tech and high touch. Key components for effective telemonitoring-enabled patient engagement include:
- Set the stage early. Generally, when patients are ready to go home from the hospital they are confused, worried or groggy from medications, making it difficult for them to take in new information. It is best to introduce the concept of telemonitoring to potential candidates early in their stay and reinforce that they will be contacted soon after discharge. It's helpful if physicians and nurses mention remote monitoring, since patients trust their advice. Helping patients understand and become comfortable with the idea of remote monitoring before leaving for home improves the chances they will participate in the program.
- Wait a day or two to reach out to discharged patients. The best time to approach individuals is after they have had time to decompress, relax and settle down at home, which typically takes 24 to 48 hours. By then, they will be ready to hear more about telemonitoring, ask further questions and decide whether to enroll. It is imperative that facilities involve patients' relatives and caregivers and gain their support. Hospitals also should inform and assure physicians that they will alert and consult them whenever necessary.
- Eliminate self-reporting by patients. A key reason telemonitoring initiatives fail is that patients are asked to self-report data. Bluetooth-enabled monitors, digital scales and medication dispensers that automatically transmit this information to a secure website for review overcome this barrier.
- Allocate resources. Hospitals that add remote monitoring to the existing workload of nurses and case managers may find them spending considerable time on administrative tasks. That's why it may make sense to consider outsourcing a remote monitoring program.
Moving forward, organizations' ability to compete, manage risk and succeed in a value-based environment will depend to a large degree on providing proactive care and engaging patients with chronic diseases. Remote monitoring is an effective and powerful tool to deliver high-quality, cost-effective treatment for the costliest patients, navigate challenging market forces, and optimize patient satisfaction and financial performance.
Nesim Bildirici is president and CEO of AMC Health.