The chronic heart failure clinic at St. Vincent Health in Indianapolis was doing all it could to keep one of its patients out of the hospital. Despite keeping close tabs on her and sending home-health teams to see her, the woman missed medical appointments, was unable to keep her disease in check, and was admitted to the hospital 13 times in 2011.
But during her last hospitalization in December 2011, she agreed to go home with a special mobile device that would take her vital signs and allow her to have videoconferences each day with a case management nurse. She, along with other patients in the pilot project who were testing the device, would be monitored for 30 days after discharge. The medical team would track her health status closely and use the daily video conversations to educate her about the medications and self-care that would keep her healthy.
The result: The patient has not been back to the hospital for nine months. In 2011, her hospital care cost $156,000 in 2011; so far in 2012, she has rung up just $1,500.
This patient is an example of a readmission avoided at a time when reducing avoidable readmissions is a top priority for hospitals. Medicare has begun fining hospitals for having too many readmissions, and rates of readmission will be published on the HospitalCompare website.
Her results, along with those of the study group so far, have been remarkable, says Alan Snell, M.D., lead investigator of the videoconferencing project and chief medical informatics officer at St. Vincent Health. "It's been pretty amazing," he says. "The numbers are far better than we expected."
The group of patients using the devices had an overall readmission rate of 3 percent, compared with the control group (16 percent), and a national average readmission rate of 20 to 21 percent for patients with chronic heart failure and chronic obstructive pulmonary disease. The pilot involved several hospitals of all types in and around Indianapolis and was supported by a $1 million grant from the Central Indiana Beacon Community. Because there were such marked improvements, in January the program was offered to hospitals outside of the constraints of the study.
One major goal of the project is to crack the difficult nut of engaging patients. The device carries 17 embedded videos on various topics of self-care. "You can give the patient a handout, but you don't know if they've read or understood it," Snell says. "Now, through these tools in a mobile device, you can tell if patients are engaging, whether they are understanding their diseases."
Snell also was struck by the emotional connection patients made with their case managers through the daily video conversations. When the team went to the Indianapolis woman's home several months after the pilot was over, she and her case manager had a tearful reunion.
Tracking patients at home through various high-tech devices is not a new concept; such devices have been marketed to manage chronic care patients for more than a decade. "The big difference is the videoconferencing capability," Snell says. "It's not just the technology, it's using the technology to connect to the patient where they are, in the setting where they are comfortable."
Many Ways to Connect
Information technology is offering new possibilities for connecting with patients, says Jennifer Covich Bordenick, CEO of the eHealth Initiative.
"We're getting away from the idea of the patient walking into the doctor's office and sitting in front of the doctor," she says. More important is the idea of multiple touch points — connecting with a provider as often as needed. "It can be a phone call; it can be a text message; it can be a videoconference. All of those touch points can really help coordinate care for patients," she says.
Mobile phone applications also show promise, Bordenick says, noting that 45 percent of adult Americans are now carrying a smart phone.
The Office of the National Coordinator for Health Information Technology is offering financial rewards to innovators who come up with creative technologies to resolve nagging problems, such as transitioning patients from hospital to home and getting patients scheduled with post-discharge, follow-up appointments. Some of the winning entries have relied on mobile technologies to reach both patients and providers.
The research indicates that there is no single solution to prevent readmissions, according to a report on the topic by IT organization CSC's Global Institute for Emerging Healthcare Practices. After reviewing the literature, the author reported that the most promising approaches involve patient-centered discharge instructions along with post-discharge telephone calls.
With the advent of payment reform that promotes coordinated care, hospitals are moving into closer relationships with medical practices and other organizations in their health care markets. They need to be aware of the potential for overlap of post-discharge care, notes Jane Metzger, author of the CSC report. Having multiple care managers tracking the same patients would be confusing and wasteful.
As useful mobile technologies are developed, their adoption will depend on patients' finding them convenient and providers' being paid to participate, Bordenick says. "One of the biggest challenges here is payment reform, reimbursement and liability," she says. "The more flexible payers can be in terms of reimbursement, the better."
For more on using innovative case management to keep patients out of the hospital, read our October cover story "ED Interventions."
Jan Greene is a freelance writer in Alameda, Calif.
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