Use Case Study: Remote Patient Monitoring for Chronic Disease

Transcription

1 Use Case Study: Remote Patient Monitoring for Chronic Disease Hackensack Alliance Accountable Care Organization New Jersey March 2014

2 The Hackensack Alliance Accountable Care Organization (ACO) was established to participate in the Medicare Shared Savings Program, received NCQA Level 1 certification in December 2013, and serves approximately 40,000 patients with the recent addition of a commercial contract. Physician founded and backed by Hackensack Medical Center, the ACO s mission is to provide patients with high quality service and medical care, while reducing the growth in care expenditures through enhanced care coordination, preventive care, patient empowerment, and practices supported by medical research. In order for patients to receive quality care that makes a positive difference, the ACO physicians and nurses work closely with patients, family members and other providers to coordinate care across medical specialties and care settings. Executive Summary HIMSS mhealth Community, powered by mhimss, provides stories of mvalue, successes, and lessons learned from implementation and use of mhealth. The mvalue Case Study Submission program has crosswalked the HIMSS Health IT Value Suite program, a comprehensive knowledge repository that classifies, quantifies and articulates the clinical, financial, and business impact of health IT investments with the mhimss Roadmap, a strategic framework for providers to implement mobile and wireless technologies. The Roadmap highlights six key areas of focus; Technology, New Care Models, Standards, Policy, Privacy/Security, and ROI/Payment. The intent is to leverage these examples to assist in supporting decision-making and deployment for any hospital, Health System, or Provider group looking to deploy mobile and wireless technologies. mhealth Technology Remote Monitoring and Disease Management Tablet Goals Achieved 1. Decreased hospital readmission rate 2. Improved patient compliance and patient activation 3. Improved patient satisfaction Health IT Value: Savings 1. Reduced 30-day readmission rate associated costs April 2014 Page 2 Copyright 2014 Healthcare Information and Management Systems Society (HIMSS)

3 Case Study Snapshot The Hackensack Alliance ACO serves a large 40,000 patient population, many of which are elderly, disabled, and living with chronic disease. When managing this many patients, ACOs need an efficient and effective method for monitoring and caring for outpatients to avoid costly readmissions. With this issue in mind, Hackensack ACO piloted an outpatient, mobile disease monitoring and management tool for patients to use in their own homes. The ACO s goals were to 1) evaluate the impact of nurse-directed patient education on patient self-management of their chronic diseases, 2) evaluate the extent 30-day hospital readmissions decreased as a result of patient disease self-management using a 4G android tablet. The patient engagement platform, provided by Health Recovery Solutions (HRS) enabled Hackensack University Medical Center and its ACO to utilize existing staff to monitor patient compliance with diet, weight monitoring, blood sugar monitoring and medication adherence. The HRS platform also helped patients identify symptoms early so they did not evolve into problems that required the emergency room and/or hospitalization. Patients were also provided integrated Bluetooth devices such as blood pressure cuff, pulse oximeter and glucometer so that hemodynamics could be concurrently reviewed. By utilizing existing staff and focusing on these aspects of proactive interventions and reinforcement of patient education, the ACO produced a 30-day readmission rate of only 5.5% and provided patients with a better quality of life. mhealth Purpose What events or observations triggered the decision to make changes at your organization? Describe the issue or workflow you set out to improve with a mhealth solution. In order to successfully reduce readmissions and provide better quality of care, we needed a more efficient system utilizing existing staff to manage a large population of patients outside the hospital. ---Denise Patriaco, Director of Care Coordination, Hackensack Alliance ACO According to Denise Patriaco, Director of Care Coordination for the Hackensack Alliance ACO, the organization faced challenges with outpatient care management, chronic disease monitoring, and hospital readmission rates. Chronic heart failure, in particular, is a high volume, high cost diagnosis that s yielding many readmissions in our hospital and across the nation, she said. The national average Copyright 2014 Healthcare Information and Management Systems Society (HIMSS) readmission rate for heart failure has remained steady at 20-25% for several years despite hospitals working harder to lower their individual readmission rate. Studies have shown that more than 50% of these readmissions can be prevented. Patriaco explained that the organization wasn t properly equipped to efficiently monitor and April 2014 Page 3

4 deliver care to this large outpatient population, and that they needed a mechanism to engage patients in their own care. It s difficult to facilitate follow-up interaction without an effective information delivery system, she said. In order to successfully reduce readmissions and provide better quality of care, we needed a more efficient system utilizing existing staff to manage a large population of patients outside the hospital. Leadership/Governance Describe the leadership/governance of your implementation (champions, supporters, management). Initially, the Heart Failure Program research team at Hackensack Medical Center approached Patriaco about Health Recovery Solutions and its PatientConnect TM 4G tablet platform. After trialing other home telehealth devices, she championed the selection of this device and platform for the ACO chronic disease management program. Our population consists of elderly or disabled patients. The companies we were trialing had clumsy devices which required manipulation, wiring into phone lines or Wi-Fi, which most of our patients did not have, Patriaco explained. So, I was very excited to find this mobile, 4G Internet tablet with embedded Wi-Fi and easy to use Bluetooth devices. ACO leadership, including the Chief Medical Officer and Chairman of the Board, approved the pilot and technology platform. The IT department wasn t involved because data from the tablet was delivered to a closed system and not integrated with the hospital and ACO physician practice EMRs. Milestones & Metrics What was your implementation plan and how was the outcome measured? The ACO was involved in the randomized trial mid-2012 through mid-2013 with 50 chronic heart failure patients at Hackensack University Medical Center and Holy Name Medical Center. They gave the tablet to half the patients and maintained the other half as control group that didn t use the tablet. According to Patriaco, they started with chronic heart failure because it was a high volume, high cost diagnosis that was yielding many readmissions for the hospital. The tablet was later loaded with diabetes and COPD and used with ACO patients only. The ACO nursing staff, called Nurse Navigators, customized the tablets for the patients, selecting either English or Spanish and loading each tablet with individual patient information, medications, educational videos, and survey questions. The nurses also sent patients home with wireless Bluetooth devices that could be utilized by the patients to track key physiological information, such as pulse oximeter, glucometer, blood pressure cuff, and scale. They gave the tablets to patients prior to hospital discharge and at practice offices after discharge, and demonstrated how to use them. Patients were encouraged to watch the educational videos on the tablets before being discharged or leaving the office. The Heart Failure Program was the first to trial the technology platform. The nursing staff managed the daily aspects of the pilot, including patient education, patient engagement, tracking patient self-management of their heart failure, and reviewing the information delivered by the tablet.

5 Following discharge, the patients used the tablets for 30 days and were monitored by the Nurse Navigators. Patients were instructed on which medications to take, along with the appropriate dosage time, and to use one of the Bluetooth monitoring tools as scheduled to collect key physical indicators like weight and blood pressure. Data was measured at the individual patient level and at the aggregate pilot patient population level. If a patient didn t input the required data within an hour of the designated time, an alert was triggered and sent via phone and to the Navigator. The alert resulted in the Navigator calling the patient. If the alert was triggered after normal business hours, it was automatically rerouted to the on-call hospital nurse Patient Navigator. Patients could also proactively call through the tablet or video chat with a nurse. The nurses monitored the data via a dedicated web portal, ClinicianConnect TM, that s part of the overall technology platform. The ACO measured clinical data for individual patients and across the pilot patient populations,

6 including patient age, total number of alerts across patients and number of alerts per day; 30-, 60- and 90-day readmissions; daily medication and weight measuring adherence, weight loss, daily activity, pulse measuring, and daily survey completion. The tablets came with a box that included a self-addressed return label and prepaid postage. Therefore, once the patient was done using the tablet, they simply mailed it back at no cost to them or to the ACO. alerts generated per day and a total of 431 high risk intervention alerts sent throughout the life of the pilot program. Patient adherence to prescribed activity level and recording activity was also high: activity entry - 61%, daily average activity time 27 minutes. Although an unintended outcome, participating patients also lost weight, 8.5 pounds on average. Financial Considerations How was your mhealth project funded? Outcomes What outcomes did you observe from the implementation of the mhealth solution? Did it meet your intended purpose? Were there unintended outcomes that arose, positive or negative? Did you need to respond to any of the unintended outcomes? The pilot proved the platform s value. The ACO patients that used the tablet post hospital discharge had a 5.5% 30-day readmission rate, compared to a 28% readmission rate for the trial control group. There were three 60-day readmissions and no 90-day readmissions. The average patient was 75 years old with an ejection fraction below 40%. Average patient adherence for monitoring and recording their data on the tablet was high: medication - 79%, glucose - 87%, blood pressure - 93%, pulse-ox %, daily survey response - 80%. There were on average 2.5 HRS funded the pilot program and the ACO received a grant from Verizon to pay for the first year of tablet use once the pilot ended. According to Patriaco, the ACO will provide ongoing funding after the grant ends. The tablet program has been very successful, she said. If we give the tablet to 30 patients and it saves one readmission, we ve saved money. As an early adopter, our cost is less than $100 per patient per month. And the financial impact is great because it costs us about $300 to keep a patient on the program for 90 days. Conclusions Would you change anything about the solution or the implementation? Do you have any additional lessons learned? What s next? ACO leadership and the Hackensack Medical Center Heart Failure Program team were pleased with the program and its impact on helping the team provide effective outpatient care. Upon introducing the program to the Navigation staff and enrolling all patients, it was clear that aside from the significantly lower readmission rate, there was also an astonishing amount of data available to us from the mobile tablet platform, Patriaco added. She also noted that the only part of the

7 implementation they would have changed was how they enrolled patients. Initially, the Navigators offered the tablet as an optional tool rather than requiring patients to use it. As a result, Patriaco said the organization missed patients at first because older people were afraid of the technology. Now, the nursing staff tells patients that the physician requires it and they get it into the patient s hands right away and relieve most of their fear of technology in the first 10 minutes. Additional Insights and Lessons Learned Patriaco shared the following insights and lessons learned: The ACO is able to customize the tablets for each patient and adjust the diagnoses, patient requirements and survey questions as needed remotely and in real time. Training the Patient Navigators is very simple. The most time-consuming part was inputting medications on the tablets correctly. However, the technology vendor provides an easy step-by-step guide and monitors the data being input onto the tablets. Initially, the ACO wasn t confident about whether the elderly population would adopt the use of the technology. The pilot program and subsequent rollout of the tablets has proven that the ACO s elderly patients are, in fact, using it and enjoying using it. Our patients like the tablet so much they don t want to give it back! Patriaco said. Most elderly patients don t welcome it or want it, but once they start using it, it becomes their friend and they love it. What s Next The ACO is expanding the use of the technology platform. The tablet was traditionally given to patients once they ve been readmitted to the hospital. It s now being given to patients who have not yet been readmitted but are at high risk for readmission based on set criteria. The tablet is also being used by the ACO Navigators in the outpatient setting when patients are visiting primary care offices for follow up visits. The ACO is also working with HRS on new initiatives and platform functionality. They re working to incorporate more features that keep patients engaged and motivated to use the tablet. Patriaco notes, though, that they are conscious of not putting too much on the tablets to prevent them from becoming too confusing for the patients. They re also working to create a generic, preventive use platform for any patient, such as providing reminders to take medications and monitoring vital signs. In addition, the ACO is reviewing a version of the platform for use with chronically ill patients and for younger populations living with a disease other than a primary cancer diagnosis. The ACO also plans to roll out additional diagnoses and conditions, such as coronary disease for post heart attack patients, once the technology vendor makes them available. mhimss is the globally-focused mobile initiative offered by HIMSS. As a cause-based, mission-driven 51-year-old non-profit, HIMSS created mhimss as a platform for all stakeholders within the global mobile community to drive positive, transformational change in health and healthcare through the best use of IT. Copyright 2014 Healthcare Information and Management Systems Society (HIMSS) The inclusion of an organization name, product, or service in this document should not be construed as a HIMSS endorsement of such organization, product, or service, nor is the failure to include an organization name, product, or service to be construed as disapproval. For more information visit