Home Healthcare Is Reaching Out: Are You Making the Connection?
As the baby boomer population ages and the incidence of chronic illness continues to rise, effective home healthcare can help facilities meet the increasing demand for services. A quality program also can help prevent avoidable hospital readmissions, which the Centers for Medicare & Medicaid Services (CMS) has identified as a significant problem. Home health is helping facilities with their efforts to develop strategies for accountable care organizations (ACOs) and establish remote patient monitoring.
Placing more weight upon a fragile healthcare ecosystem is the fact that the baby boomers are continuing to age. The oldest of the baby boom generation turned 65 in 2011—10,000 each day. That kicks off a retirement boom that will extend over the next two decades. A 2006 Government Accountability Office (GAO) study on the effects of the baby boomer generation found that 2002 Health and Retirement Study data indicated that only 8 percent of the leading edge of the baby boomers had long-term care health insurance at that time. However, projections showed that 25 percent of people age 65 in 2006 will use nursing home care.
The rise of baby boomers using home care services in conjunction with the high rates of chronic illness presents a unique problem in the face of a changing U.S. healthcare landscape that will place more emphasis on quality measures, such as patient readmissions. Thus, it is likely that more sick patients will move into the home care setting and better methods are needed to prevent readmissions.
Some organizations are showing powerful, positive results to patient readmission problems by tackling the problem head-on, especially when it comes to an aging population seeking home healthcare. For example, as part of a $1 million Beacon Community-funded project for remote patient monitoring, St. Vincent Health in Indianapolis found that the use of videoconferencing through mobile devices and monitoring patients' daily blood pressure, weight and oxygen saturation reduced readmissions during a clinical trial.
Eighty patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) have been enrolled in the St. Vincent study after the first year, with only two patients being readmitted in their 30-day follow-up period, according to Alan D. Snell, MD, CMIO. "We monitor, educate and communicate with them for 30 days to make sure they understand the disease process and their diet," he says. The baseline readmission rates for St. Vincent's hovered around the national U.S. average of 20 percent in 2009.
This type of telemonitoring program comes at a time when the need for reduced readmissions is paramount, as CMS has estimated the cost of avoidable readmissions at more than $17 billion a year. In fact, in 2012 CMS will stop paying for preventable readmissions for heart failure and pneumonia.
One major problem in the transition of care is medication duplication through the lack of medication reconciliation. Snell hopes to reduce this cause of readmissions through the use of telemonitoring devices and educational opportunities for patients. Another objective is to help patients better understand their chronic medical condition and make a greater investment in their personal health.
St. Vincent seems to be keeping up with the trends in the industry. Market researcher Kalorama Information reported in October that wireless patient monitors that can transmit a patient's vital signs across a hospital or connect a patient's home with a provider's office are the fastest growing medical device in terms of revenue earned. Between 2008 and 2010, these devices experienced a growth rate of 23 percent with the main driver being the aging population.
According to Snell, St. Vincent is ready to expand the trial early in 2012 to diabetes, pneumonia and other diagnoses that put patients at risk for readmissions.
At Partners HealthCare in Boston, a telemonitoring program that enrolls about 1,000 patients annually also has shown promising results. According to Joseph C. Kvedar, MD, founder and director of the Center for Connected Health at Partners, its connected cardiac care program for heart failure patients has reduced hospital readmission rates by 50 percent via the use of tabletop devices that upload vital signs to a dashboard for clinicians to monitor. Patients' vitals are taken in the morning to begin the dataflow for the day, says Kvedar. Later in the day, if a patient doesn't upload vitals or if vitals are off parameters, a telemonitoring nurse from Partners will reach out to the patient.
Partners also has been testing medical adherence technologies in hopes of assisting home care. For instance, the organization launched a trial to test medical adherence to GloCaps, a cap that fits prescription bottles that glows in the dark or plays a ring-tone when it is time for a patient to take his or her medication. Kvedar says that the technology took medical adherence from a baseline of 50 percent to 98 percent among 60 enrollees. "It works well, but we're still figuring out where it fits in the supply chain and how to realize the value," says Kvedar.
Identifying people before they are sick is the goal, he says. "Home care organizations in 2011 should be using telehealth technology that combines nursing components and data analytics to provide a synergistic relationship to improve patient care and outcomes."
This could be word to the wise as the data on patient admissions do not bode well for readmission improvements ooverall. The results from a five-year study from 2004 to 2009 at the Dartmouth Atlas Project of the Dartmouth Institute for Health Policy & Clinical Practice in Lebanon, N.H., showed little variation in patient readmission rates. An examination of 10.7 million hospital discharge records for Medicare patients found that across the U.S., there was little change in 30-day readmission rates regardless of the cause of initial hospitalization. "Readmission rates following surgery were 12.7 percent in both 2004 and 2009, while readmission rates for medical conditions rose slightly from 15.9 percent in 2004 to 16.1 percent in 2009," the report found. "Overall, 42.9 percent of patients who were released to go home from the hospital after medical treatment had a primary care visit within two weeks in 2009."
According to a report published in January 2009 in Telemedicine and e-Health, the cost of the Veterans Health Administration's nationwide home telehealth program Care Coordination/Home Telehealth (CCHT) was $1,600 per patient per year, which is "substantially less than other non-institutional care programs and nursing home care." CCHT involves the implementation of health informatics, home telehealth and disease management technologies to assist patients who live independently at home. Adam Darkins, MD, of the Department of Veterans Affairs, and colleagues wrote that routine analysis of data obtained for quality and performance purposes from a cohort of 17,025 CCHT patients showed the benefits of a 25 percent reduction in inpatient days, a 19 percent reduction in hospital admissions and mean satisfaction ratings of 86 percent.
The costs of telemedicine videoconferencing systems and transmission service are no longer a major barrier to deployments, according to a October 2010 report from market research firm Frost & Sullivan. Equipment prices have gone down while endpoint functionality, especially video quality, has improved substantially, according to the report.
"We're seeing larger agencies adopt telehealth," says Erik Bermudez, research manager at KLAS, a healthcare technology market research company based in Orem, Utah. However, according to a September report, KLAS found that most home care vendors have no interoperability for efficiently sharing data with affiliated hospitals and clinics. "There were no specific reasons mentioned for the little interoperability, meaning the ability to link between home health systems with an affiliate hospital EMR," says Bermudez.
The reasons for lack of interoperability are widespread. For instance, Partners is not integrating home health data into the EMR because they are currently building out display configurations for when it is integrated later in 2012, according to Kvedar. St. Vincent opted not to use the grant funding to interface the home monitoring devices into EHRs, but Snell understands that will be an important integration strategy going forward. "The goal is to reach as many patients as we can, in order to learn from this study the right approach and strategies for remote patient monitoring," Snell says.
The use of telehealth to increase nursing efficiency also is appealing for Centura. "Home care is a capitated system," says Denholm. Telehealth nurses at Centura can check on 20 to 22 patients a day as compared to eight patients a day using traditional home care services, she says. "It's a huge workforce strategy."
"It's a growth industry," points out Kvedar. Home health/telehealth initiatives, while focusing on accountable care organization (ACO) development and reducing patient readmissions, are not fully realized across the U.S. healthcare system, he says. For example, Centura is pulling back its use of videoconferencing and focusing more on remote patient monitoring, according to Denholm. Telemonitors in the home include the taking of vital signs, like oximeter readings and weight, and also ask a series of questions customized to patients based on comorbidities. Those results are uploaded to telehealth nurse stations in real time. If the signs are outside of previously set parameters, the nurses will intervene, says Denholm. "We also have software to trend the data and email that information to physicians."
Denholm says that many professionals tell her that they can't gain the results that Centura has experienced. However, "it's about the art and science of nursing." She says organizations need to use technology to take advantage of patient information and establish "actionable reactions" when patients' conditions decline. "There's a huge interest in programs and technology that can assist people in staying healthy," concludes Denholm. As facilities gain experience in this arena, the results will prove their worth. "There is a role for telehealth in all circumstances in integrated or freestanding systems."
Looming challenges
The future patient landscape can look grim. According to the Centers for Disease Control and Prevention's (CDC) website, seven out of 10 U.S. deaths each year result from chronic disease. Specifically, heart disease, cancer and stroke account for more than 50 percent of all deaths annually.Placing more weight upon a fragile healthcare ecosystem is the fact that the baby boomers are continuing to age. The oldest of the baby boom generation turned 65 in 2011—10,000 each day. That kicks off a retirement boom that will extend over the next two decades. A 2006 Government Accountability Office (GAO) study on the effects of the baby boomer generation found that 2002 Health and Retirement Study data indicated that only 8 percent of the leading edge of the baby boomers had long-term care health insurance at that time. However, projections showed that 25 percent of people age 65 in 2006 will use nursing home care.
The rise of baby boomers using home care services in conjunction with the high rates of chronic illness presents a unique problem in the face of a changing U.S. healthcare landscape that will place more emphasis on quality measures, such as patient readmissions. Thus, it is likely that more sick patients will move into the home care setting and better methods are needed to prevent readmissions.
Moving forward, reducing visits
Telemedicine, the use of IT and telecommunication technology to assist clinical care practices, has the capability to transcend healthcare across state lines to assist patient care.Some organizations are showing powerful, positive results to patient readmission problems by tackling the problem head-on, especially when it comes to an aging population seeking home healthcare. For example, as part of a $1 million Beacon Community-funded project for remote patient monitoring, St. Vincent Health in Indianapolis found that the use of videoconferencing through mobile devices and monitoring patients' daily blood pressure, weight and oxygen saturation reduced readmissions during a clinical trial.
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| In a pilot program at St. Vincent Health in Indianapolis, only two patients out of 80 were readmitted in a 30-day follow-up period. |
This type of telemonitoring program comes at a time when the need for reduced readmissions is paramount, as CMS has estimated the cost of avoidable readmissions at more than $17 billion a year. In fact, in 2012 CMS will stop paying for preventable readmissions for heart failure and pneumonia.
One major problem in the transition of care is medication duplication through the lack of medication reconciliation. Snell hopes to reduce this cause of readmissions through the use of telemonitoring devices and educational opportunities for patients. Another objective is to help patients better understand their chronic medical condition and make a greater investment in their personal health.
St. Vincent seems to be keeping up with the trends in the industry. Market researcher Kalorama Information reported in October that wireless patient monitors that can transmit a patient's vital signs across a hospital or connect a patient's home with a provider's office are the fastest growing medical device in terms of revenue earned. Between 2008 and 2010, these devices experienced a growth rate of 23 percent with the main driver being the aging population.
According to Snell, St. Vincent is ready to expand the trial early in 2012 to diabetes, pneumonia and other diagnoses that put patients at risk for readmissions.
Cutting readmission rates
Erin Denholm, MSN, RN, CEO of Centura Health at Home, a faith-based statewide system headquartered in Denver, also has seen great progress in its home care divisions. Seven years ago, Centura created a strategy to move towards readmission prevention with impressive results. Beginning with CHF patients, Centura identified "frequent flyers" and put them on telehealth videoconferencing services, which decreased emergency room (ER) visits by 100 percent and hospitalization by 90 percent. After a six-month trial period, the original cohort was followed for three years during which Centura continued to see the patient population stay out of the ER (100 percent) and the hospital (84 percent). "For those who did enter a care setting, we found they did not go for CHF problems," says Denholm.At Partners HealthCare in Boston, a telemonitoring program that enrolls about 1,000 patients annually also has shown promising results. According to Joseph C. Kvedar, MD, founder and director of the Center for Connected Health at Partners, its connected cardiac care program for heart failure patients has reduced hospital readmission rates by 50 percent via the use of tabletop devices that upload vital signs to a dashboard for clinicians to monitor. Patients' vitals are taken in the morning to begin the dataflow for the day, says Kvedar. Later in the day, if a patient doesn't upload vitals or if vitals are off parameters, a telemonitoring nurse from Partners will reach out to the patient.
Partners also has been testing medical adherence technologies in hopes of assisting home care. For instance, the organization launched a trial to test medical adherence to GloCaps, a cap that fits prescription bottles that glows in the dark or plays a ring-tone when it is time for a patient to take his or her medication. Kvedar says that the technology took medical adherence from a baseline of 50 percent to 98 percent among 60 enrollees. "It works well, but we're still figuring out where it fits in the supply chain and how to realize the value," says Kvedar.
Identifying people before they are sick is the goal, he says. "Home care organizations in 2011 should be using telehealth technology that combines nursing components and data analytics to provide a synergistic relationship to improve patient care and outcomes."
This could be word to the wise as the data on patient admissions do not bode well for readmission improvements ooverall. The results from a five-year study from 2004 to 2009 at the Dartmouth Atlas Project of the Dartmouth Institute for Health Policy & Clinical Practice in Lebanon, N.H., showed little variation in patient readmission rates. An examination of 10.7 million hospital discharge records for Medicare patients found that across the U.S., there was little change in 30-day readmission rates regardless of the cause of initial hospitalization. "Readmission rates following surgery were 12.7 percent in both 2004 and 2009, while readmission rates for medical conditions rose slightly from 15.9 percent in 2004 to 16.1 percent in 2009," the report found. "Overall, 42.9 percent of patients who were released to go home from the hospital after medical treatment had a primary care visit within two weeks in 2009."
Costs not a barrier
One of the reasons home health initiatives can be successful is because of the reduced costs of technology. "We ask ourselves how we can work together with smaller hospitals and large academic centers to coordinate transitions of care," says Snell. "Telemonitoring is the natural progression to monitor patients in a small community or long-term care facility. It makes sense because the technology is cheaper and the reliability of the wireless networks has made these efforts more a reality and less of a pipedream."According to a report published in January 2009 in Telemedicine and e-Health, the cost of the Veterans Health Administration's nationwide home telehealth program Care Coordination/Home Telehealth (CCHT) was $1,600 per patient per year, which is "substantially less than other non-institutional care programs and nursing home care." CCHT involves the implementation of health informatics, home telehealth and disease management technologies to assist patients who live independently at home. Adam Darkins, MD, of the Department of Veterans Affairs, and colleagues wrote that routine analysis of data obtained for quality and performance purposes from a cohort of 17,025 CCHT patients showed the benefits of a 25 percent reduction in inpatient days, a 19 percent reduction in hospital admissions and mean satisfaction ratings of 86 percent.
The costs of telemedicine videoconferencing systems and transmission service are no longer a major barrier to deployments, according to a October 2010 report from market research firm Frost & Sullivan. Equipment prices have gone down while endpoint functionality, especially video quality, has improved substantially, according to the report.
"We're seeing larger agencies adopt telehealth," says Erik Bermudez, research manager at KLAS, a healthcare technology market research company based in Orem, Utah. However, according to a September report, KLAS found that most home care vendors have no interoperability for efficiently sharing data with affiliated hospitals and clinics. "There were no specific reasons mentioned for the little interoperability, meaning the ability to link between home health systems with an affiliate hospital EMR," says Bermudez.
The reasons for lack of interoperability are widespread. For instance, Partners is not integrating home health data into the EMR because they are currently building out display configurations for when it is integrated later in 2012, according to Kvedar. St. Vincent opted not to use the grant funding to interface the home monitoring devices into EHRs, but Snell understands that will be an important integration strategy going forward. "The goal is to reach as many patients as we can, in order to learn from this study the right approach and strategies for remote patient monitoring," Snell says.
The use of telehealth to increase nursing efficiency also is appealing for Centura. "Home care is a capitated system," says Denholm. Telehealth nurses at Centura can check on 20 to 22 patients a day as compared to eight patients a day using traditional home care services, she says. "It's a huge workforce strategy."
Down the line
"Home health agencies need to look at the purchase as a relationship and not go into purchasing a system with blinders," says Bermudez. He points out that of the home health agencies KLAS spoke with, 60 percent are not using telehealth services, whereas 40 percent are leveraging that technology. In addition, the report found that keeping on top of government regulations is a complex and constant task for both providers and vendors."It's a growth industry," points out Kvedar. Home health/telehealth initiatives, while focusing on accountable care organization (ACO) development and reducing patient readmissions, are not fully realized across the U.S. healthcare system, he says. For example, Centura is pulling back its use of videoconferencing and focusing more on remote patient monitoring, according to Denholm. Telemonitors in the home include the taking of vital signs, like oximeter readings and weight, and also ask a series of questions customized to patients based on comorbidities. Those results are uploaded to telehealth nurse stations in real time. If the signs are outside of previously set parameters, the nurses will intervene, says Denholm. "We also have software to trend the data and email that information to physicians."
Where to fit?
Three years ago, Centura received a $100,000 grant which was used to expand their call center to 24/7 coverage and cross-train nurses to telehealth. The organization also has been piloting among 60 assisted living patients an effort to make their telehealth program included as an assisted living service. Twelve percent of those 60 patients used the program in the first year, and Centura just received an additional $300,000 grant for a three-year period to expand the pilot.Denholm says that many professionals tell her that they can't gain the results that Centura has experienced. However, "it's about the art and science of nursing." She says organizations need to use technology to take advantage of patient information and establish "actionable reactions" when patients' conditions decline. "There's a huge interest in programs and technology that can assist people in staying healthy," concludes Denholm. As facilities gain experience in this arena, the results will prove their worth. "There is a role for telehealth in all circumstances in integrated or freestanding systems."
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