Reducing 30-day Hospital Readmissions for Congestive Heart Failure Patients by Utilizing Remote Patient Monitoring (RPM) Technology
Sharp HealthCare Foundation
As an extension of the Sharp HealthCare Lean Six Sigma project focused on reducing 30-day readmissions, the CHF Remote Patient Monitoring Program focuses on leveraging technology and health coaching to help patients from two Sharp hospitals manage their congestive heart failure condition. The program uses telehealth and the evidence-based ‘care transitions’ approach to help unfunded, Medi-Cal/CMS and Medicare Fee for Service (unassigned) patients stay independent, well managed at home, and out of the acute care setting. The program is 90% funded from grants and corporate sponsorship and enrolls patients free of charge. The intense 90-day intervention includes daily remote monitoring using a Cardiocom’s Telescale, at least two home visits, unlimited telephonic support and an overall focus on improving patient activation and confidence.
Sharp HealthCare’s Remote Patient Monitoring Program is effective in reducing 30-day and 90-day readmissions as well as number of admissions. The study enrolled 80 patients, 66 of whom completed the 90 day program during the 8 month recruiting period. The RPM program compared the outcomes of enrolled patients diagnosed with primary, secondary or tertiary heart failure with a reference group of similarly diagnosed patients, with the same payor mix who were not enrolled in the RPM program. There were statistically significant differences in care utilization between groups. The RPM 30-day readmission rate was 10%, compared with a 20.7% rate for the reference group. There was also a significant difference in readmissions per patient between groups: 1 (sd, 0) versus 1.25 (sd, .46). These results continued into the 90-day post index-discharge time frame: RPM group 90-day readmission rate was 21.2% compared with 39.6% for the reference group. The number of readmission per person was also significantly reduced at this time frame: 1.29 (sd, .47) vs. 1.67 (sd, 1.05). These results only reflect care utilization at Sharp HealthCare and not care that may have been delivered at non-Sharp HealthCare facilities.
WHO WAS INVOLVED?
Innovator: Sharp HealthCare including Sharp Grossmont Hospital and Sharp Chula Vista Medical Center; Corporate Partner: Cardiocom™; Community Partner: San Diego Beacon Community
WHAT THEY DID
Problem Addressed: The key problem addressed through the CHF RPM program is the need to reduce 30-day readmissions. Meeting the challenge of hospital readmissions is paramount for four reasons:
1) Patients are not thriving post-discharge due to gaps in their transition from hospital to home;
2) Readmissions for this population are an expense to the providers for the underserved population;
3) Unnecessary readmissions limit hospital bed capacity; and
4) Changes to CMS reimbursement will penalize hospitals with poor performance on 30-day readmissions for target diagnoses.
The underserved/unassigned population is at a greater risk for post-discharge complications due to gaps in their transition from hospital to home. While services may exist for these patients, they have challenges in navigating the complexities of the health care system while dealing with their medical conditions. Additionally, while these patients receive thorough education while they are in the hospital on their disease and how to access community resources, they are often overloaded with excessive amounts of information when they are least likely to comprehend it.
Simply put, across the board readmissions result in millions of dollars in direct costs to Sharp HealthCare each year ($9.5 million in the CHF patient population, and almost $80 million for all patients annually).
Reducing readmissions frees up hospital beds for patients who are in need. The primary benefactor of this is ED patients who are often waiting excessively for a bed to become available to receive treatment. In the last decade, California has lost more than 70 community hospitals and emergency departments, including Scripps Hospital East in 2000. According to the Abaris report on San Diego County’s Safety Net commissioned by the County and The California Endowment, San Diego will experience a need for 37.4% more hospital beds by 2025. Providing these beds is problematic in the current economic environment, due to the national economy and issues unique to California and San Diego.
CMS is in the process of implementing changes to reimbursement that penalize hospitals underperforming in treating specific diseases. Sanctions will be determined by benchmarked performance and readmission rates. While the specifics are yet to be finalized, based on historical data for all of Sharp’s Medicare patients, the organization is at risk to lose at a minimum of $2.8 million in reimbursement for heart failure readmissions and $1.2 million for chronic obstructive pulmonary disease (COPD) readmissions.
Patient Population: Patients were admitted to two system hospitals with NYHA Class II and III stage heart failure. Admission to the program was focused on patients who are in the underserved group for health insurance: Medi-Cal, County Medical Services, Molina, Medicare/Medi-Cal, Self-pay, and Medicare FFS were the primary payers.
Description of the Innovative Activity: The RPM pilot program at Sharp HealthCare was designed for patients with chronic heart failure who are uninsured, under insured, or unassigned (Medicare Fee-For-Service with no designated PCP). These patients must become better engaged in their own care. The technology used in this intervention is a new telehealth scale that allows patients to engage in their own care and maintain their independence at home through a system of support interventions including: 90 days of daily monitoring of symptoms and weight to ensure new learning has taken place; support from the local RPM nurse health coach and vendor’s telemonitoring nurses for variances in weight or symptoms; two home visits – one at the beginning of program to ensure proper use of equipment and personalize program to the patient and one at the end to facilitate graduation from the program; and daily reminder of medication compliance via the device. The details of the program are as follows:
Assessment in hospital by nurse health coach. Home visit (within 7-10 days after discharge). Patients are identified in a hospital system by a “CHF screening tool” (developed at Sharp HealthCare) and Pro-BNP (Brain Natriuretic Peptide) review list. The nurse health coach screens patient for inclusion criteria and then visits patient. When the patient agrees to be in the program, s/he signs the HIPAA and consent form. Subsequently, the Cardiocom Telescale™ is ordered when the patient is discharged from the hospital. Before leaving the hospital, written information regarding management of CHF is given to the patient for review in the hospital and during the home visit.
Patients are evaluated on their ability to manage their heart failure by using the Heart Failure Self-Care Index evaluation. This evaluation looks at maintenance, management and confidence scores in regards to managing their heart failure.
Home visit (1st of 2) within 7-10 days, aligning with the arrival of the Cardiocom Telescale™ The nurse health coach follows the discharge of the patient from the hospital with a home visit timed with the arrival of the Cardiocom Telescale.™ This keeps in step with the Transitions Model for management of chronic disease, as the program flows from the hospital to home. Care management is arranged by the nurse coordinator that the patient met in the hospital. By seeing the same health care professional, the patient remains comfortable as the patient already knows/recognizes the health care provider. The goal of the home visit is to review heart failure management and ensure that the patient is proficient with use of the Cardiocom Telescale™. The review includes:
- Medication Management – Focus on self-management which includes reconciliation of all medications and education regarding use of all medications, especially diuretics. Patient given pill box to organize medications.
- Knowledge of Red Flags – Review signs and symptoms of congestive heart failure, specifically knowledge of worsening symptoms and the appropriate response including when to call the doctor and/or use the emergency room. This information originates in the hospital at discharge in the form of the Heart failure zone document (green – safe; yellow – caution of worsening symptoms; red – access ED) is re-emphasized in the home.
- Diet and Nutrition – Review low salt diet and fluid restriction, provide National Heart Lung and Blood Institute (NHLBI) “Keep the Beat” Cookbook and Mrs. Dash salt-free seasoning.
- Review of Technology and Device – Demonstration of use of Cardiocom Telescale™ with teach back.
90 days of monitoring by Cardiocom™, with use of Cardiocom Telescale™ Daily upload of weight and Health Check questions are completed by the patient and reviewed by nursing staff at Cardiocom and the nurse coordinator at the hospital. The Health Check Score is a numeric value that characterizes a patient’s wellness. It is based on the patient’s weight measurement and answers to symptoms questions. Each Health Check question has been assigned a relative value from 1-10 based on symptom severity. A Phone call from the program coordinator and/or phone call follow-up by the Cardiocom Nurse Coordinator is made to patient and physician for variances in weight or symptoms. This daily upload of biometric data and reinforcement of recognition of signs and symptoms of heart failure exacerbation is key to patient understanding.
Nurse coordinator available to patient as resource while active in the program.
Home visit (2ND of 2) to facilitate graduation of program. Nurse health coach graduates patients from the program to self-care during a final home visit. This interaction covers a review of the program’s education and the patient’s progress with managing their CHF and weight. To facilitate the transition from the RPM program to self-care a resource guide is provided connecting the patient to community resources such as community clinics, social services, and transportation. Additionally, patients are provided with a digital scale to use in their daily monitoring of their weight.
Additional home visit as needed.
DID IT WORK?
Summary of Results:
Care Utilization Outcomes
Sharp Healthcare’s Remote Patient Monitoring Program compared the outcomes of enrolled patients diagnosed with primary, secondary or tertiary heart failure with a reference group of similarly diagnosed patients, with the same payor mix, who were not enrolled in the RPM program. There were significant differences in care utilization between groups. RPM 30-day readmission rate was 10%, compared with a 20.7% rate for the reference group. There was also a significant difference in readmissions per patient between groups: 1 (sd, 0) vs 1.25 (sd, .46). These results continued into the 90-day post index-discharge time frame: RPM group 90-day readmission rate was 21.2%, compared with 39.6% for the reference group. The number of readmission per person was also significantly reduced at this time frame: 1.29 (sd, .47) vs. 1.67 (sd, 1.05).
Patient Satisfaction Outcomes
Patient satisfaction with the program was measured using the Centura Telehealth Patient Satisfaction tool. This survey was completed by patients during the graduation home visit with the nurse health coach. All but one patient was extremely satisfied with all aspects of the program (mode for all questions = 5. 1=No, definitely not, 2=I don’t think so, 3=Maybe yes, maybe no, 4=Yes, 5=Yes). For question #9: “The care I received with Telehealth technology was just a good as having a nurse come to my house”, had over 75% respond with Yes (4s and 5s).
Quality of Life Outcomes
Below are results from the patients who completed the Remote Monitoring Program:
- Patient Maintenance Activation: A SCHFI score above 70 is indicative of patient activation in maintenance of heart failure symptoms. Only 2% of all patients at enrollment met the threshold for maintenance activation, whereas 98% of all patients met the threshold at end of program. The mean score for patients at enrollment was 50.25 (sd, 19.68), which showed patients as a whole were not self-activated for maintenance of their heart failure (Riegel et al 2009). By the end of the program, the mean maintenance score was 88.77 (sd, 9.62), indicative of self-activated behavior. The literature states that an increase of above one half of a standard deviation can be considered a clinically relevant change in scores.
- Patient Symptom Management: A SCHFI score above 70 is indicative of patient activation in management of their heart failure symptoms. All but one patient scored below 70 at enrollment. At program graduation, only one patient scored below 70.
- Patient Confidence: A SCHFI score above 70 is indicative of patient activation in confidence in the ability to care for their heart failure symptoms by themselves (self-care confidence). Only 19% of all patients met the threshold for confidence at enrollment, whereas 92% of all patients met the threshold at end of program. The mean score for patients at enrollment was 54.79 (sd, 27.59), meaning that on average patients were not confident in their ability to manage their disease. By the end of the program, the mean confidence score was 92.41 (sd, 11.27), demonstrating a marked increase in confidence.
HOW THEY DID IT?
Context of the Innovation: Sharp HealthCare, a California nonprofit 501(c)(3) public benefit corporation, is the largest integrated delivery system in San Diego County, providing care to more than 785,000 individuals annually throughout the County. Sharp comprises four acute-care hospitals, three specialty hospitals, two affiliated medical groups, a health plan, two long-term care facilities, a professional liability insurance company, and three philanthropic foundations. Designated a Pioneer Accountable Care Organization, Sharp HealthCare is one of 32 ACOs across the nation that will work with CMS to pilot a program for 32,000 Medicare beneficiaries that will enhance engagement between patients and their medical providers in the coordination of care and services across all aspects of their health care needs.
As an extension of Sharp HealthCare’s Lean Six Sigma project focused on reducing 30-day readmissions, the CHF RPM Program was created to focus on leveraging technology and health coaching to help patients from Sharp Grossmont Hospital and Sharp Chula Vista Medical Center in managing their heart failure. The program uses telehealth scales and the evidence-based ‘care transitions’ approach to help unfunded, Medi-Cal/CMS and Medicare Fee for Service (unassigned) patients stay independent, well managed at home and out of the acute care setting. This program is offered free of charge to qualifying patients and includes daily remote monitoring using a telehealth scale, at least two home visits, unlimited telephonic support and an overall focus on improving patient activation and confidence.
Resources Used and Skills Needed:
- Staffing: One RPM nurse health coach implemented the program at two hospitals. The following teams at each site helped to support this position:
Sharp Chula Vista: Cardiovascular Service Program Manager, Nurse, and Lead Case Manager
Sharp Grossmont: Cardiovascular Services Director, Manager of Case Management, and Senior Cardiac Specialist
Sharp Hospice: Director of Sharp Hospice, Clinical Nurse for Transitions
Corporate: Director of Lean Six Sigma and Foundation resources
- Costs: The program’s primary cost consisted of the full-time RN nurse health coach and program operating expenses. Additional expenses included the cost of the telehealth scale rental, the RN monitoring service and cellular equipment rental, and biostatistician resources to help with the evaluation plan and data analysis.
Getting Started With This Innovation:
- Target Population: It is important to understand the clinical and demographic characteristics of patientsin that an RPM program will be successful for specific patient groups. Patients who are thriving on their own may not need this disease management intervention. Conversely, late stage CHF patients may need a more intense intervention.
- Health Coach (RN/LVN): Health coaches should have the following characteristics: relationship builders, advanced understanding of target diagnoses, flexible to meet patients’ needs, likeable, persistent, resourceful, empathetic and with an entrepreneurial spirit.
- Organizational Support: In addition to funding resources, organizations initiating a CHF RPM intervention need senior and/or executive leadership support.
Sustaining This Innovation: Initial grant funding for the RPM project has ended, yet the innovation continues at Sharp HealthCare with internal funding. The Foundation was successful in securing additional funding to expand the program to a different disease state. Sharp has expanded the the utilization of a chronic care RN manager to serve as a health coach for patients with COPD, and provides at least two home visits, unlimited telephonic support and an overall focus on improving patient activation and confidence. Future funding for RPM for Sharp’s managed care patients will be budgeted as an operating expense as would any other post-acute service. The ROI of the program is realized in the reduction in the cost of care for these patients. For non-affiliated patients, funding will be pursued through funding opportunities and programs that subsidize the cost of care for underfunded and unfunded patients to further strengthen the case for support of this innovative project.
Sharp has been using RPM within its Sharp Rees-Stealy Medical Group (SRS) since 2006. The newly created Pioneer ACO will add an additional 32,000 new members to the health system, many of whom have the same demographic profile as the RPM project. Because of the success of the RPM project, the ACO is planning to use the RPM intervention to manage CHF patients, and is exploring using the program for use with End Stage Renal Disease patients.
Critical to the success of the program is a commitment to the program by those leading it and interacting with patients; tracking and reviewing data regularly to validate that the program is working or to make course corrections if it is not; and physician support and operational leadership.
Other Considerations and Lessons:
- Balancing high demand for program resources with targeted patient selection: Remain focused on patients that this program can serve particularly when clinicians refer patients that need more resources
- The target patient population (under funded/served) does not always have a primary care or specialty physician: Established relationships with community clinics and ED on call panel physicians
- Patients without a telephone land line were initially excluded: Additional cellular technology was obtained to enroll these patients
- Time invested in recruitment of staff resources is time well spent: The model requires a nurse health coach to do marketing, patient recruitment and patient care – not every RN wants to wear all of these hats
- Program cannot help every patient: Patient selection criteria has to be very specific (inclusion and exclusion criteria) and strictly adhered to for effectiveness
- Cellular/mobile health products are required to meet needs of patients: Many patients do not have telephone land lines for wired devices and some patients need a device that they can take with them as they move from one caregiver to another