Reducing 30-day Hospital Readmissions through a Home Health TeleStation Monitoring Program for Heart Failure Patients
Dignity Health (formerly Catholic Healthcare West) sought to expand on an already robust and successful telephonic care management system to include remote patient monitoring technology. The goal of this remote patient monitoring program was to allow elderly patients to remain in a healthcare setting of their choice while self-managing chronic diseases such as heart failure. Key elements of the program included:
- Building a network of distance health service delivery based on reliable, easy-to-use, integrated remote patient monitoring technology that supports equitable access for patients and efficacy for clinicians.
- Improving the quality of care and clinical outcomes to include early detection, and intervention and reductions in avoidable hospitalizations.
- Improving patient compliance with medications, diet, weight monitoring and symptom management.
- Improving physician engagement and patient satisfaction.
The program was funded through grant funding from the Center for Technology and Aging and in-kind contributions from Dignity Health. The 6-month intervention includes daily remote monitoring using Philips’ TeleStation and a minimum of one home visit. The program targets Medicare patients over the age of 60 with class 3 or 4 heart failure who are at risk of re-hospitalization for an exacerbation of heart failure or related co-morbid conditions.
Dignity Health’s Remote Patient Monitoring Program is effective in reducing the rate of 30-day readmissions to three Dignity Health hospitals on the Central Coast of California (Marian Regional Medical Center, Arroyo Grande Community Hospital, and French Hospital Medical Center). Of the 51 patients enrolled into the program, 39 were on monitors six months or longer. Of the remaining 11, two were removed for SNF placement, three declined continuing in the program, two died, and five remain on monitors. Of the patients enrolled in the program for six months or more, there was a 58% reduction in readmissions compared to the six-month period preceding program enrollment. Readmissions for patients with heart failure within 30 days of discharge from the hospitalization immediately preceding program enrollment was 5% for patients enrolled in the program compared to 23% for non-monitored patients during the same time period. This program has significant scalability and is the model being used for replication at Dignity Health in two additional service areas.
WHO WAS INVOLVED?
Innovator: Dignity Health including Marian Regional Medical Center, Arroyo Grande Community Hospital, and French Hospital Medical Center; Corporate Partner: Philips Healthcare, a division of Philips Electronics North America Corporation;
WHAT THEY DID
Problem Addressed: Dignity Health serves over 22 million individuals living in central and coastal California. Among this population, 42-45% of patients have been identified as frail elderly, or at least 85 years of age. Dignity Health currently operates 17 home health agencies and eight hospice programs serving the California home health market. Over 600,000 patients were admitted to Dignity Health facilities in 2009, with over 144,000 medical inpatient admissions. Readmissions for patients with heart failure was and continues to be the number one challenge requiring aggressive programs for better community-based care management of patients with this disease. CMS estimates that costs associated with preventable readmissions exceed 17 billion annually. A recent Cochrane review concluded that telemonitoring of patients with heart failure reduced the rate of death from any cause by 44% and the rate of heart failure related hospitalizations by 21% (Inglis, SC, Clark, RA, McAllister FA, et. al, 2010). At the initiation of this program in 2011, Dignity Health Hospitals of the Central Coast were seeing a 20-25% composite readmission rate within 30 days (AMI, Pneumonia, CHF). Significant improvement was needed to better meet the needs of patients with heart failure and help them remain independent at home.
Patient Population: Fifty-one (51) Medicare FFS or Medicare Advantage patients with heart failure were enrolled into the program and placed on remote patient monitors. Twenty percent (20%) of this cohort experienced a concurrent episode of Medicare home health care at some point during their participation in the program. All had primary care physicians, of which 20% were Cardiologists.
Description of the Program: The RPM program at Dignity Health Hospitals on the Central Coast was designed to be complementary to a well-established telephonic care management program housed within a home health agency. The program was intended to avoid being dependent on traditional Medicare home health eligibility requirements. Patients were monitored for up to six months in order to demonstrate the long-term effectiveness of the program within an integrated delivery network. Three heart failure RNs with extensive experience in cardiology and clinical case management were hired to provide clinical management to community-based monitored patients in a three-hospital service area of 250 sq. miles. The heart failure case managers identified potential patients at risk for hospitalization by:
- Daily review of a three-hospital census for diagnoses either suggestive of, or definitive for, CHF.
- Daily review of all BNP or other pertinent lab results indicating a probable primary or secondary diagnosis of CHF.
- Daily rounding at each of the three hospitals. Once patients are identified, heart failure case managers:
- Visit patients in the acute facility to introduce the program and begin instruction in the management of heart failure when possible.
- Contact physicians for a referral to the program upon discharge.
- Make contact with potential enrollees within 72 hours upon discharge from the acute care facility.
Note: patients may be accepted into the RPM program as a result of a visit to the ED at any of the three hospitals for heart failure or related conditions and from a physician office referral. Once the patient and physician agree to the program:
- A program RN goes to the home and sets up the TeleStation and required peripherals (blood pressure, weight scale, pulse-oximetry) and continues teaching.
- Vital sign parameters are established and monitoring is begun.
- Teaching is then continued using customizable surveys, which are pushed out to the patient at predetermined intervals. The patient answers the questions using easy to read buttons on the TeleStation and the results feed into the telehealth record.
- TeleStation teaching is augmented with the use of standardized education material.
- Nurses review all vital signs, which flag individuals as being out of the established normal parameters on a daily basis. All abnormal readings are faxed to the physician and the patient is called for further assessment/instruction as indicated.
- The efficacy of the program is assessed at eight-week intervals using the Stanford self-efficacy tool and the Centura Telehealth Patient Satisfaction Tool embedded in the Philips program.
Enrollment/Selection Criteria: Fifty-one (51) patients were enrolled for up to six-months of telehealth monitoring. All inpatients identified with heart failure were eligible if they met the specific program criteria. Patient and/or MD refusal for otherwise eligible patients negated enrollment into the program. Of the 51 patients enrolled into the program, 39 were on monitors six months or longer. Of the remaining 11, two were removed for SNF placement, three declined continuing in the program, two died, and five remain on monitors.
The initial enrollment criteria were determined to be too general. Recommendations for the future include: a) assure that all patients over the age of 80-85 are enrolled into the program as this has proved to be a significant factor associated with re-hospitalization, b) consider whether patients with renal failure should be excluded, and c) determine whether SNF-based patients should be included or excluded.
Dignity Health’s Remote Patient Monitoring Program compared utilization and cost outcomes of enrolled patients diagnosed with heart failure with a reference group of similarly diagnosed patients, who were not enrolled in the RPM program. The program also examined differences within and between both groups before enrollment in the program and after. Patient experience and efficacy with disease self-management was evaluated for those patients in the study group monitored for at least eight weeks.
- Readmission within 30 days
- Readmissions within 6 months
- CPC for acute hospital stay six months after intervention compared to six months post intervention
- Patient experience with technology
- Self-perception of disease management efficacy
Program Outcomes: Routine outcomes analysis for performance measurement of healthcare resource utilization by patients on remote patient monitoring involved comparing hospital admission dates for patients enrolled in the monitoring program and those who were not. Of the patients enrolled in the program for six months or more, there was a 58% reduction in readmissions compared to the six-month period preceding program enrollment. Readmissions for patients with heart failure within 30 days of discharge from the hospitalization immediately preceding program enrollment was 5% for patients enrolled in the program compared to 23% for non-monitored patients during the same time period.
Total costs associated with acute care hospitalizations were decreased 58% for the study population as compared to the cost of hospitalizations for the same patients six months prior to enrollment from $703,176 to $296,520. Emergency room visits for CHF or related conditions that did not result in a hospitalization, decreased during this period by 17% further lowering costs for this population of patients by $3,000. The average cost per ED visit for patients with a primary diagnosis of heart failure was $767. The average cost for a hospitalization for a diagnosis of heart failure or related condition was $8,472.
The ROI analysis of Dignity Health’s RPM program indicates a modest Year 1 ROI of 0.4, although there is a high dollar return per patient of $9,882.
Project Limitations: There are several limitations to this project, which should be considered. This project was conducted as a stand-alone program associated with a local integrated delivery network wholly owned by Dignity Health. Although developed and implemented within the system’s home health agency, results may not be comparable to other home health based programs, which typically define TeleStation eligibility in association with a billable episode of home health.
Further, it should be considered that patients were enrolled into the program based on their willingness to participate. Patients who may have benefited from the program but who refused it were not enrolled. Also, there was no attempt to randomly assign patients to the program. This may introduce selection bias as a result of serving a disproportionate share of self-motivated patients.
Lastly, it is important to remember that remote patient monitoring is primarily a technological tool of a larger care management model effort designed to address the clinical needs of patients with chronic disease using a team of trained individuals. Clinical process re-engineering is necessary to enhance the current program (i.e., making nursing interventions 24/7 instead of 8-5 M-F, with the adding of medical protocols to enable real-time clinical interventions to address urgent medical needs), as well as to create the clinical, quality, education, business, logistic and organizational systems necessary to support the deployment of this technology throughout the enterprise.
HOW THEY DID IT
Context of the Innovation: Dignity Health (formerly Catholic Healthcare West) is the fifth largest health care system in the country. Dignity Health Central Coast consists of three acute care hospitals, primary care clinics, long-term care, acute rehab and the system’s largest home health, hospice and home infusion program. The Central Coast service area home health division developed a telephonic care management program for community-based patients with heart failure in 2004, progressing to the use of remote patient monitoring through the grant. This project was undertaken in order to: a) position the Central Coast to better manage the care of patients across the continuum, b) better meet the components of health care reform (value based purchasing/readmission penalties), and c) pilot a care management tool for possible replication in other markets within Dignity Health.
Planning and Development Process: The following represents the key implementation steps and timeline utilized in preparing for and the ultimate deployment of the program and the technology.
Month 1 – Begin planning phase for TeleStation development:
- Implementation team identified
- Vendor partner selected
- Weekly telephonic meetings with vendor partner initiated
- Month 2 – Hire RN Care Managers:
- RN Care Managers retained for both the northern and southern end of the service area in order to care for patients from three hospitals.
- Month 3 – Month 6 – Conduct presentations to medical staff committees and hospital leadership/governance.
- Month 2 – Month 6 – Complete standard operating procedures for medical group/home health collaboration and use of remote patient monitoring systems.
- Month 6 – Vendor partner on-site for four day training of staff and deployment.
- Month 7 – Begin accepting patients into the remote patient monitoring system.
- Month 8 – Complete the development of instruments to measure outcomes and begin surveys.
Getting Started With This Innovation: The consensus of the RPM project team as to important prerequisites to a successful launch include:
- Adequate funding for the technology component of the project is critical.
- Clarify project context: it is important to clearly identify where the project best fits within the organization; i.e., should it clinic-based, home health based, otherwise community-based, or hospital based.
- Administrative capacity to move the project forward must be in place before team members are identified and pulled together.
Sustaining This Innovation: The success of the RPM program at Dignity Health, Central Coast Service Area has led to the decision to continue the program within the home health agency. This will require the operational integration of the program (systems, staff and technology) into the home health agency. Dignity Health is in process of embedding the RPM interface into its EHR so that home health clinicians can monitor patients 7 days/week and potentially 24hrs/day. The program will be at least partially funded through expected cost savings (fewer nursing visits) over the term of a home health episode. This step will necessarily reduce the current six-month monitor window allowed during the grant period to 60-120 days for eligible patients eligible who are enrolled in a Medicare episode of home health care. Coverage of patients beyond that window of time or for those not eligible for home health care under Medicare is yet to be determined and will depend on the results of the return on investment analysis. Dignity Health has the potential to expand the program throughout its Home Health Division which includes 17 home health agencies and 8 hospices in California, Arizona, and Nevada.
Other Considerations and Lessons: Creating the vision for the use of remote patient monitoring technology in the management of Dignity Health, Central Coast Service Area’s patients with Heart Failure and subsequent program implementation yielded a number of findings. Some of the most practical lessons learned and recommendations are as follows:
- Vendor Partner Selection – This was one of the most challenging issues faced by the implementation team. Remote patient monitor technology is continually changing. The devices themselves, price points, and the availability of technology partners shift frequently. It is very important to conduct a thorough review using a robust request for proposal to just a few carefully selected companies. Patient data security and privacy protection as well as definitions of intellectual property can be time-consuming contract points which could lead to delays.
- IT Issues – IT issues can be very complex and a source for unexpected cost. It is highly advisable to have experienced support staff on both the vendor selection team as well as on the implementation team to assure that all questions affecting both the current and future success of the project are considered. Of special note are the issues and costs associated with the building of interfaces necessary for the program model.
- Telephonic to RPM Program – The implementation of this remote patient monitoring program was built on the long-standing success of a telephonic care management program for patients with heart failure in the organization. Nurses familiar with the telephonic program struggled in the beginning with identifying high-risk patients who would benefit from monitoring.
- Opt In/Opt Out – The RPM project was set up to require a physician’s order before enrolling patients into the RPM program. Although medical staff involvement in the approval of parameters or other special considerations prior to enrollment in the program is necessary, it is likely that automatic enrollment of all patients identified to be at risk of readmission for heart failure would achieve better results. This approach would facilitate timelier enrollment and the enrollment of potentially non-compliant patients who would initially try to refuse enrollment. This would improve both the volume of patients in the program as well as the capacity to prevent readmissions. This may be especially true and pertinent for non-home health based programs developed within a health care system.
- 30-Day vs. 60-Day Outcomes and Aligned Incentives – The selection of quality and financial outcome targets and goals is potentially dependent on the organization and its structure within which a RPM project is considered. Any telehealth implementation must consider its value proposition accordingly. Examples include: should program success be defined in terms of the avoidance of readmissions within 30-days (value based purchasing and ACD) or otherwise bundled or at risk payment structures versus a longer term chronic care strategy.
- Staffing – A successful program needs both dedicated field staff (RNs) as well as administrative staff. There are too many steps from program inception to completion to move it forward in increments with existing resources. This program was fully prepared with experienced heart failure clinicians, which carried the program forward during unanticipated gaps in administrative support.
- Patient Access to Program Staff – In order to optimize the effectiveness of a remote patient monitoring program in reducing re-hospitalizations it is highly preferable to make the care management oversight available 24/7. Seventy-five percent (75%) of patient re-hospitalizations for heart failure occurred between 5 pm and 8 am.