Remote Patient Monitoring in a Federally Qualified Health Center
AltaMed Health Services
AltaMed Health Services, a Federally Qualified Health Center that also operates a Program of All inclusive Care for the Elderly (PACE), conducted a remote patient monitoring (RPM) pilot program with PACE participants that had at least one diagnosed chronic illness, including congestive heart failure, hypertension, diabetes, and/or COPD. By definition, PACE participants are frail elderly and categorized as high-risk needing skilled and intermediate care.
Goals of the RPM initiative were to:
- Promote independence and increase self-management habits and healthy behavior among frail older adults living in urban low income communities
- Sustain the independence of frail elderly, who have been diagnosed with ongoing chronic conditions, allowing them to live independently and remain in the community
- Reduce costs of care by reducing avoidable acute hospital or long term care facility use
- Improve healthcare outcomes with earlier recognition of dangerous health indicators and rapid treatment
- Establish and expand a new healthcare paraprofessional “Telehealth Technician” training program
Results from the initiative indicate that use of RPM was associated with increased confidence and understanding with regard to self-management of chronic diseases, decreases in hospital and long-term care facility usage, and improvements in some health status indicators.
WHO WAS INVOLVED?
- AltaMed Health Services, a non-profit regional network founded in 1969, is the largest Federally Qualified Health Center (FQHC) in California
- East Los Angeles Community College provided Telehealth Technician Training
- Ideal Life was the RPM equipment vendor
WHAT THEY DID
Ideal Life technology was used to monitor patients’ vital signs, thus allowing timely intervention to help prevent exacerbations and complications. Peripheral devices used to gather vital signs included: 1) blood pressure cuffs for patients with hypertension and/or congestive heart failure, 2) digital weight scales for patients with congestive heart failure, and 3) glucose meters for diabetic patients.
Frail elderly Hispanic persons with an average age of 76 years, monolingual Spanish, residents of the urban low-income area of Boyle Heights (East Los Angeles), with little or no formal education. Chronic diseases: Hypertension, Diabetes, Congestive Heart Failure, Hyperlipidemia, Arthritis.
Pertinent Quality Measures
Congestive Heart Failure (CHF) => Body weight
Hypotension and Hypertension => Blood pressure reading
Diabetes => HbA1c
Hospital admissions, hospital days, ER visits, SNF-Rehab, and SNF days were tracked and compared for both Intervention and Comparison Groups. Established American Heart Association (AHA) guidelines for hypertension and congestive heart failure monitoring were used for monitoring participant vitals unless other parameters were requested by the physician. AHA guidelines for vitals were used as follows: Systolic blood pressure of 120-140mm Hg; Diastolic pressure 80-90mm Hg. Pulse 60-80 beats per minute. Either weight gain or loss of 3 pounds daily; gain of 5 pounds per week.
Providers wrote an order to install equipment andsent the request to the RN Case Manager and the Telehealth Technician. The Telehealth Technician contacted the participant to introduce the project and the benefits of participating, equipment to be used, and project expectations. If the participant agreed, the Telehealth Technician provided enrollment information and coordinated a date for a home visit to install the equipment and further explain the RPM program and process.
Upon patient enrollment in the program, all RN Case Managers and the Telehealth Technician received daily alerts. All alerts required a follow-up. When RPM devices showed a slightly abnormal reading, a message was sent to the Telehealth Technician who would then call to screen and educate the patient on medication, diet, exercise, and any other unusual symptoms. The Telehealth Technician was responsible for notifying an RN Case Manager when alerts were severe and out of range. For highly abnormal readings, an RN Case Manager called the patient and performed a Telephonic Triage Call. The provider was notified of the abnormal reading and the determination was made whether to schedule the patient for a clinic visit.
The Telehealth Technician was responsible for day-to-day monitoring of participants who did not transmit an alert, ensuring that participants remained compliant with monitoring their blood pressure, glucose, and weight as ordered by the primary care provider. The provider requested further intervention for the interdisciplinary team members as needed, e.g., a patient with an elevated HbA1c of 9.0 might need dietary education.
Summary of Results
PACE program clients were invited to participate in the telehealth pilot if they had at least one diagnosed chronic illness that included congestive heart failure, hypertension, diabetes, and/or COPD. Qualifying participants were screened by the primary care providers and referred to the RPM staff for project recruitment.
Forty-six PACE clients agreed to participate in the pilot study—23 of which were in the Intervention Group and the remaining 23 were in the Comparison Group. Comparison Group participants were monitored through clinic visits and Electronic Health Record (EHR) data and did not receive in-home monitoring equipment. The Intervention Group was tracked with RPM equipment installed in their homes.
Descriptive characteristics of the participants include: 31 were Latina females and 15 were Latino males; all were older adults (mean age of 77 years) with low incomes and chronic illness; and all resided in AltaMed’s service areas in East Los Angeles.
- HbA1c: Among diabetic patients (N=12), a higher percentage (42%) in the Intervention Group experienced a decrease in HbA1c values, which indicates improved glycemic control. A similar portion (16%) of the Intervention and Comparison group experienced “no change” in HbA1c values.
- Weight: Weight change results were mixed. Two thirds of diabetic participants in the Intervention Group experienced a decrease in weight. The other third experienced an increase in weight.
- Blood Pressure: There was a general decrease (64%) in blood pressure (BP) readings for the Intervention Group. A similar portion (36%) of the Intervention and Comparison group experienced “no change” in BP during the pilot program.
The Intervention Group showed fewer hospital admissions, hospital days, and SNF days than the Comparison Group while ER visits and SNF-Rehab days were the same for both groups.
Health, Daily Activities, and Health Confidence Outcomes
In general, the pilot suggested improvement in self-reports on health, activities, and confidence in managing health concerns. Preliminary clinical indicators and utilization results also point to areas of improvement for participants in the Intervention Group.
At the time of enrollment and six months post-enrollment, a 10-question health, daily activities, and health confidence questionnaire was administered to the Intervention Group. Self-assessments generally improved by the six-month follow up: a greater number of patients (18/23, 78%) rated their health as fair or better at 6-month follow up compared to the time of enrollment (7/23, 22%). A decrease in bodily pain and reported severe pain and an increase in reports of no bodily pain were reported at 6-month follow-up compared to the time of enrollment. There was a 25% increase in satisfaction regarding ability to do physical activities at 6-month follow-up compared to the time of enrollment.
Responses to the pre- and post-survey, as well as the clinical and utilization metrics, support the key elements and purpose for the pilot program:
- Goal: to promote independence and increase self-management habits and healthy behavior among frail older adults living in urban low income communities. Outcomes: in rating of health status and confidence in health for the post-intervention group, all had higher levels of confidence in understanding and managing their chronic condition.
- Goal: to sustain the independence of frail elderly who have been diagnosed with ongoing chronic conditions, allowing them to live independently and remain in the community. Outcomes: results of utilization measures indicated lower rates of admissions, hospital days, and SNF days. None of the participants were institutionalized long term.
Context of the Innovation
AltaMed Health Services, a 501 (c )(3) regional network founded in 1969, is the largest Federally Qualified Health Center (FQHC) in California. A provider of choice for Latinos and other communities of color, AltaMed offers a continuum of multilingual, culturally competent health and preventive care services that include primary and dental care, maternal and child health care, OB/GYN, geriatric medicine, PACE, HIV/AIDS treatment and intervention, family planning, youth outreach and pregnancy prevention, breast healthcare, and health insurance/managed care enrollment. AltaMed offers 40 service delivery sites across the Medically Underserved Areas (MUAs) in Los Angeles and Orange Counties. The Remote Patient Monitoring Project patients were referred from the Boyle Height Clinic in East Los Angeles.
Healthy People 2020 are the nation’s 10 year goals and objectives for health promotion and disease prevention. An initiative of Health People 2020 is to improve health, function and quality of life for older adults.
Planning, Development, and Training Process
Planning meetings with Ideal Life, vendors for the equipment and AltaMed’s information technology (IT) department were conducted for the first nine months of the grant. An IT task force was created to insure that the equipment was the most appropriate for the project.
Project personnel were extensively trained.
- Telehealth Technician Training. Technicians received 40 hours of training each with an additional lab component for 6 technicians at East Los Angeles Community College.
- Primary Care Provider Training. The PACE Primary Care Providers received a 3 hour in-service on the requirements for patient participation in the Remote Patient Monitoring Project.
- RN Training. RN Case Managers received a 4 hour in-service on telehealth communication and documentation, including telephonic triage.
Funding for this project was made possible through the Center for Technology and Aging and with in-kind donations from AltaMed Health Services.
Getting Started With This Innovation
The remote patient monitoring project requires dedicated and trained staff. Without this, the project will not be as effective. Technology intervention is critical to this project and must have a knowledgeable team at implementation.
Sustaining The Program
AltaMed is continuing all components of the program. After a delayed start, the Remote Patient Monitoring program has become a routine component of clinical care for AltaMed. Patients are continuing to be referred for remote monitoring. Long term program sustainability is contingent upon retaining a dedicated and trained staff, support from project management, and obtaining additional funding. AltaMed is in the process of seeking additional funding given the proven results of fewer hospitalization, ER, and SNF days, and improved patient care. Agency clinical and operational staff support the continuation of RPM with plans to budget enough for actual true cost including maintenance and repairs to equipment.
Limited willingness to participate. Sixty-one PACE clients were invited to participate in the Intervention Group. Twenty-six (43%) agreed to participate. Three of the 26 later dis-enrolled from the pilot program which resulted in 23 final Intervention Group participants. Similarly, 35 PACE clients were invited to participate in the Comparison Group. Twelve declined which resulted in 23 final Comparison Group participants.
Small sample sizes. Results should be interpreted with caution because of the small sample size of 23 in the Intervention Group and 23 in the Comparison Group. Subgroup analyses were limited as a result, e.g., the analysis of the 12 diabetic patients in the pilot.
Intervention adherence and persistence. Periodic disconnection of equipment occurred causing a delay in alerts and follow-up. In the future program staff will require commitment from participant and family members to maintain the designated devices fully operational at all times.