CHRISTUS Health was recognized as a semifinalist in the 2013 Healthcare Informatics Innovator Awards program. Leaders of this team, along with leaders of the four finalist teams, will be recognized at the Healthcare Informatics Innovator Awards Reception, to be held in Orlando on Feb. 24.
In April of 2010, CHRISTUS St. Michael Health System in Texarkana, Texas launched a one-year care transition intervention program with the goal to reduce hospital readmissions of patients diagnosed with specific chronic illnesses, such as congestive heart failure (CHF), coronary artery disease (CAD), hypertension, diabetes, myocardial infarction (MI), pneumonia, and chronic obstructive pulmonary disease (COPD).
These diagnoses have been associated with a high number of complications and high readmission rates within 30 days of a patient’s initial discharge, according to Shannon Clifton, director, connected care at CHRISTUS Health, which includes more than 40 hospitals and facilities in seven U.S. states.
Clifton says the core of the program—which was developed with the goal of getting patients to both learn and apply new self-care skills to help them assert a more active role during care transition—is a trained and certified care transition nurse (CTN) who identifies underinsured inpatients with the targeted diagnoses in the hospital’s daily census. Prior to discharge from the hospital, the CTN will visit the patient to begin the process of a successful transition from hospital to home, which includes medication review, thus preparing the patient to begin self-management at home, Clifton explains.
The other component of the care transition program is a home visit made by the CTN to the patient’s home within seven days of discharge. Once the home visit is completed, the CTN will make at least three follow-up phone calls during the 33-day program (two days later, a week after that, and then two weeks later) to assess the patient’s health status and provide clinical guidance as needed, Clifton says.
While the home visit affords the CTN the opportunity to review additional medication orders, educate patients about warning signs of a worsening condition, review the personal health record, and provide support in communicating with the patient’s existing care providers, it has its drawbacks, says Clifton.
“First, the CTN has stated that many patients are hesitant to allow her into their homes and, as a result, patients [may] decline from participating in the care transition program,” she says. “Second, for those who do agree to a home visit and can be enrolled in the program, some live as far as 50 miles away from the hospital, thus requiring the CTN to spend approximately 500 hours per year away from the hospital, reducing the number of patients that can be transitioned. And lastly, CTNs are limited by the amount of interaction they can have with her patients while enrolled in the program because of the amount of time she spends away from the hospital conducting the home visit. As a result, program efficiency and growth is limited,” Clifton says.
GOING A STEP FURTHER
As a result, in August 2012, CHRISTUS Health partnered with the Plano, Texas-based Vivify Health and AT&T to determine if a remote patient monitoring solution (RPMS) would increase the number of chronically-ill patients, specifically patients diagnosed with CHF being transitioned every 33-days without requiring additional program staff and/or compromising current program outcomes.
This pilot would last one year and would only include patients with a principle diagnosis of CHF who had already consented to participate in the traditional care transitions program at St. Michael Health System, Clifton says.
“The RPMS allows the CTN to customize care plans on an individual basis, provide real-time collection and secure transmission of data, and promote virtual interaction with the patient for purposes of real-time health assessments and intervention,” says Clifton. “This process will eliminate home visits, which improves program efficiency by returning the CTN to bed-side, thus available to enroll and transition more patients,” she adds.
The patients use the RPMS daily by answering a series of 10-15 questions or more—depending on patient response— which may require additional drop down questions, thus directing the patient to increase his or her self-health governance. An alarm will sound to remind patients to answer the questions, should they forget, and the CTN will be notified if a patient does not answer the daily questions so a phone call reminder can be initiated, Clifton says.
Once each patient has answered their daily questions, the CTN receives updates on her Vivify Health login account; however, the CTN will be alerted via text and/or e-mail when a patient responds to a question that may indicate a health concern, Clifton explains. “This will increase the CTN’s interaction with the program’s patients since the CTN can then call those specific patients, assess their health status, and provide clinical guidance,” she says. “The RPMS would replace the initial home visit currently made by the CTN, thus allowing for both increased interaction with patients throughout the transition period and increased program enrollment since less time would be spent away from the hospital.”
The results of the RPMS pilot have been encouraging—76 patients enrolled in the RPMS pilot through November 2013, 44 of whom used the technology for 33-days; 32 used it for 90-days. All patients had decreased average inpatient admissions and 30-day readmissions, Clifton says.
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