If you or someone you know has heart failure, Mr. Smith's story will sound familiar. Mr. Smith is not real, but his story is. Home care nurse managers with Salem Hospital Home Care, a home health agency in Salem, Ore., have heard this story many times.
Mr. Smith, age 76, arrives at the emergency department (ED) gasping for breath. His ankles are swollen; his blood pressure is high. He is diagnosed with heart failure and admitted to the hospital.
After five days of inpatient treatment, he is sent home with a prescription for diuretics, a set of dietary guidelines, and a packet of instructions for self-care. Two weeks later, Mr. Smith's condition exacerbates, so he returns to the ED and is rehospitalized for same condition.
After an additional 3-4 days of rehospitalization, Mr. Smith is discharged and sent home with same care instructions. Another two weeks pass. Mr. Smith once again appears in the ED and the cycle starts over.
What went wrong? Mr. Smith's story is typical of patients with chronic conditions that are not closely monitored, in a system better suited for treating acute conditions. Preventing such hospitalizations is one instance where advances in home healthcare are making a difference.
Growing ranks of the chronically ill
Chronic conditions currently affect one in four persons over age 65 and consume three out of every four Medicare dollars. The most common chronic conditions include diabetes, chronic obstructive pulmonary disease, arthritis, and heart failure.
Of these conditions, heart failure has been singled out as disproportionately expensive. Numerous studies reveal that better outcomes for heart failure patients depend on what happens in the first two or three weeks after hospital discharge, so those patients can especially benefit from home monitoring.
The challenge for home care agencies in providing this level of service is how to meet a growing demand from an increasing number of chronically ill patients, with a shrinking pool of home care nurses and declining reimbursements. Salem Hospital Home Care recognized the challenge several years ago when it began searching for a way to preserve quality outcomes while extending the reach of existing staff.
Published reports on successful applications of telehealth in other states made it apparent that technology held the solution. The Department of Veterans Affairs (VA), an early explorer in the field of telemedicine, began studying the potential of technology in 1997 with a small tele-mental health project in Lincoln, Neb. Positive results from this and other studies over the years have led the VA to formally implement large telemedicine systems.
The State of Hawaii Access Telehealth Network (STAN), which went live in July 1998, links hospitals and providers in several islands of the South Pacific. STAN provides an array of telemedical, educational, and conferencing services beyond home health monitoring, reaching patients and providers in remote communities. Savings in travel costs total hundreds of thousands of dollars.
After researching different systems on the market, Salem Hospital Home Care settled on the telemonitoring system that includes a central station for receiving data, software for organizing and presenting the data, and portable monitoring units to send to patients' homes. The monitoring units come with attachments and peripherals that transmit vitals such as weight, oxygen saturation, blood pressure, and blood sugar level over an ordinary telephone line. The agency purchased 150 units.
This particular system is a Federal Drug Administration Class II medical device, which requires a doctor's prescription. Because few Oregon doctors had previous experience with telemonitoring, Salem Hospital Home Care had to convince them to give the monitors a try.
How telemonitors work
If Mr. Smith had been prescribed a telemonitor when he left the hospital the first time, things would likely have turned out much different for him.
Within a day of discharge, a Salem Hospital Home Care nurse delivers a portable monitoring unit to Mr. Smith and teaches him how to use it. The unit is about the size of a clock radio and fits easily on the kitchen table.
The unit alerts Mr. Smith in a clear computer-simulated voice that it's time to take his vitals. The voice, which can be programmed to speak in nine languages, guides Mr. Smith through weighing himself, taking his blood pressure, and measuring his blood-oxygen saturation. The voice asks him a few key questions: Is he feeling well? Is he in pain? Has he fallen? Has he had trouble taking his medicine? Mr. Smith answers by pushing a yes or no button, and then pushes a button to transmit the data.
Each day for the next 48 days that Mr. Smith has home care, his vitals are displayed on the central station monitor, where a specially trained nurse checks them. At the first sign of an exacerbation, the nurse notifies Mr. Smith's doctor and his regular home care nurse. When Mr. Smith is discharged from home care, he is referred to the hospital's outpatient clinic for heart failure patients, where he continues to manage his condition outside the ED or hospital.
Salem Hospital Home Care believes most home care clients are good candidates for telemonitoring. Only a few may not be — for example, people who have significant cognitive impairment and no one at home to help them, or people with certain psychiatric challenges who might be too easily startled by the unit's computer voice or transmission sounds.
Improved outcomes, increased productivity
To assess the effect of the telemonitors on nurse productivity and patient outcomes, Salem Hospital Home Care tracks all ED visits and hospitalizations every day for each nurse. The nurse's caseload, as well as the patient's diagnosis and the length of time the patient has received home care, is factored in. Productive hours per visit have decreased by 12 percent since the start of telemonitoring.
Data collected by Outcome and Assessment Information Set (OASIS) and analyzed by Outcome Concept Systems show that between October 2004 and September 2005, Salem Hospital Home Care's heart failure patients with telemonitors had a hospital admission rate of 6.3 percent compared with 28 percent for those without telemonitors.
Medicare and other insurers do not yet pay for telemonitoring visits. Until they do, small independent agencies may not see an immediate financial benefit. According to Salem Hospital Home Care managers, however, telemonitoring can help all agencies extend nursing services and save labor costs.
Pat Emmerson, M.S., is a communications specialist at Acumentra Health (formerly OMPRO), the Medicare Quality Improvement Organization for Oregon under contract with CMS. The contents presented do not necessarily reflect CMS policy.