Clinical leaders at the Tacoma, Wash.-based MultiCare Health System, a six-hospital integrated healthcare delivery system, have been utilizing remote monitoring and telehealth technologies for more than a decade, with a focus on improving outcomes and reducing readmissions among patients with chronic conditions. As digital health technologies have advanced from basic vital-sign data collection, to Bluetooth-enabled mobile platforms and video interfaces, the MultiCare team has been able to expand its telehealth program, and is seeing significant results with reducing readmission rates.
Lynnell Hornbeck, home health manager at MultiCare, says the health system initiated its telehealth program more than a decade ago, primarily focusing on heart failure patients, and working with Honeywell Life Care Solutions, a Brookfield, Wis.-based telehealth software vendor.
“At the time, there were reasons to start remote monitoring and telehealth, and one of the reasons was to look at alternative ways to deliver care rather than in-home visits. For home health, the reimbursement model had changed and was more of a capitated or bundled payment-type approach, rather than per visit, particularly for nursing visits,” Hornbeck says. “But another large reason was from an outcome perspective; there was some information coming out about the benefits of telemonitoring with improving outcomes and reducing readmissions. It was early back then, 15 years ago, and with our initial project, the equipment we used was older technology; it wasn’t wireless, it had the basic vital sign capacity, and there was no video or face-to-face capability with that equipment.”
Fast-forward to today, and MultiCare’s Telehealth Chronic Disease Management program for Home Health patients has grown from 10 remote monitors to 100, and has expanded to include patients with pulmonary conditions, mostly chronic pulmonary obstructive disorder (COPD), as well as pneumonia, in addition to the heart disease patients. MultiCare continues to work with Honeywell and leverages the vendor’s telemonitoring and video conferencing capabilities through its LifeStream 5.2 telehealth software.
With a census of 80-90 patients per registered nurse, patients participating in the program report their blood pressure, respirations, weight and oximetry on a daily basis using a tablet, called the Honeywell Genesis Touch, and this tablet transmits the biometrics to Honeywell’s LifeStream Management Suite.
The software alerts the nurse to abnormal values, resulting in a staff intervention, Hornbeck says. This may include medication education, enactment of physician ordered action plan, or coordinating patient appointments with providers. Interventions are provided telephonically or via video visit.
Hornbeck reports that the telehealth program for home health patients has helped to reduce 30-day readmissions rates for heart failure and COPD patients. “That’s our key metric, our readmission rate. Year-to-date data, 30-day readmission rates for heart failure patients is 4 percent, and 30-day readmissions for COPD patients is 2 percent. So, it’s very successful,” she says, adding, “What I would highlight, in particular with COPD patients, is a lot of articles and literature for tele-monitoring have not been supportive of the use of it for COPD patients. With our program, we use a lot of medical protocols, and with addition of the video and the engagement and the unique interventions, we feel it’s been quite successful. We’re proud of the fact that we’ve been able to use this with that COPD population as well.”
Kelly Gariando, R.N., telehealth registered nurse at MultiCare, says that the remote monitoring technology is a valuable tool, but the technology alone doesn’t achieve those results. “We have about 80 to 90 patients active at any one time, and our monthly interventions to achieve that is over 700 interventions. So, it is a lot of work; it is not just the vitals coming in, and then, once in a while, we call patients. There’s a lot of calls and a lot of coordinating with physicians and reviewing physicians’ notes after a patient sees a doctor. We’re on Epic, so we can see the physicians’ notes, and then we call the patient and say, ‘I see you saw the doctor and your meds were changed, did you pick up your antibiotics or your medications?’ It’s a very interactive type of monitoring. And, I would say a full 50 percent of the time those patients needed those follow ups for a variety of reasons, such as they had not yet picked up their medications or they left the doctor’s office with questions about the meds and didn’t understand why the doctor was changing things, and didn’t want to ask.”
Hornbeck adds, “When we speak to others about this program, we really emphasize that a tool is wonderful but if you just put it in the home and don’t have any protocols around it, if you don’t have the intensive tools that have been developed, along with the willingness to respond and be proactive and have the clinical aspect of it, all of that is very important. It is all of that together that makes this program successful.”
The Engagement Piece
Many clinical leaders at hospitals and health systems talk about “high-tech, high-touch,” and that concept seems to be driving the success of the remote monitoring program for MultiCare’s home health patients. Hornbeck says implementing the video interface capability as part of the remote monitoring program as an alternative to nurses conducting at-home visits has been a critical factor. “The video aspect of it is, from an engagement perspective, is huge,” she says.
She elaborates, “We use it to further assess the patient, or ‘eyes’ on a patient, but also from an ability to engage the patient and coach them through different treatments. So, it’s responsive, such as responding to abnormal information that the patient is having an issue, but we also do some proactive video interactions with these patients. I would say in particular with the COPD pulmonary population, I think what’s different is that video component and, in combination with the biometric data and other assessment data, we’re actually able to see them, that’s a large difference.”
The video interactions enable the telehealth nurses to virtually “reach” into the home talk to patients in real-time when they are experiencing a problem. For instance, if a COPD patient is experiencing shortness of breath, Gariando says she can talk the patient through using their pulse oximetry to measure oxygen saturation and to use their spirometry and then coach the patient through the proper technique of using their nebulizer. “Then we re-check them so they can see the real-time biometrics and they’ll see their oxygen levels come up and they can see that for themselves in the home. That is all done with a video visit.”
Gariando stresses the importance of walking the patients through those treatments. “It shows the patient how effective their equipment can be because there is a chronic problem with the COPD population, even though they have the nebulizer, they don’t use them very often. That’s an example of a video visit where we can actually show them, in real time, actual improvements.”
As another example of how the video capabilities combined with the biometric data enables effective patient coaching, Gariando says telehealth nurses can demonstrate to a heart failure patient how compliance with their treatments, such as taking an extra water pill, has helped to keep their vitals at the right levels that day, and compare that biometric data to a previous day’s data when the patient wasn’t compliant and their vitals fell out of parameter.
The video visits and coaching also might focus on diet education. “Generally speaking, I would say at least 80 percent of the patients who have COPD also have heart failure, and a lot of the teaching is getting them to understand that when you can’t breathe that symptom starts with diet non-compliance. So, if a patient’s weight goes up or they have more shortness of breath, I will say, ‘Okay, tell me what you had to eat yesterday.’ And, if they went to a particular restaurant and we can pull up a menu and we’ll screen share with them and show them that this is the amount of sodium you had. And, we also use colored handouts to show them the process that when you eat salt, you hold more fluid in your body, and that fluid builds up and it goes to your lungs and so today you are short of breath,” Gariando says.
Hornbeck and other clinical leaders at MultiCare have learned important lessons on their telehealth journey. “You must have a way to engage the patient very quickly, and have the technology work from the beginning, that’s important to engage the patient. And, I would say the second lesson is that you must have the clinical platform and clinical expertise to go along with the technology. So, work with your partners,” Hornbeck says, adding, “Work with your health system, find a physician or provider to be a champion. When we started with heart failure, we partnered closely with the Pulse Heart Institute, some of the physicians, pharmacists and medical directors, to come up with clinical protocols that were blessed by them. That way, it’s more accepted by other providers when we begin to implement these protocols.”
What’s more, Hornbeck says it’s critical to get senior leadership support for these initiatives. “If you are going to go forward with this to get funding, you want to understand how to speak to that audience. We had some interesting experiences as we presented to different audiences and key stakeholders and the things that we thought would speak to them, and amazingly enough, to some audiences, readmission rates don’t speak to them. They want to hear about something else, they want to hear real stories. You need to know who your audience is when you’re going to put your proposal together so you can present the benefit that speaks to them.”
One ongoing challenge to building support for telehealth and remote monitoring programs is the lack of direct reimbursement, Hornbeck says. “You have to get people to understand what the benefits are; it’s indirect, it’s a cost avoidance, it’s a cost savings model. A lot of people still think about fee-for-service. Certainly, there is virtual medicine out there and a lot of people are very familiar with that, and it’s taking off because it’s provider-driven. With this particular model, it’s still a little early, especially on the West Coast, for payers to jump on board and pay as part of their bundles. I think that’s just on the horizon. That’s the cultural shift, to get people to move from that fee-for-service perspective to a perspective of seeing the cost savings associated with keeping people out of the hospital.”