Consortium hopes to reduce readmissions
Key is use of wireless management
As health care reform has directed national focus to finding ways to improve public health and cut medical costs, leading hospitals, providers, and others are seeking ways to improve care transitions.
As part of this effort, a consortium of hospitals in California recently received a $9.9 million federal grant to study the use of wireless and telephone care management of heart failure patients. The goal will be to reduce hospital readmission rates and overall medical care utilization.
"I think the main impetus for us getting started in this area is looking at variations of health care outcomes across the medical center," says Michael Ong, MD, PhD, an assistant professor at the University of California Los Angeles (UCLA) School of Medicine, and the principal investigator involved in the three-year project.
The consortium includes five University of California medical schools and Cedars-Sinai Medical Center. They'll work together to enroll patients in a randomized control trial with three arms, including one arm for standard care.
"With health care reform, there's a lot of interest in reducing overall utilization," Ong says. "We've looked at certain types of existing interventions shown to improve those metrics."
Examples include the transitional care model developed by Mary D. Naylor, PhD, RN, and another such model developed by Eric A. Coleman, MD, MPH, he notes.
"One thing we had seen from these models is that while they may be cost-effective from the payer's perspective, they had a low adoption rate because of the cost of doing these types of interventions," Ong says. "We were looking to find interventions that could be effective and reduce overall cost in terms of utilization and implementation."
Researchers found there is existing literature on using remote monitoring as a way to improve care, but reduce overall program costs, he adds.
"Having structured telephone monitoring can be a substitute for some things you can get from a home care visit," he says. "We were interested in testing out ways to adapting these types of approaches that would be more feasible for implementation."
The federally funded study will enroll patients who are 55 years and older and have been hospitalized for heart failure. Investigators selected this population because of its association with high readmission rates, Ong says.
"We know that there is a likely failure in terms of what happens after they get discharged because of the high rate of these patients being rehospitalized within 30 days," he explains. "Half do not have an outpatient visit before being rehospitalized, so somewhere along the way, we don't get them back in care as needed."
The study will look at two types of interventions, including a structured telephone monitoring call that uses a basic home phone and a remote monitoring approach, using wireless devices placed in people's homes.
"We have a centralized call center that worked for all six medical centers rather than one for each medical center, which reduces costs and duplication," Ong says. "It's run by nurses who conduct structured telephone interviews."
Nurses, who likely will be at the level of advanced practice nurses or nurse practitioners, will question patients about their heart failure symptoms and medical issues. For the first 30 days post-discharge from the hospital, nurses will speak with patients at least once a week, and after that there will continue to be structured calls for up to six months, he says.
The call center will be operated weekdays during working hours, so patients will be instructed to call for emergency help if they have problems during the evening or weekend hours.
"We will be reaching out to patients to make sure they're on track, but it's not a substitute for their usual care," Ong notes. "If we're substituting for their actual care system, then that's defeating the purpose."
The call center nurses will ask patients about their scheduled visits with community providers and assist them with making appointments when necessary.
The second intervention will collect data about patients' compliance with discharge instructions, such as checking weight and blood pressure. The remote monitoring device is a Bluetooth device that includes a central device plugged into the home's telephone jack. It uses a digital scale to transmit information back to the call center. It also asks patients to respond to a half dozen standard "yes or no" questions daily. These address symptoms, such as shortness of breath, Ong explains.
"If they're not sending information back, then someone will call them," he adds.
The wireless monitoring device also sends data from a special weight scale and a blood pressure monitoring device. So, each time patients use these tools, the results are sent to the call center, where they can be analyzed, Ong explains.
"If there are certain parameters exceeded, it will trigger a warning," he adds. "Then, the centralized call center will call the patient to ask, 'How are you doing? We noticed your weight has been increasing over the last several days. Have you had any changes in your diet, or is there a problem with your medications?'"
The call center nurse will help the patient troubleshoot and get into the right kind of care to address the problem.
"What we were looking at is you could do structured telephone contact with people, but probably not every patient needs that," Ong says. "So, if you have a way of monitoring patients to make sure they're not running into trouble, then we can tailor resources to address the people who need them most, and that will reduce overall costs."
Investigators will study the enrolled patients' rehospitalization rates within 30 days and 180 days, as well as overall costs, mortality rates, and quality of life, based on standard surveys.
"We know that each of these six medical centers have tried out various approaches, and certain things were effective, but targeted to smaller groups of the heart failure population and not to everyone," Ong says. "We're expanding it to help all heart failure patients."
As health care reform has directed national focus to finding ways to improve public health and cut medical costs, leading hospitals, providers, and others are seeking ways to improve care transitions.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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