Unplanned 30-day readmissions can be significantly reduced through care coordination, telehealth, and remote monitoring.
- Remote patient monitoring has been instrumental in cutting 30-day readmissions for patients with congestive heart failure (CHF) at Sharp HealthCare, a non-profit hospital system in the San Diego area, says a new case study from the Center for Technology and Aging. The use of telehealth, personal patient coaching, and care coordination strategies helped to decrease the 30-day unplanned return rate from 20.7% in a control group to just 10% for patients participating in the CHF Remote Patient Monitoring program.
As the financial penalties for 30-day readmissions begin to pile up, hospitals are seeking new strategies for ensuring that once patients are discharged, they can readjust to their home setting, recover from acute episodes, and continue to properly manage their chronic conditions. At Sharp, congestive heart failure readmissions alone incur $9.5 million in preventative costs, while all-cause readmissions rack up close to $80 million.
To tackle the expensive problem, Sharp focused particularly on underserved and low-income patients, many of whom were self-pay patients or covered by Medicaid or Medicare services. “The underserved/unassigned population is at a greater risk for post-discharge complications due to gaps in their transition from hospital to home,” the study explains.
“While services may exist for these patients, they have challenges in navigating the complexities of the health care system while dealing with their medical conditions. Additionally, while these patients receive thorough education while they are in the hospital on their disease and how to access community resources, they are often overloaded with excessive amounts of information when they are least likely to comprehend it.”
The intervention arm of the pilot included giving patients a telehealth scale, providing 90 days of daily monitoring of weight and CHF symptoms, support from a nurse health coach, and two home visits at the beginning and end of the program. During the initial home visit, a nurse reviews the use of the home monitoring equipment, educates patients on medication management and proper dietary habits, and addresses any knowledge gaps, questions, or concerns.
Patients complete daily health checks and weigh-ins, and the data is electronically uploaded to the nursing staff. Patients receive phone calls in response to significant variations in symptoms or statistics, and a nurse coordinator is always available to patients as a resource throughout the program.
The results of the pilot were encouraging. In addition to reducing the 30-day readmission rate by half, the program contributed to ongoing declines in readmissions at the 90-day mark. Just 21.2% of patients participating in the program were readmitted at 90-days compared to 39.6% of similar patients in a control group. Patient satisfaction with the program was high, with more than 75% of respondents noting that the remote monitoring was just as effective as having a nurse come to their house on a regular basis. Patients also reported higher levels of confidence when it came to self-management and engagement.
Sharp HealthCare suggests several key factors to consider for other healthcare organizations looking to conduct similar projects. Understanding the target population, stratifying patients appropriately, and focusing on the patients most likely to benefit from limited resources is the first major step towards effective population health management. Such population health programs are also in need of firm organizational support, the study adds, investment in the recruitment of high quality staff members, and ongoing commitment from executive leaders.