Dignity Health (formerly Catholic Healthcare West) sought to expand on an already robust and successful telephonic care management system to include remote patient monitoring technology. The goal of this remote patient monitoring program was to allow elderly patients to remain in a healthcare setting of their choice while self-managing chronic diseases such as heart failure. Key elements of the program included:
The program was funded through grant funding from the Center for Technology and Aging and in-kind contributions from Dignity Health. The 6-month intervention includes daily remote monitoring using Philips’ TeleStation and a minimum of one home visit. The program targets Medicare patients over the age of 60 with class 3 or 4 heart failure who are at risk of re-hospitalization for an exacerbation of heart failure or related co-morbid conditions.
Dignity Health’s Remote Patient Monitoring Program is effective in reducing the rate of 30-day readmissions to three Dignity Health hospitals on the Central Coast of California (Marian Regional Medical Center, Arroyo Grande Community Hospital, and French Hospital Medical Center). Of the 51 patients enrolled into the program, 39 were on monitors six months or longer. Of the remaining 11, two were removed for SNF placement, three declined continuing in the program, two died, and five remain on monitors. Of the patients enrolled in the program for six months or more, there was a 58% reduction in readmissions compared to the six-month period preceding program enrollment. Readmissions for patients with heart failure within 30 days of discharge from the hospitalization immediately preceding program enrollment was 5% for patients enrolled in the program compared to 23% for non-monitored patients during the same time period. This program has significant scalability and is the model being used for replication at Dignity Health in two additional service areas.
WHO WAS INVOLVED?
Innovator: Dignity Health including Marian Regional Medical Center, Arroyo Grande Community Hospital, and French Hospital Medical Center; Corporate Partner: Philips Healthcare, a division of Philips Electronics North America Corporation;
WHAT THEY DID
Problem Addressed: Dignity Health serves over 22 million individuals living in central and coastal California. Among this population, 42-45% of patients have been identified as frail elderly, or at least 85 years of age. Dignity Health currently operates 17 home health agencies and eight hospice programs serving the California home health market. Over 600,000 patients were admitted to Dignity Health facilities in 2009, with over 144,000 medical inpatient admissions. Readmissions for patients with heart failure was and continues to be the number one challenge requiring aggressive programs for better community-based care management of patients with this disease. CMS estimates that costs associated with preventable readmissions exceed 17 billion annually. A recent Cochrane review concluded that telemonitoring of patients with heart failure reduced the rate of death from any cause by 44% and the rate of heart failure related hospitalizations by 21% (Inglis, SC, Clark, RA, McAllister FA, et. al, 2010). At the initiation of this program in 2011, Dignity Health Hospitals of the Central Coast were seeing a 20-25% composite readmission rate within 30 days (AMI, Pneumonia, CHF). Significant improvement was needed to better meet the needs of patients with heart failure and help them remain independent at home.
Patient Population: Fifty-one (51) Medicare FFS or Medicare Advantage patients with heart failure were enrolled into the program and placed on remote patient monitors. Twenty percent (20%) of this cohort experienced a concurrent episode of Medicare home health care at some point during their participation in the program. All had primary care physicians, of which 20% were Cardiologists.
Description of the Program: The RPM program at Dignity Health Hospitals on the Central Coast was designed to be complementary to a well-established telephonic care management program housed within a home health agency. The program was intended to avoid being dependent on traditional Medicare home health eligibility requirements. Patients were monitored for up to six months in order to demonstrate the long-term effectiveness of the program within an integrated delivery network. Three heart failure RNs with extensive experience in cardiology and clinical case management were hired to provide clinical management to community-based monitored patients in a three-hospital service area of 250 sq. miles. The heart failure case managers identified potential patients at risk for hospitalization by:
Note: patients may be accepted into the RPM program as a result of a visit to the ED at any of the three hospitals for heart failure or related conditions and from a physician office referral. Once the patient and physician agree to the program:
Enrollment/Selection Criteria: Fifty-one (51) patients were enrolled for up to six-months of telehealth monitoring. All inpatients identified with heart failure were eligible if they met the specific program criteria. Patient and/or MD refusal for otherwise eligible patients negated enrollment into the program. Of the 51 patients enrolled into the program, 39 were on monitors six months or longer. Of the remaining 11, two were removed for SNF placement, three declined continuing in the program, two died, and five remain on monitors.
The initial enrollment criteria were determined to be too general. Recommendations for the future include: a) assure that all patients over the age of 80-85 are enrolled into the program as this has proved to be a significant factor associated with re-hospitalization, b) consider whether patients with renal failure should be excluded, and c) determine whether SNF-based patients should be included or excluded.
Dignity Health’s Remote Patient Monitoring Program compared utilization and cost outcomes of enrolled patients diagnosed with heart failure with a reference group of similarly diagnosed patients, who were not enrolled in the RPM program. The program also examined differences within and between both groups before enrollment in the program and after. Patient experience and efficacy with disease self-management was evaluated for those patients in the study group monitored for at least eight weeks.
Program Outcomes: Routine outcomes analysis for performance measurement of healthcare resource utilization by patients on remote patient monitoring involved comparing hospital admission dates for patients enrolled in the monitoring program and those who were not. Of the patients enrolled in the program for six months or more, there was a 58% reduction in readmissions compared to the six-month period preceding program enrollment. Readmissions for patients with heart failure within 30 days of discharge from the hospitalization immediately preceding program enrollment was 5% for patients enrolled in the program compared to 23% for non-monitored patients during the same time period.
Total costs associated with acute care hospitalizations were decreased 58% for the study population as compared to the cost of hospitalizations for the same patients six months prior to enrollment from $703,176 to $296,520. Emergency room visits for CHF or related conditions that did not result in a hospitalization, decreased during this period by 17% further lowering costs for this population of patients by $3,000. The average cost per ED visit for patients with a primary diagnosis of heart failure was $767. The average cost for a hospitalization for a diagnosis of heart failure or related condition was $8,472.
The ROI analysis of Dignity Health’s RPM program indicates a modest Year 1 ROI of 0.4, although there is a high dollar return per patient of $9,882.
Project Limitations: There are several limitations to this project, which should be considered. This project was conducted as a stand-alone program associated with a local integrated delivery network wholly owned by Dignity Health. Although developed and implemented within the system’s home health agency, results may not be comparable to other home health based programs, which typically define TeleStation eligibility in association with a billable episode of home health.
Further, it should be considered that patients were enrolled into the program based on their willingness to participate. Patients who may have benefited from the program but who refused it were not enrolled. Also, there was no attempt to randomly assign patients to the program. This may introduce selection bias as a result of serving a disproportionate share of self-motivated patients.
Lastly, it is important to remember that remote patient monitoring is primarily a technological tool of a larger care management model effort designed to address the clinical needs of patients with chronic disease using a team of trained individuals. Clinical process re-engineering is necessary to enhance the current program (i.e., making nursing interventions 24/7 instead of 8-5 M-F, with the adding of medical protocols to enable real-time clinical interventions to address urgent medical needs), as well as to create the clinical, quality, education, business, logistic and organizational systems necessary to support the deployment of this technology throughout the enterprise.
HOW THEY DID IT
Context of the Innovation: Dignity Health (formerly Catholic Healthcare West) is the fifth largest health care system in the country. Dignity Health Central Coast consists of three acute care hospitals, primary care clinics, long-term care, acute rehab and the system’s largest home health, hospice and home infusion program. The Central Coast service area home health division developed a telephonic care management program for community-based patients with heart failure in 2004, progressing to the use of remote patient monitoring through the grant. This project was undertaken in order to: a) position the Central Coast to better manage the care of patients across the continuum, b) better meet the components of health care reform (value based purchasing/readmission penalties), and c) pilot a care management tool for possible replication in other markets within Dignity Health.
Planning and Development Process: The following represents the key implementation steps and timeline utilized in preparing for and the ultimate deployment of the program and the technology.
Getting Started With This Innovation: The consensus of the RPM project team as to important prerequisites to a successful launch include:
Sustaining This Innovation: The success of the RPM program at Dignity Health, Central Coast Service Area has led to the decision to continue the program within the home health agency. This will require the operational integration of the program (systems, staff and technology) into the home health agency. Dignity Health is in process of embedding the RPM interface into its EHR so that home health clinicians can monitor patients 7 days/week and potentially 24hrs/day. The program will be at least partially funded through expected cost savings (fewer nursing visits) over the term of a home health episode. This step will necessarily reduce the current six-month monitor window allowed during the grant period to 60-120 days for eligible patients eligible who are enrolled in a Medicare episode of home health care. Coverage of patients beyond that window of time or for those not eligible for home health care under Medicare is yet to be determined and will depend on the results of the return on investment analysis. Dignity Health has the potential to expand the program throughout its Home Health Division which includes 17 home health agencies and 8 hospices in California, Arizona, and Nevada.
Other Considerations and Lessons: Creating the vision for the use of remote patient monitoring technology in the management of Dignity Health, Central Coast Service Area’s patients with Heart Failure and subsequent program implementation yielded a number of findings. Some of the most practical lessons learned and recommendations are as follows: