Improving the Application of Remote Electronic Monitoring of Chronic Disease in Older Adult Patients

Project Summary

To enhance the quality of life for elderly patients with chronic disease using a telephone-based home monitoring technology that aims to reduce health utilization.

Technology

Interactive voice response (IVR) technology

Targeted Locations

Los Angeles, California

Collaborators

Physicians and allied health professionals at HealthCare Partners Medical Group (HCP).

12-Month Goals

• Reduce health utilization; ED/UC visits, bed days, admissions, readmissions at 30-days.
• Provide clinical parameters to health providers that helps prevent chronic disease exacerbations.
• Provide user-friendly technology that permits older adults to live in their chosen residence.
• Ease the burden/stress of caregivers treating patients with chronic disease.

Older Adult Population

1st year: 100-140 older adults (≥65yo) with chronic disease (i.e., COPD, CHF, CAD, diabetes, HTN)
5th year: potential to reach 3000-4000 within HCP sites

Setting/Provider Type

Accountable care organization. Patient homes and HealthCare Partners Medical Group clinicians.

Measurable Outcomes

Health outcomes will be measured by hospital admission and readmission rates, urgent care and emergency department visits, total cost of care, deaths in the hospital, disease management case load/cost of disease management on a per member, per month basis as juxtaposed against total cost of care and mortality. Patient and case management satisfaction will be quantified by a questionnaire aimed to improve patient care by enhancing remote technology and optimizing its’ ease of use.

Replication, Dissemination Plan

HCP is one of Southern California’s largest providers of senior care. HCP can help influence health care policy using HIT with older, chronically ill populations by sharing lessons learned with other collaborators and organizations. HCP will also identify dual-eligible, Medi-Medi patients who may benefit from remote monitoring technologies thereby impacting greater numbers of patients.

Sustainability Plan

HCP has shown reduced costs per patient, per month with a COPD patient-centric disease program. By reducing health costs (decreased admissions/readmissions, bed-days, ED/UC visits), these savings can off-set program implementation expenses thereby helping to impart sustainability and maintaining the program. Continued savings can occur as the chronic disease IVR technology program is expanded on a broader scale.

Funding Request

$100,000

Matching Funds

$87,000