Web Exclusives

Real-Time Data From the Home Improve Outcomes

By Jane Fields, RN, MSN, MS, and Melody Wilding, LMSW

Gathering real-time data from patients’ homes enables prompt response to health concerns, reducing costs and promoting aging in place.

Most medical treatments involve a trip to a physician’s office or hospital, yet patients spend most of their time in their own homes. In the established medical model, the home environment has become a “black box” where care providers are cut off from patients and unable to record day-to-day changes in their clinical conditions and behavior. This environment often leads to negative outcomes in the longer-term care process—costly and unnecessary events that could be eliminated with the right real-time, actionable data from the home.

Many care providers currently rely on outdated tools with limited diagnostic value, such as paper forms and phone calls, to collect care data from patients’ homes. This produces a communication gap that results in more frequent emergency department (ED) visits and hospitalizations as well as increased use of other expensive health services, all of which escalate costs and degrade the quality of the patient experience. This reality is driving demand for care-coordination technology within the home-based care model.

Creating a user-friendly system that not only facilitates but also incentivizes data provision is the future of improved care for older adults and those with chronic conditions. In-home health-tracking systems enable home care aides, family caregivers, and patients to enter real-time health data—covering variables from medication intake and vital signs to daily routines and even state of mind—regardless of computer skill or medical literacy. Physicians, nursing personnel, and other care coordinators can then easily review a patient’s health information and care patterns. This new class of digital tools captures comprehensive information from the home and creates an environment for effective care provision unlike any previously available.

Real-time data improve affordability and quality of care through the following:

Reduce hospitalizations and prevent readmissions of elderly patients: Research shows that 75% of Medicare hospital readmissions may be preventable. In fact, one in nine hospital admissions actually is a rehospitalization that takes place within 30 days of discharge. This is a problem that real-time data from the home can help solve.

By revealing developing problems before they require costly care services, digital care management systems help providers determine who is at risk of readmission and offer hospitals protection against strict new Medicare penalties that went into effect in October 2012. This process helps to differentiate cases that can utilize lower-cost services, such as a phone call, from those cases that require high-cost emergency response and hospital-based intervention.

Enables early intervention and improved monitoring of clinical status: Real-time information about a patient helps home-care providers monitor, communicate, and triage rapid changes in status to avoid preventable deterioration. Because Web-based care information is available instantaneously, significant events or trends can be spotted right away.

Analyzing data over days, weeks, or longer also allows providers to recognize patterns of decline and spot emerging problems earlier. While in-home caregivers may not notice or report small day-to-day changes, a digital patient care record helps visualize these patterns over time. For example, a geriatrician could see that a dementia patient is experiencing significant changes in sleep patterns, which can affect behavior and mood throughout the day.

Enhances care coordination efforts and enables better care transitions: The use of real-time data generated from a patient’s home creates collaborative opportunities for health care providers. It bridges the gap in care coordination, creating an exchange of information among patients, caregivers, and health care providers that improves patient-doctor communication. Physicians, insurance caseworkers, nurses, and family caregivers can simultaneously work to make collective decisions about the care process.

Digital care management presents a unique opportunity to better integrate home health aides into the larger care team. Empowering the professional caregiver who spends the most time with the patient can positively impact the quality of care delivered.

What’s more, today’s in-home health record systems offer critical health and behavioral information that is formatted to fit within a home care coordinator’s workflow, streamlining administration and improving productivity through efficient management.

Enables aging in place with comfort: Using real-time clinical and behavioral data generated from patients’ homes keeps them longer in the comfortable and familiar environment of home, potentially saving the health care system billions in care costs and Medicare penalties over the coming decades. Real-time health data also reduce transitions to more expensive care settings, including nursing homes, assisted-living facilities, and rehabilitation centers.

Delivers a comprehensive picture of patients’ behavioral and clinical conditions: Real-time care information from a patient’s home provides a comprehensive picture of care, helping providers treat conditions in a holistic manner. Unlike the previous generation of “telecare” platforms, today’s in-home health data systems can record important variables such as blood pressure and weight, and also provide insight into the factors and actions that produced the readings. For example, a 2-lb weight gain within 48 hours can be significant for a congestive heart failure patient but provides little help in determining the best course of treatment. However, receiving an instantaneous alert about this rapid change combined with dietary patterns, a medication intake calendar, and an activity log helps providers adjust the plan of care and offer customized treatment.

Reduces insurance claims and lowers premiums: By enabling early intervention, digital care management will have a systematic impact on reducing insurance claims and lowering premiums. Access to real-time information from the home allows closer monitoring of patients’ compliance with care plans and medication adherence, enabling better control of chronic conditions over the long term, which drives down coverage costs.

Digital care management systems promote patient engagement and education, which can influence positive health-related behavior change. This, in return, drives down insurance companies’ costs.

Makes technology easy: Unlike previous programs, new care-monitoring tools are “high-tech light tech” and require limited technical experience yet offer powerful care management functionality that can influence health-related outcomes such as reducing ED visits, nursing visits, and hospitalizations. These tools leverage technology already available in the home, such as smartphones, tablets, or personal computers, to collect vital care information.

The Value of Real-Time Data
Beginning in October 2012, a trial of eCaring, a Web-based care management system, was conducted with eight high-risk geriatric home care patients in New York City. After 90 days, the system had prevented nine ED visits, three hospitalizations, 12 doctor visits, and three unplanned nurse visits. Several participating patients historically had visited the ED as frequently as twice per month.

The following two examples from the trial speak to the system’s cost-saving and care-improvement potential. Names have been changed to protect patients’ privacy.

• Hazel typically made several ED visits each month for high blood sugar and changes in her mental condition. But since beginning the trial, she has not visited the ED at all.

With eCaring’s alert for high blood sugar, care managers could address the problem with Hazel’s caregiver immediately via phone. A registered nurse provided in-home instruction to help Hazel better understand ways to manage her condition, preventing expensive hospitalization. eCaring enabled Hazel’s physician to intervene remotely, working over the phone with the care team to change her medication.

• Harold visited the ED twice per month on average for blood sugar fluctuations caused by a noncompliant diet. But since he began using the system, he hasn’t returned. Real-time monitoring helped Harold’s care team better regulate his nutritional habits and keep him on his diet plan.

As in Hazel’s case, a high blood sugar alert from eCaring allowed caregivers to take appropriate action early in the home, preventing the need for rehospitalization. With the information from eCaring, Harold’s nurse could make home visits that precluded a hospital visit.

Timely notification and early intervention prevented a substantial number of ED visits, resulting in significant cost savings to the health care system and improved care outcomes for patients. Using real-time data from patients’ homes generated savings of more than $60,000, or about $2,500 per patient per month, while the system’s costs were around $50 per patient per month.

Despite the benefits, there remain obstacles to overcome in encouraging widespread adoption of real-time online care management systems. In particular, addressing educational and instructional resources and Internet connectivity issues within the customer community is important. It will take a concerted effort from patients, caretakers, physicians, nurses, and health care providers to surmount these challenges in order to reap the benefits of this new technology.

For patients, the benefits include reducing the need for expensive recurring hospital stays, and allowing for more affordable and comfortable care in the home environment. For health care providers, this means avoiding costly Medicare penalties associated with preventable readmissions while at the same time stratifying which patients require immediate interventions to avoid high-cost services.

— Jane Fields, RN, MSN, MS, is vice president of care management at eCaring and a nationally recognized expert in home care.

— Melody Wilding, LMSW, director of outreach and strategic communications at eCaring, is a trained geriatric social worker and an expert on aging and health care technology.