Telehealth and the Cardiac Patient

1
Telehealth and the Cardiac Patient
2
Delnor Home Care

• Hospital-based home care agency
• A department of Delnor Hospital
• located in Geneva, IL
• Case mix-75 Medicare
• Provide skilled services
• Average daily census of 140 patients
• Six field RNs (4.5 FTEs)

3
Research

• According to the Institute for Healthcare
  Improvement (IHI), Congestive Heart Failure (CHF)
  is a major and growing public health problem
• According to the Center for Disease Control
  (CDC), heart failure is the most common reason
  for hospitalization among people with Medicare
• One of the IHI initiatives is to significantly
  improve care and reduce readmissions for patients
  with CHF

4
Research

• It is well documented that patients struggle in
  self-managing their chronic disease
• Decreased LOS in hospitalsless patient education
  in disease management
• Telehealth can both improve efficiency and ensure
  a timely response to situations that might
  otherwise deteriorate rapidly

5
What We Found

• Emergent Care 26.6
• National Reference 22
• Rehospitalization 24.5
• National Reference 24.5
• Reports 08/06-07/07 State OASIS Reports

6
What We Found

• Reports singled out CHF as the main reason our
  patients were rehospitalized
• 28.8 of the Home Care CHF patients were
  rehospitalized during their episode of care

7
Solutions

• CHF pathways
• New patient teaching tools
• Staff education
• Phone telemonitoring of patients

8
Program Start

• The process began January 25, 2007
• Written charter, action plan, workflow analysis
• Meetings were held every 2-4 weeks
• Site visit well_at_home agency June 2007
• Plan was presented to key groups at hospital
  including
• Department leaders
• Discharge planners
• Marketing staff
• Key cardiology practice

9
Program Start

• Eleven well_at_home units were delivered
• Training was initiated on October 9, 2007
• Go-LIVE with first patient October 10, 2007
• Celebration luncheon!

10
Project Team

• Multiple personnel from various departments
  participated
• Physician sponsor
• Executive director sponsor
• Project manager
• QI/Education specialist
• Therapy coordinator
• Patient care coordinator

11
Project Team Continued

• Home care liaison
• Intake specialist
• IS coordinator
• Marketing specialist
• Discharge planning coordinator
• Field RN

12
Project Goals

• Achieve better use of resources
• Improve quality of life
• Decrease rehospitalization
• Decrease emergent care

13
Criteria for Home Care Telehealth

• Home care eligibility for telehealth
• Physicians orders for home care
• RN service needed
• Functional status
• Adequate manual dexterity
• Adequate sensory ability to operate equipment
  (vision/hearing)

14
Criteria for Home Care Telehealth

• Psychosocial Status
• Patient/caregiver are willing to give consent to
  the use of telemonitoring
• Patient/caregiver able to understand directions
• Patient/caregiver compliance
• Home Environment
• Home has land phone line
• Home environment will not damage equipment

15
Criteria for Home Care Telehealth

• Clinical Status may include
• Current diagnosis of CHF
• History of one or more hospitalizations or
  emergency room visits for disease
  onset/exacerbation
• Deficits in CHF self-care management
• History of problems adhering to disease
  management recommendations (medication
  management, diet, knowledge of disease processes/
  adverse signs/symptoms to report)

16
Referral Process

• Potential patients identified by hospital
  personnel based on telehealth criteria
• To include physician, RNs, discharge planners,
  home care liaison
• Physician order signed stating may have
  telehealth
• Telehealth and disease-specific protocol
  completed by physician
• Home care liaison/case managers discuss
  telehealth with patient/caregivers
• Referral to home care intake

17
Roadblocks

• Staff buy-in
• Physician resistance
• Patient reluctance
• Referral sources
• Cost
• Hardware
• Software
• Training
• Management of patient data

18
Interventions Field Staff

• A field RN was placed on the implementation team
• Field staff were kept informed of the progress of
  implementation
• Education to the field staff
• One-on-one assistance in setting up pathways,
  orders, and loading the monitors
• Joint visits to set up monitors in patients
  homes
• Additional pay per visit for set up well_at_home

19
Interventions Physicians

• One-on-one meetings with key physician practices
• Articles in the physician newsletters
• Demonstrations at various physician meetings
• Participation in CV strategic planning meeting
  for cardiac continuum of care

20
Interventions Patients

• Scripting made available to the field staff
• Assistance provided when requested
• Family members involved
• Phone contact with patients the day following
  monitor placement

21
Interventions Referral Sources

• Education and demonstrations provided to
• Hospital clinical coordinators
• Hospital discharge planners
• Education provided at the mandatory RN education
  days attended by all hospital RNs

22
Interventions Cost

• CHF is a low HHRG scoring diagnosis
• The average number of visits for CHF patient
  without telehealth was 11.8
• Our goal is to reduce the number of visits of
  well_at_home patients by 3.5
• The cost of travel reimbursement has skyrocketed
• Patients will receive visits when needed and
  unnecessary visits will be eliminated
• Pay-for-performance is coming

23
Interventions Management of Patient Data

• Policy and procedures
• Education to the field staff regarding data
  assessment and documentation of interventions
• Monitoring and managing alerts and trends in data
• Assist from office RNs when needed
• Initiation of wireless connections for field
  staff laptops

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Case Study 1Howard

• 73-year-old male veteran
• Alert, oriented, with no memory deficits
• Non-compliant
• Lives with non-supportive non-compliant wife
• Nonsmoker
• Sleep apnea but unwilling to wear Bi-PAP
• Complains of difficulty sleeping
• Orthopnea
• Incontinent of urine
• Chronic obesity
• History of depression

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HowardPrevious History

• Hospital stays for
• Back pain, spinal stenosis, renal insufficiency
• Acute MI in 2002 and 2007
• CHF 2002 and 2003
• Atrial Fibrillation 2003
• Seen by home care 07/12/06-08/25/06 for therapy
  visits due to spinal stenosis

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Howard Home Care Course

• Hospitalized 10/01/07-10/09/07 with diagnoses of
  Acute MI, CHF
• Admitted to home care 10/10/07
• SN visits scheduled 16
• PT visits scheduled four
• 22 SN visits made (two episodes of care)
• Four PT visits made (first episode)

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Howard Home Care Course

• Diagnoses
• CHF
• COPD
• Type II Insulin-Dependent Diabetes
• History of Acute MI
• Renal insufficiency
• History of skin cancer
• Spinal Stenosis
• Hypertension
• Anemia

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Howard Home Care Course

• Medications

29
Howard Home Care Course

• Baseline data
• Weight 250 pounds
• Bilateral lower extremity edema 1 pitting
• BP 108/60
• Pulse 80 and regular
• Respirations 20
• Mild dyspnea on ambulation and ADLs
• On continuous Oxygen 2 L per nasal cannula

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Howard Home Care Course

• Patient education
• Cardiac care, energy conservation
• Medications (including oxygen)
• Disease process
• Diet
• Symptom management and reporting including
  dyspnea and pain management
• Safety, emergent care management

31
Howard Home Care Course

• Patient instructed in medications and was able to
  fill his own medication box
• RN found patient non-compliant with medication
  regimen in filling medication planner and in
  taking medications
• Patient was instructed in use and safety with
  oxygen therapy but was found to be non-compliant
  in wearing his oxygen
• Patient non-compliant with using Bi-Pap

32
Howard Home Care Course

• Assessments and interventions
• Vital signs including weight
• Cardiac function
• Edema
• Respiratory status
• Pulse oximetry
• Endocrine status
• Lab values (BMP, CBC, A1C)

33
Howard Home Care Course

• Scheduled physician appointment 11/12/07
• The patient was in the car waiting for his wife
  to bring his portable oxygen
• On the wifes return to the car the patient was
  unresponsive
• The wife called the paramedics and patient was
  taken to the emergency room

34
Howard Home Care Course

• Emergency room found patient unresponsive due to
  hypoxia
• Pleural effusions
• Pulse oximetry was 55 on room air
• BNP 627 (0-100)
• Chest x-ray was consistent with CHF and pulmonary
  edema
• Patient was hospitalized and stabilized
• Discharged home on 11/22/07

35
Howard Home Care Course

• Home Care services resumed on 11/23/2007
• Patient was started on well_at_home telehealth on
  11/26/07
• Education included
• Energy conservation
• Disease process
• Cardiac medications

36
Howard Home Care Course

• Monitoring included
• BP
• Pulse
• Pulse oxygenation
• Weight
• Reporting s/s included
• Difficulty sleeping
• Dyspnea
• Edema

37
Howard well_at_home Data

• 12/03/07 order received for Bumex 3 mg daily

38
Howard well_at_home Data

• Weight stabilized until 12/19/07 increase in 4
  lbs in one day.
• Physician had discontinued Aldactone 12/21/07
  (office visit)

39
Howard well_at_home Data

• Physician was notified of weight and Aldactone
  reordered 1/4/08

40
Howard well_at_home Data

• We discussed weight increase with wife. She had
  not refilled Aldactone due to waiting to get it
  from the VA
• 1/8/08 additional 2mg Bumex given. Weight down
  5 lbs in one day

41
Howard well_at_home Data

• Weight stabilized in a 5-6 lb range up and down.
  Oxygen discontinued as Bi-Pap used more
  consistently. Discharged 2/5/08.

42
Case Study 2Ruth

• 84-year-old female non-smoker, recently moved in
  with daughter from out of state
• Good family support
• Alert, oriented with no memory deficits
• Patient usually manages CHF with additional Lasix
  for weight gain of several pounds
• Patient anxious with nighttime dyspnea
• Admitted to the hospital 1/5/08 with Exacerbation
  of CHF, A-Fib, Pleural Effusion, UTI

43
Ruth

• History includes
• CHF
• Atrial fibrillation
• Longstanding Coronary Artery Disease
• MI x 2 with placement of stents and quadruple
  bypass
• Pacemaker status
• Insomnia
• 
  

44
RuthHistory Continued

• Hypertensive kidney disease
• Hyperlipidemia
• Type II insulin dependent diabetes, controlled
• Cataracts, Macular degeneration
• Urinary incontinence

45
RuthHome Care Course

• Admitted to Home Care after hospital discharge on
  1/14/08 (14 SN visits, 19 PT visits made in one
  episode)
• Baseline vital signs
• Pulse 60 regular
• BP 110/60
• Weight 148 pounds
• Pulse oxygenation 92
• Trace pedal edema
• Mild dyspnea on walking gt20 ft. and up stairs

46
RuthHome Care Course

• Medications
• Digoxin
• Aldactone
• Coumadin
• Aspirin
• Lipitor
• Lasix
• Folic Acid
• Isosorbide Mononitrate
• NTG sublingual PRN
• Potassium
• Coreg

47
RuthHome Care Course
Medications
48
RuthHome Care Course

• Telemonitoring with well_at_home began on 1/16/08
• Monitoring included
• Pulse
• BP
• Pulse oxygenation
• Weight
• Blood glucose
• Symptom reporting included
• Dyspnea
• Edema

49
RuthHome Care Course

• well_at_home Education included
• CHF disease process
• Cardiac medications
• Type II DM
• Hypoglycemia
• 2gm NA ADA diet

50
Ruthwell_at_home Data
Patient reported moderate dyspnea at night. She
took additional Lasix on own. Coreg increased to
1.5 tabs on 1/18. Wt decreased significantly.
Pulse lt 60 on 1/18/08, Digoxin decreased to QOD
51
Ruthwell_at_home Data
1/28/08, patient cancelled therapy-felt ill,
reported dyspnea, abdominal distention. Alert
message on well_at_home instructed patient to call
Home Care RN. Patient rehospitalized.
52
RuthRe-admission to Hospital

• In Emergency Room Patient reported increased
  weight gain with dyspnea on lying down, heaviness
  in chest, difficulty sleeping and feeling weak.
  She said she wanted to get it checked out.
• Hospitalization Medication management
• CHF exacerbation
• Pleural effusion
• A-Fib, Left bundle branch block, UTI
• BNP 414 (0-100)
• Dig level 0.4 (0.8-2.0)
• Discharged to home 2/5/08

53
RuthHome Care ROC 2/6/08

• Vitals Pulse 68 regular, BP 117/57
• Weight 140 pounds, no edema
• Pulse ox 93, denies dyspnea
• Medications
• Discontinued Lasix
• Added Bumex 2mg BID
• Discontinued Insulin
• Added Starlix before meals
• Resumed well_at_home monitoring, symptom reporting,
  and education

54
Ruthwell_at_home Data

• On ROC, weight was 140 lbs, which decreased to
  134 lbs on 2/8/08. Patient complained of
  nighttime dyspnea. Oxygen ordered even though
  pulse ox above 88 (paid self pay). Weight
  increased to 146.8 lbs on 2/18/08 data faxed to
  physician.

55
Ruthwell_at_home Data

• 2/20/08, patient lost a couple of pounds, but
  still complained of dyspnea and heaviness in
  chest at night. Physician notified. Additional
  Bumex and Aldactone given 2/21/08. Additional
  Bumex given 2/23/08 with weight loss and improved
  breathing.

56
Ruthwell_at_home Data

• Weight increase again and additional Aldactone
  given 3/5/08. Patient moved back to her home out
  of state and discharged from home care 3/11/08.
  Printed discharge instructions given, including
  weight log and medication list.

57
Case Study 3Rose

• 84-year-old female, lives in own home. Has paid
  caregiver from 9a.m. 11p.m. daily. Caregiver
  presented home care nurse with challenges as she
  seemed competitive with nursing management and
  was very controlling.
• Daughter lived close by, but only involved when
  needed.

58
RoseHome Care Course

• Alert, oriented
• Legally blind
• Dyspnea when walking gt 20 ft, and up stairs
• Low NA diet
• Incontinence Urine
• Hospitalized 5/7/08 with CHF. Was diuresed and
  discharged to home care services on 5/13/08.

59
RoseHome Care Course

• History includes
• MI with stent placement
• Triple bypass surgery in 2002
• Carotid endarterectomy 2007
• Atrial Fib
• High cholesterol
• History of CVA

60
RoseHome Care Course Continued

• Hypertension
• Parkinson's
• Type II DM w/ophthalmic manifestations
• Legally blind
• Hypothyroid
• Anxiety
• Stopped smoking at age 55

61
RoseHome Care Course

• Admitted to home care 5/14/08
• Baseline vitals
• Pulse 92 irregular
• RRs 20
• BP 124/66
• Weight 166 pounds
• Dyspnea on walking 20 ft. and up stairs
• Edema 1 pitting bilateral lower extremities
• Frequent anxiety
• Routine labs, PT/INR, BMP

62
RoseHome Care Course

• Medications

63
RoseHome Care Course

• Telemonitoring with well_at_home began on 5/19/08
• Telemonitoring included
• Blood glucose
• BP
• Pulse
• Weight
• Reporting included
• Dyspnea
• Edema
• Education not sent to monitor, but SN reviewed
  cardiac care/management each visit

64
Rosewell_at_home Data
5/19/08, pulse 115-125. BP elevated. Patient
complained of feeling anxious. well_at_home data
faxed and physician notified patient was not
taking Lorazepam.
65
Rosewell_at_home Data
66
Rosewell_at_home Data
67
Rosewell_at_home Data
6/11/08, BP and pulse reported low. Dig level
drawn-normal. Caregiver stated physician
decreased Zestril by half. 6/13/08 BP increased
to 203/81. Additional Bumex given.
68
Rosewell_at_home Data

• Daughter concerned about weight loss and
  decreased appetite.

69
Rosewell_at_home Data
70
Rosewell_at_home Data
On 6/19/08, patient complained of feeling weak,
sweaty, lightheaded, heaviness in chest.
Caregiver called 911.
71
Hospitalization

• In Emergency Room (ER) Patient complained of
  feeling increased weakness, lightheaded, clammy,
  sweating, chest tightness prior to caregiver
  calling 911. Had improved by the time she arrived
  in the emergency room
• Pulse ox 100 on room air, vitals stable
• Daughter spoke privately to physician regarding
  concern about frequent complaints of weakness,
  and patients frequent phone calls to physician.
  Based on initial evaluation, emergency room
  physician felt patient did not need monitoring.
  EKG showed atrial flutter at regular rate

72
Hospitalization

• While in the Emergency Room, the ER physician was
  notified by the RN that patient was having
  irregular heart rate with slow ventricular
  response with pauses lasting up to 4.5 seconds
• Cardiologist was paged
• Patient was treated in the ER and admitted to the
  floor
• Pacemaker was inserted the next day

73
Home Care Resumption of Care 6/26/08

• Medications resumed
• New antibiotic for UTI
• New NTG sublingual PRN
• SN visits resumed for cardiac monitoring, wound,
  and pain management
• PT/INR, BMP, Dig level ordered
• Accuchecks per caregiver
• well_at_home telehealth resumed

74
Rosewell_at_home Data
Patient had periodic dips in pulse and BP, but
did not report any unusual symptoms
75
Rosewell_at_home Data
76
RoseHome Care Course

• Rest of home care course uneventful
• Patient still becomes easily stressed leading to
  anxiety, but feeling better overall
• Daughter will become more involved with with
  medication order management and physician
  follow-up visits

77
Where are We Now?

78
One Year Later

• Emergent Care 22
• National Reference 18.7
• Rehospitalization 21.9
• National Reference 23.5
• Reports 08/07-07/08 State OASIS Reports

79
Patient Case Study Update

• Howard
• Has been out of hospital since discharge from
  home care 2/5/08
• No emergent care episodes
• States hes kept up with weight log and
  medication instructions his nurse left him with
• Feels that telehealth made a difference is
  keeping him out of hospital
• He admits to gaining some weight back and is
  being treated for depression, but he gets out of
  the house more often

80
Patient Case Study Update

• Ruth Moved back with her daughter
• Has been out of the hospital since discharge from
  home care on 3/12/08
• No emergent care episodes
• States she has kept up with education materials
  including weight log, and diabetes log her nurse
  left her with
• Has had no weight gain, no fluid in lungs
• States shes not sure telehealth is what kept her
  out of hospital because her daughters watch her
  like a hawk

81
Patient Case Study Update

• Rose
• Has been out of the hospital since discharge from
  Home Care on 7/11/08
• No emergent care episodes
• States she has kept up with education materials
  including the weight log her nurse left her with
• She is more up and about and walks a lot with her
  caregiver
• Feels telehealth made a difference in keeping her
  out of hospital

82
The Winding Road
83
The Winding Road

• Decreased SN visits?
• Some resistance (Pay-per-visit)
• Costs
• Education
• Medication reminders
• Protocols
• Limited well_at_home monitors
• Integration with hospital cardiac initiatives
  key to success

84
Data

• Collect data and run rehospitalization and
  emergent care reports on an ongoing basis-a time
  consuming process
• Be clear as to what initiatives your agency will
  be tracking
• Create a rehospitalization log and assign one
  designated staff member to keep up with it

85
Data

• Suggested data to include in log
• Name, start of care date, telehealth start date
• Telehealth discharge date, agency discharge date
• OASIS time point history
• Emergent care reason
• Rehospitalization reason
• Home care medical diagnoses
• Rehospitalization diagnoses
• Visit frequency

86
Patient Satisfaction

• Patient satisfaction is one of our QI indicators
• The majority of our patients are very satisfied
• with telehealth
• Gave me a sense of security
• Helped me control my symptoms
• Helped keep me out of the hospital
• Id recommend it to others

87
Bibliography

• Institute for Healthcare Improvement (IHI)
• Center for Disease Control (CDC)
• Caring, July 2008 Vol XXVII, No. 7,
  Telemonitoring A Positive Impact on Patient
  Outcomes