VNA Care Network Foundation (VNACNF), in partnership with Atrius Health, is now offering a far more comprehensive telemonitoring program to better care for our shared patients, boost clinical outcomes, and prevent hospital readmissions.
Patients are referred to this new program by their clinician. The program promotes early detection of new or worsening symptoms and applies appropriate clinical reaction and treatment from either VNACNF or the patient’s Atrius Health primary care team. In turn, this access to daily monitoring and care promotes quality of care and patient satisfaction while lowering the need for emergency treatment and preventing hospital readmissions.
The newly expanded program maintains the Certified Home Telemonitoring Program but now includes the new Remote Patient Monitoring Program (RPM). While the two programs differ in a few ways, both expand access to telemonitoring services to a much wider population of patients. With the new RPM Program, a patient does not need to meet the certified home health criteria to benefit from telemonitoring; including homebound status.
Who Benefits from Telehealth?
This is a patient self-management system, which delivers daily remote monitoring of patients’ blood pressure, pulse, weight, and blood oxygen levels tailored in accordance with individualized patient symptom management and care needs. The program is best suited for patients who have been diagnosed with COPD, hypertension, heart failure, those who have had a recent cardiac surgery, need assistance with cardiopulmonary medication adherence, and/or who have pneumonia or other respiratory complications. Additionally telemonitoring may also benefit patients who struggle with symptom management such as daily weight checks, monitoring blood pressure, and adherence to specific diets.
The program is built around a consistent and collaborative communication strategy between patients, VNACNF nurses, and the Atrius Health primary care team. While patients receive full training on the equipment, its basic, intuitive tools, including one-step automatic send capabilities, make it easy for a wide range of patients to understand its functionality. The system alerts the VNACNF nurse before a major medical event occurs and significant changes in vital signs result in an immediate communication to the patient and the doctor.
Case Study
Patient R.P. has suffered a long history of heart failure. In the past two years, the patient had been hospitalized once, lasting three days, with significant incurred costs. During that same time-period she had been to the ED twice. In April 2015, while admitted to certified home care without telemonitoring, the patient was once again hospitalized for heart failure. Upon being discharged from the hospital patient R.P. was readmitted to certified home care, but this time placed in the telemonitoring program, and has not been hospitalized since. In June, the patient no longer required certified home care services but was still at risk for rehospitalization, and so was seamlessly transferred into the RPM program. Since admission to the RPM program, patient R.P has remained both out of the hospital and the ED. She has also exhibited more independence in her care and verbalized how much more comfortable she is in self-care.
The RPM program has certainly contributed to patient R.P.’s good health. Her vitals remain stable and with constant oversight, have not fallen outside her physician’s set parameters.
Specific Outcomes
Our data shows that on average, Atrius Health patients admitted to home care with telemonitoring have a 0-4% rehospitalization rate in the first 60 days of care. The national acute care hospitalization rate for all patients receiving home health care services is 23%.
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