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If these walls could talk: utilizing health data from the home to reduce unnecessary readmission

User Category: BlogOn: October 2, 2015

headWhen it comes to gathering valuable data about the health of elderly individuals with multiple chronic health issues, there’s no place like home. We are experiencing a time of tremendous change in the health care industry. Fueled by the ACA, the push to managed care, value-based payments, capitated rates, CMS penalties and policies, Medicaid Redesign efforts, and the unrelenting realities of demographics and economics, we face the necessity of making basic changes in how care is administered, managed, monitored and integrated if we are to achieve the goals of lowering costs and utilizations while enhancing care quality for the neediest segments of our population. For example, in New York State, dual eligibles (seniors that qualify for both Medicare and Medicaid assistance) make up 15% of the Medicaid population, yet account for 39% of total Medicaid patient costs. On a national level, there are more than nine million dual eligible patients that cost over $250 billion a year, among them, 55% live with three or more chronic illnesses.

The 2012 Medicare Readmission Reduction Program coupled with tighter budgets for states and managed care organizations, stricter capitation rates, and everincreasing service costs make care management across the continuum of care a critical component for maintaining patient health. These changing requirements and trends are why there needs to be an overall commitment and prioritization from the healthcare community to invest in home healthcare information technologies that connect clinicians, care providers and coverage payers with patients. By providing payers, plans and providers with real-time monitoring of chronic conditions common to the aging population, we will fill a critical void in today’s ACA. Technology that supports real-time health monitoring in the patient’s home has the potential to revolutionize transitional care from hospital to home as well as improve long-term home care outcomes enormously.

A patient’s home is an untapped data resource that can provide insights into the patient’s current conditions and behaviors to help identify and respond rapidly to health issues as they emerge, rather than after they have seriously escalated. Even when professionals are a part of the care support team, the home can become a “black box” where aides clock in for duty but document their visits in uncoordinated and unproductive ways. For many elderly people with long-term care needs, monitoring blood sugar and blood pressure levels, keeping track of weight gains or losses, observing symptoms associated with dehydration, infection, depression and other health concerns is done by family caregivers or home health aides. There is little standardization of what needs to be monitored, and often, each entity supporting a patient functions within a different “language”.

With the help of technological tools, which can range from smart sensors and telemonitoring to interactive systems such as eCaring that collect extensive unstructured human touchpoint data, the “black box” of healthcare monitoring can be transformed into a matrix of data where home health aides and family caregivers can input 500-1,000 data points per month, which can be used to respond rapidly to situations and trends requiring immediate attention, keeping small problems in the home from escalating to big ones requiring hospitalization. Here are eight key benefits that can be achieved by prioritizing the collection and utilization of real-time home health data in 2015 and beyond:



1. Bringing the Internet into the home to shed light on the “black box”.

Often overlooked in a country where 58% of Americans have smartphones is that the neediest and often costliest health care users often fall below the poverty line and have no Internet access in their homes. This lack of connectivity leads to a “black box” effect, inhibiting a care team from having access to or knowledge of the significant events taking place in the home every day that lead to the costly use of health services. Bringing the Internet to the homes of America’s most expensive users, who are often low-income seniors that qualify for both Medicare and Medicaid assistance (“dual eligible”), quickly transforms the home into a rich source of meaningful data. With Internet access, seniors and their caregivers can transmit important patient data in real-time to care managers and doctors, as well as open the world of the Internet to the homes of the many that the “Information Super Highway” still passes by.


2. Creating a universal language for healthcare communication through the use of recognizable icons and symbols.

Just as important as the establishment of the Web in the home is functional access to technology by creating systems that can be quickly understood by the home health aide, patient and family, each of whom have varying levels of computer skills and English literacy limitations. Traditional systems used to record activities, such as phone, fax and paper, have limited utility, are cumbersome and error prone. Using icon-based systems, such as the one provided saw the value of an icon-rich software system for reporting real-time results of patients with congestive heart failure (CHF). As one of the nation’s leading cardiovascular care providers, Beth Israel enrolled a group of its patients with CHF in a real-time monitoring post-discharge program to assess the impact on reducing readmission within 30 days. Beth Israel requested CHF-specific easy-to-understand icons, care management tools, and a tracking component for each patient participating in the trial. Beth Israel learned that the system’s new icons eliminated any language barrier, while ensuring quick input of key data on the patient’s weight, medication regimen, behavioral patterns and vital signs.


3. Creating a continuum of care through improved communication. Better, consistent data from the home allows for sharing of patient information across the entire care team, including care managers, providers, hospitals, and health plan coordinators.

This continuous stream of communication provides the best means to engage the home care worker and patients, who are more likely to provide data input if their care team responds in a timely way. Knowing that “someone was there” and “I am not alone” helps patients cope and adhere to the plan of care prescribed by their physician. The continuum of care system also empowers patients to have increased responsibility for their own care and make informed decisions about the services they require.


4. Modifying monitoring to meet the critical needs of a particular patient population.

One of the leading causes of readmissions is readmissions is CHF, followed by pneumonia, chronic obstructive pulmonary disease (COPD), urinary tract infection, and diabetes. Heart failure can often lead to comorbidities, including dementia, renal failure, and hypertension. Heart failure affects nearly 6 million Americans annually, with 550,000 new patients diagnosed each year. Four out of every five cases of heart failure occur in older adults. CHF is associated with over 1 million hospitalizations annually. The majority are readmissions or re-hospitalizations. CHF is in part responsible for close to $35 billion that is spent on heart failure each year. To reduce the risks associated with CHF, real-time monitoring can be utilized to track sudden weight gain, swelling of ankles, shortness of breath, chest pain, severe fatigue, loss of appetite, frequent nighttime urination, rapid heartbeat and other critical factors.


5. Tracking critical activities, vital signs, medications and mental and physical states to help address problems before they lead to hospitalization.

Using real-time data, members of the care team can quickly spot changes or new trends that require immediate attention, keeping small problems in the home from leading to visits to the ER. In the case of Beth Israel, data inputted by the home aide or the patient was quickly uploaded to the Cloud where information was evaluated by a care manager. The program showed significant, quantifiable reductions. Beth Israel saw its average rate of 29% CHF patient readmissions drop by 60% to 10.5% for this trial population.


6. Sharing information, through 24/7 web access, lowers stress for patients, caregivers, and families.

Unstable conditions cause stress that can lead to a rapid heartbeat, immune system compromise, fatigue, and time off from work. Knowing that they can remain at home with the support of an entire care team at the touch of a button gives patients a greater peace of mind and sense of control over their situation and progress. Longer stays at home increase comfort and lower stress as well as costs for patients, families, and caregivers. Caregiver stress is associated with over $35 billion a year in business costs.


7. Using analytics by patient populations to improve risk stratification and assessment.

Most risk stratification programs are based on prior history and in-hospital experience, with generalized risk factors. Real-time post-discharge care data can substantially enhance assessments for determining readmissions and utilization risk. Analytics can also help predict outcomes of recovery while pointing to outliers that may need further attention. Harnessing analytics can also determine best next steps in a particular patient population, as well as assessing care management performance among providers and the sharing of best practices. In the case of a UCLA study, analytics of remote monitoring for heart failure patients predicted associated medical costs, optimization of care, and reduction of overall readmission costs by 61.5%.


8. Improving time management of activities and expenses.

Tracking of actual vs. budgeted or reimbursable time is demanded by today’s payers. Using technology rather than telephone or, even worse, paper time sheets, can reduce time spent on time entry and increase accuracy. Resources can be better managed, which is essential under capitated rate and value and performance payment systems. The success of real-time monitoring in reducing readmissions for patients with CHF at Beth Israel has led to the development of different modules for the needs of other special patient populations. Among the patient populations being considered for real-time data monitoring modules are patients with developmental disabilities, COPD, diabetes, acute myocardial infarction, and other likely causes of readmission. The proven success of new digital media tools that can be used in the home to significantly reduce hospital readmissions and lower overall patient long-term care costs is a bright spot on the emerging healthcare landscape. Scaling up the introduction and deployment of these home-based systems is a certain “homerun” for healthcare.



Robert M. Herzog, MA, is a pioneer in applying new media and technologies to develop companies and solutions to critical problems in healthcare, media, Internet utilization, energy and the environment. He is the Founder and Chief Executive Offi cer of eCaring, Inc., a Web-based home health care management and monitoring system that brings the benefits of digital record keeping and communications to the millions of Americans receiving home health care. Mr. Herzog has an extensive background in digital media and creative enterprises as an entrepreneur and executive. Mr. Herzog graduated from Williams College, and his primary professional interests include improving information sharing and reducing overall health care costs.