Canady, Lisa M. RN, BSN, MSN
In the current healthcare arena, it is imperative that home healthcare agencies seek to reduce costs and produce positive outcomes from the care they give. Telemonitoring offers the ability to monitor closely the daily status of the patients that home healthcare agencies serve, to provide best practice care, and to produce positive outcomes from that care. This article presents the experience of how 1 hospital-based agency implemented a home telemonitoring program and describes the lessons learned throughout the process.
The current healthcare arena demands cost reduction and improved patient care outcomes from home healthcare agencies (HHAs). The direction that each HHA chooses to take to answer these demands will set the stage for their future. This article describes the steps needed to implement a telemonitoring program. The description is based on how 1 HHA chose its course of action and set it in motion and shows what was learned throughout the process.
Why Must We Change?
Home healthcare providers currently face pressures of many kinds (Utterback, 2005). With the changing demographics of patients served by HHAs, many are faced with the problem of shifting their focus of care. The baby boomers of America have received much attention in recent years. It is stated that they comprise 28% of the population, or 7 million people (Utterback, 2005).
With the possibility of serving many more patients in the future, HHAs must search for cost-effective care strategies. Home telemonitoring can be successful in assisting HHAs with the demographic and financial issues they face in delivering quality care (Honeywell HomMed, LLC, 2005).* The Balanced Budget Act of 1997 has mandated that a system to encourage efficiency by HHAs be established in the payment system (Jeng Lin et. al., 2005). The prospective payment system (PPS) was created, which operates on a system of payment according to a national standard for the complete episode of care provided (Jeng Lin et. al., 2005).
Currently, the Centers for Medicare and Medicaid Services (CMS) is planning to change to a pay-for-performance (P4P) system, whereby the HHA will be reimbursed according to actual agency performance in predetermined areas (U.S. Department of Health and Human Services, 2005a). The CMS is developing and implementing P4P initiatives to support quality improvement in the care of their beneficiaries (U.S. Department of Health and Human Services, 2005a).
For HHAs to improve quality, they must focus their energy on improving the outcomes of care given. The measurement data for these outcomes are gathered for each HHA by way of information submitted to state agencies via the Outcome and Assessment Information Set (OASIS). Currently, the publicly reported quality measurement categories defined by CMS include clinical, functional, and service-related measures (U.S. Department of Health and Human Services, 2005b).
Hospitalization has a negative impact on the healthcare system, and our patients tell us that it creates a significant emotional and financial burden on them and their families. In an analysis of ideas to reduce this occurrence, home telemonitoring emerged as a viable option for 1 HHA to choose for improvement of these outcomes. It has been stated that home telemonitoring technology assists HHAs in providing thorough care while conserving personnel and financial resources (Utterback, 2005).
This case study examined 1 HHA's experience implementing a home telemonitoring program. The HHA is hospital based and provides care to patients in the rural Southeast. The advantages of initiating a home telemonitoring program identified by this HHA were the abilities to capture daily data from the patient, identify problems early, provide prompt intervention, reduce emergent care visits, reduce hospital readmissions, and increase positive outcomes achieved by the agency.
The Implementation Process
The HHA began by researching current technology available. After the key elements of the various systems had been examined, the 3 systems determined to be the best fit for the HHA's needs and expectations were selected. The vendors of these 3 systems were contacted and requested to demonstrate their equipment. The HHA then chose the vendor it thought would best assist in attaining the agency's goals and be the easiest for their patients to operate.
Many factors affected the choice of the telemonitoring system. The major attraction was that the system chosen is Web based, meaning that care providers can access patient data from any location with the use of Web-enabled technology. Additionally, it includes measures controlled by the HHA that ensure the privacy and security of patient data. The system is attached to the patient's existing phone, eliminating the need of adding a second phone line for operation, and there is no need to purchase additional equipment. It operates independently. It offers the agency a wide variety of choices in the assessment of their patients and has the capability to send reminders and messages to the patient. It also has the feature of automatic translation. There is the potential for future expansion because the system is software driven, eliminating the need for extra patient visits to make changes in the system program. Changes are made by the HHA via the Web, and the system automatically updates the program routinely (WebVMC, n.d.).
Before installation of the system, it was imperative that the HHA obtain buy-in from both the local physicians and the staff. For the program to be successful, physicians must first understand what the system is used to do and how the information collected will assist in the care of the patient. If the physicians have a good understanding of the program, they will be much more likely to request the system for their patients.
This also is true for the patient care staff. The clinical staff must view the system as a tool to assist them in caring for their patients and realize that if used properly, the system could lessen their workload and offer them the opportunity to help their patients avoid crisis situations. One suggestion by this HHA is that a marketing campaign would be of great benefit before initiation or soon after initiation of the system to foster physician interest.
Another important step in the process is to select a coordinator for the system. As the HHA learned, the implementation of a program requires that the coordinator be dedicated to the telemonitoring program, from beginning to end. For the coordinator to be successful, he or she should be included in the entire process, from viewing the demonstrations of prospective systems to selection of the final product. The coordinator also must be given extensive training on the system before implementation because he or she will be responsible for the ongoing maintenance and support of the system, as well as the training of clinical staff and other personnel. The coordinator should be well versed in the operations of the system before the first installation.
In the same context, the clinical staff should receive in-depth training before the first installation. They will be the frontline warriors in the field at the point of care, installing and teaching the system to the participants. Furthermore, they will be the best source for identification of potential participants for the program. For the clinical staff to feel and appear proficient, they should have the opportunity for hands-on practice with the system. It is a must that they understand what is required for installation and exactly how to educate the patient and caregivers in the operation of the equipment. There is a potential for negligence if HHA staff, patients, and their caregivers do not understand how to operate the telemonitoring devices (Hogue, 2005).
An important lesson learned during the initiation process was that to ensure success, the team should develop a plan with roles and responsibilities clearly defined before beginning implementation. Decisions must be made about such things as how participants will be identified, who will be responsible for obtaining orders, how these orders will be communicated to the coordinator in preparation for installations, and when the system will be installed. This sounds like a simple task. However, if this task is not carefully conceived, confusion and ineffectiveness will occur once implementation begins.
The described program experienced this problem. Examples included clinicians securing orders for the program from physicians without first assessing the client or obtaining their consent, multiple clinicians requesting orders for the system for the same client, and systems assigned to clients, taken from the building, but never installed in the client's home. The HHA learned how important it is for each component of the program to be defined in writing and communicated well to all staff involved to achieve success. Furthermore, policies and procedures must be in place to determine how the retrieval of equipment from a patient's home will be handled. Procedures for cleaning and inventory of equipment should be written.
Once the implementation process begins, candidates should be identified, and assessments of each candidate should be completed before actual installation of the system. The assessment should include areas such as the patient's ability to use the system and the availability of necessary components in the home. The guidelines of the described HHA included possession of ability to see, hear, and tell time; ability to understand instructions; manual dexterity sufficient to operate equipment; a positive attitude toward technology; a need for skilled nurse visits, specific disease management or pain/symptom control; a functional telephone; and a functional, accessible electrical outlet. It is preferable for the candidate to have an available caregiver, although this may not be required. If the candidate has a history of frequent hospitalizations or documented noncompliance, he or she also may be considered appropriate for the program.
Once the patient has been declared eligible for the system, the physician order should be in place. The system then may be installed in the home. The clinical staff must ensure that the patient and caregiver understand the use of the system and must provide as many teaching sessions as individual participants may need (Table 1).
Once the system is discontinued with a client, a protocol must be in place for retrieval, cleaning, storage, and inventory of the equipment. The described program has delineated responsibilities for these tasks to various members of the staff. The program coordinator is responsible for retrieving the equipment from the home and returning it to the supply room clerk at the office. The clerk is responsible for cleaning, storage, and inventory of the equipment. The program administrator is responsible for assigning the equipment to individual clients.
After installation, daily monitoring and interpretation of data, timely identification of problems, and implementation of interventions are the key to reducing emergent care and hospital readmissions. Ongoing evaluation of interventions also must occur. Again, defining where the responsibility lies for completing these tasks is of utmost importance.
The first participant for the described HHA was a 78-year-old man with the diagnoses of diabetes and coronary artery disease. He resided in a small, rural area, which required considerable travel to his home for patient visits. He was determined appropriate for the program because he required skilled nurse visits, had a history of frequent hospitalizations, had pain/symptom control issues, and required specific disease management. Additionally, his home met the technology requirements.
The program was explained to the patient, and consent was obtained. The system was implemented in his home without any difficulties. While the system was used in his home, the clinical staff was able to monitor the patient's vital signs and daily weights closely and contact his physician for early intervention of an increased fluid level to avoid a hospital admission. However, after only 2 weeks of participation in the program, the patient wished to withdraw. He cited irritation with daily measurements and equipment placement in his home as reasons for withdrawal. Although staff attempted to alter his program and relocate system equipment, the patient continued to request withdrawal from the program. This first experience was valuable in that it offered the HHA insight into what expectations a participant may have and the need for flexibility on the part of the agency.
Another early participant had a more positive experience with the program. This 75-year-old woman had multiple diagnoses including heart failure, chronic obstructive pulmonary disease, and diabetes. She also resided in a rural area, and the telemonitoring program initiation in her home offered the agency an avenue for better monitoring of signs and symptoms of disease exacerbation. The length of stay for this participant was 100 days. During that time, the team was able twice to identify worsening signs and symptoms and offer early intervention to avoid hospitalization.
In the 11 months since implementation of the program, the HHA has had 34 participants, all of whom have had either a cardiac- or pulmonary-related diagnosis. The average length of stay has been 91 days, with a hospital readmission rate of 46%. The rejection rate for the system has been 15% of the total participants, with 71% of this rate attributable to the patient and/or caregiver and 29% attributable to the admitting physician.
Evaluation and Assessment
Once the system has been in place for a time, assessment of the agency's program should be completed to determine whether the program is working fluidly. Should there be any changes to how patients are identified and assessed and the system is implemented? Should there be changes to the data evaluation process? If any adjustments are identified, changes should be planned, and all clinical staff involved in the program should be included in the change process.
At the time of the HHA's evaluation, it was apparent that the program was not achieving the desired goals of the agency. The hospital readmission rate had not decreased, nor had the emergent care rate. It was determined that there was a great need to have 1 clinician oversee the program and manage the participants. The agency hired an experienced cardiac registered nurse to function as the cardiac/telemonitor case manager to manage the program. Also, it was acknowledged that the processes for the program needed to be fine tuned and that policies and procedures were in need of clarification. Along with these changes, it was decided that the HHA would embark on a new marketing blitz to facilitate physician understanding and participation with the program.
For the HHA to accomplish these tasks, a team was devised to establish policies and procedures, set program pathways, and devise a marketing plan. This team included the System Administrator, Telemonitoring Case Manager, Marketing Director, and Clinical Manager. Policies and procedures were devised for each step of the program including assessment, installation, monitoring, reporting, retrieval, infection control, storage, and inventory. Processes were developed for assessment, installation, monitoring, reporting, and discontinuation of the systems. Exact delineation of role responsibilities also was outlined during this process.
One physician concern that had emerged during initiation of the program was the possibility of increased communication from the HHA concerning the daily readings of its patients. Therefore, the team, in consultation with cardiologists, developed a set of standing orders to be followed for symptom control with regard to abnormal readings. These standing orders will be presented to the primary physician for his or her approval/signature at the time of installation of the system. This procedure will allow the clinician to be proactive in patient care, with physician contact only when symptoms cannot be controlled in the home setting.
Looking to the Future
The described program has now been in place for 14 months, and the HHA has experienced many growing pains during this implementation time. Many lessons have been learned by trial and error, and the program has improved as a result (Table 2). The assessment and installation phase of the program has been streamlined and works much more effectively. The equipment flow process has become a very efficient system since the dispersion of duties among several staff members.
After careful consideration and deliberation, the HHA has decided to use the system as a clinical assessment tool. This means that a physician's order will no longer be required to initiate the system for a candidate. However, should the staff identify problems related to the system readings, the symptom management protocol will be submitted to the physician for signature, giving the staff standing orders for treating the individual's symptoms.
After using the program for 1 year, the question “Was it worth it?” arises. The majority of staff members would answer yes, it has been worth all the man hours expended to reach this point. They feel that after the problems have been worked out, the system will be used as a powerful tool for the clinical staff. Furthermore, it is thought that the system will be a valuable patient education component of care given to the agency's clients. Only 2 staff members feel as if the program is not worth it, stating that the system is cumbersome and that clients are not really interested in using the equipment.
However, the agency as a whole is very excited about the future prospects of the telemonitoring program. It is thought that this is just the beginning of what may be accomplished within this program.
The HHA identified emergent care and hospital readmission as a high-priority quality improvement opportunity. Home telemonitoring can be a valuable tool in the improvement process. Since its initiation, the HHA has learned many lessons concerning the program. The planning process is one of the most important aspects of implementation, if not the most important. Program processes must be in place before implementation to achieve success. Physician and staff buy-in also is critically important. Once the staff becomes accustomed to the system and the processes are in place, the system should become an integral part the HHA program.
© 2008 Lippincott Williams & Wilkins, Inc.