6. Customizing alerts with tailored thresholds that require prompt attention, which are communicated to the care manager, family member, physician or other members of the care management team via text message or e-mail, enables overburdened care managers to focus their time and resources where they will have the greatest positive impact. Serious problems, like a rapid change in a vital sign, sudden weakness, slurring of speech, depression, excessive fatigue, failure to take medications, loss of vision, or sudden shortness of breath can be quickly addressed.
7. Configuring data into customizable care reports can be sorted by fields, such as mental and physical state, vital signs, sleep, eating, etc., enables better care management review and oversight. Longitudinal data can be evaluated on an hourly, daily, weekly or monthly basis to determine anomalies and trends requiring further analysis, leading to changes in long-term plans of care.
Data points can be tracked by time entry of the event and by the home aide to assess care quality and to ensure best practices. Having a historical timeline of the patient’s data points can show key inflection points or events that are outliers and indicative of preventable future problems.
8. Sharing information, through 24/7 Web access, can lead to lower stress for patients, caregivers, and families, who can have greater peace of mind by getting control over the situation and measuring progress. Patients not maintained in a stable condition cause stress, which can lead to rapid heartbeat, immune system compromise, fatigue, and time off from work. Longer stays at home increase comfort and lower stress as well as costs for patients, families, and caregivers
9. Using analytics by patient populations can 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 and 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.
10. Improving Time Management of Activities and Expenses is essential for proper distribution of limited resources. Tracking of actual vs. budgeted or reimbursable time is demanded by today’s payors. Using technology rather than telephone or, even worse, paper time sheets, can lessen time associated with 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, chronic obstructive pulmonary disease (COPD), diabetes, acute myocardial infarction, and other likely causes of readmission.
One module showing particular promise is the day-to-day work being performed by a home for people with developmental disabilities. Have a Heart, a home for people with developmental disabilities in Wisconsin, is using real-time monitoring to report on therapy progress, physical activities, medication adherence and eating habits.
As evidenced by Have a Heart, Beth Israel Medical Center, select managed care companies, and patients with CHF, real-time monitoring is at the dawn of a new technological revolution with profound implications for the millions of patients and caregivers coping each day. Technology has revolutionized real-time monitoring and reporting to the point where it can generate big data from the home to deliver on its potential for CMS, state governments, hospitals, home health aide agencies, managed care organizations, providers, accountable care organizations, medical and health homes and even families providing care. Utilizing real time actionable health care data from the home can enhance the quality of care while reducing costs and risks, thus improving health outcomes for potentially millions of elderly and chronically ill patients.
Robert Herzog is the founder and CEO of eCaring, 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.
Robert’s interest and involvement in home-based healthcare emerged several years ago when he was deeply involved in the home and extended care of his mother Grace. The issues both she and he encountered ensuring that she received proper treatment gave him the initial understanding of the problems eCaring was subsequently designed to solve.
