Home Telemonitoring for Chronic Disease
A Case Study of Resurrection Home Health Services, and Conclusions

Source: TIE - Telemedicine Information Exchange    ( http://tie.telemed.org/ )
Apr 2008
By Kevin Cassin

Introduction

Congestive heart failure (CHF) and the home use of telemonitoring equipment is an area that has recently been explored in an effort to control the cost of chronic disease ( Kinsella, 1998 ; Knox and Mischke, 1999 ). The advent of modern communication and adaptation of computer equipment has now made it possible to equip almost any home with devices that will record and report a patient's daily temperature, heart rate and blood pressure ( Schneider, 2004 ). Collectively known as vital signs (VS), this information can then be transmitted automatically to a central reporting station that is attended by clinical personnel such as a registered nurse (RN). Add to this the customization possible with these devices; they can be fitted with oxygen sensors (O2 SAT), prothrombin time and international normalized ratio (PT/INR) coagulation meters or glucose monitors. The ability of a clinician to triage a patient from a distance has come into fruition ( HomMed Company Brookfield, 2005 ).

Recent studies by healthcare providers have demonstrated the effectiveness of home monitoring in controlling length of stay (LOS) and rehospitalization costs with CHF populations ( Knox and Mischke, 1999 ; Schneider, 2004 ). Yet universal acceptance or expectation of telemonitoring use has lagged behind in many home health agencies due to cost and the high tech nature of these devices ( Kinsella, 1998 ). In the case of Resurrection Home Health Services (RHHS) , deployment of a telemonitoring system was a planned initiative first researched in 2005 (R. Prosser, personal communication, March 9, 2007). Using a grant received from the Retirement Research Foundation the implementation of this program was seeded in April, 2006 ( Prosser and Watson, 2005 ).

The HomMed telemonitor , used at RHHS, is a standardized unit that records VS, O2 SATS and weight. It also allows patients to key in answers to yes and no questions specific to their diagnosis. While commonly used with CHF populations, equipment changes allow for deployment within many different diagnostic groups. Diagnostic pathways exist not only for chronic disease such as CHF but also other types of ailments like asthma, diabetes or irregular heart beat ( HomMed Company Brookfield, 2005 ). At RHHS the telemonitor has been employed when CHF is the first or second diagnostic criteria.

Knox and Mischke (1999) demonstrated the concomitant use of telemonitors with home health visits by clinicians reduced the length of stay (LOS), rehospitalization and Emergency Room (ER) visits for CHF exacerbation. The management of patient symptoms on a daily basis in the home focused on providing quality care and enhancing patient outcomes ( Knox and Mischke, 1999 ). Clinical management of patients after hospital discharge was not replaced by telemonitoring but improved by the utilization of this tool in complex diagnostic states such as CHF ( Knox and Mischke, 1999 ). The home health clinician was better able to focus one-on-one care by actually reducing the daily visit schedule and eliminating unnecessary visits.

The barriers to the use of a new technology such as the HomMed telemonitor are not always evident when the advantages seem to be so heavily weighted toward implementation. Some traditional home health nurses may have concerns that they are being replaced by automation. That patients will suffer depersonalization from the lack of nurse to patient interaction. A patient may loose their sense of security knowing that the knock on the door is not the home health nurse. Perhaps, even the technology itself is too new to have garnered the acceptance of the medical community at large. With this in mind a study was proposed to query the sequence of medical professionals, hospital liaison, quality control and home health nurse, about the implementation of telemonitoring. What barriers stood in the way of a telemonitor protocol from becoming the standard of practice? And what changes where deemed necessary to bring this technology to home health services provided by RHHS.

Understanding Resistance and Barriers to Home Telehealth

Home telemonitoring, a new technology to RHHS, was funded under a grant by the Retirement Research Foundation in late 2005 ( Prosser and Watson, 2005 ). While it is prohibitively expensive to visit a patient daily, the telemonitor can assist by indicating when additional visits are needed and also eliminating visits that are wasteful. Like many new technologies it has run into impediments in deployment by clinical staff. The utilization of the twelve telemonitors available, to a patient population of 600, peaked in the first two months of use then trailed off.

After a few months of deployment, the utilization of the telemonitors had dwindled to a consistency of six employed per month, which was the opposite of the initial expectation. Now questions arose about implementation and why weren't the frontline clinicians using this new technology. Were they somehow afraid of this new system or was it simply a bad fit?

Employing Lewin's Change Theory ( Yoder-Wise, 2007 ; Kristonis, 2004 ), I hoped to provide a better understanding to the impediments standing in the way of this technology. Hopefully, the benefits of telemonitoring could be replicated within RHHS as they had been elsewhere ( Knox and Mischke, 1999 ).

Lewin's change theory is a force field analysis that allows us to examine the barriers and facilities of change that will lead to a successful change ( Yoder-Wise, 2007 , p. 235). The three step paradigm views behavior as a dynamic of forces working in opposite directions. The three steps unfreezing, experiencing and refreezing refer to a series of prescribed consequences progressing in a linear fashion. The facilitation of change occurs as a result of planning and leads to a new resolution within a stable social context.

The first step in planned change is unfreezing the process by which the status quo or the usual course of events is accepted. Unfreezing the barriers to change in telemonitoring implementation, we have to challenge the belief that repeated hospitalization for the control of symptoms of CHF is the expectation. The use of telemonitoring allows for a close tracking of daily parameters that will alert us to needed interventions in a patient's care. This is a facilitator of the change, an unfreezing process, enables us to intervene before a patient's symptoms spiral out of control and require readmission to the hospital.

The second step in Lewin's theory is experiencing movement toward a new resolution. Studies conducted by other agencies and published in journals have shown the benefits available with the use of home telemonitoring ( Knox and Mischke, 1999 ; Schneider, 2004 ). These studies force us toward the recognition that a better way exist to manage CHF and that it is more beneficial to the patients, clinicians and health care industry ( Kinsella, 1998 ).

Examining our present project to manage chronic disease clinical studies have demonstrated that symptom management, specific to CHF, can be achieved with the use of home telemonitoring ( Knox and Mischke, 1999 ; Schneider, 2004 ). Anecdotal episodes of managed interventions have taken place within RHHS during the initial deployment. This experiencing needs to be shared with other clinicians and reinforced. The ultimate change, of incorporating telemonitoring to enhance patient outcomes, has to be seen as a recurring variable achieved with the use of this new technology.

The last step of Lewin's process of change is step three, refreezing. Here it is important to establish a new norm or protocol that continually reinforces the change that has been implemented. By so doing we seek to avoid a return to the ways of old. By incorporating the use of telemonitors we hope to enhance patient outcomes, reduce waste and become more cost effective. Our delivery of care to the patient should be economically responsible and produce a return on investment (ROI) meaningful to RHHS.

The present study was employed to help identify hindrances that have prevented home health telemonitors from becoming the standard of care for specific diagnostic groups. The last step in Lewin's theory of planned change, refreezing, seems to be the point at which the present deployment of telemonitors has stuttered. The refreezing of a new strategy to manage patients in their homes, though not failed, was faltering.

After analyzing the data returns to a Likert scale and open ended questionnaire, it became apparent that there was wide acceptance by hospital liaisons, quality assurance personnel and home clinicians for telemonitoring. Eighty nine percent strongly agreed or agreed on three parameters of the Likert scale, that home monitoring increased the standard of care, aided patient compliance and provided patients with a sense of security or peace of mind. Seventy five percent strongly agreed or agreed that emergent care was reduced. The last of the parameters designed to measure the communication of patient data to clinicians was answered unanimously as, no opinion. Perhaps this reflects the fact that patient information does not flow directly to system computers but is captured on the central processing station, printed out weekly and forwarded to the PCP.

The open ended questions seeking answers to the under utilization of telemonitors elicited a variety of responses. There is a perceived lack of awareness on the part of primary care physicians (PCP) pertaining to the use of these devices. Some patients selected were not always appropriate or able to use the equipment. The under marketing of the telemonitoring program it self was raised. And a need for the telehealth monitor to be placed on the referral form that PCP's traditionally fill out when ordering home health care was suggested.

A second open ended question was asked about enhancement to ordering and uses. Once again the answers cited lack of involvement by the PCP. The timeliness of placement and a need for research on telemonitor use for the proper diagnosis was also indicated.

Additional questions were asked of home health nurses concerning positive and negative experiences. Those responses are cited in this study as anecdotal incidents that are attributable to home telemonitor use here at RHHS.

Conclusions

Analyzing the results of this small study within the RHHS organization, we can draw some general conclusions from these responses. The loss of momentum was not based on a negative reaction by home health nurses, liaisons and quality assurance personnel but by the way in which telemonitors were ordered for placement. Education tailored toward physician groups concerning the availability of this resource, would hopefully enhance its' utilization.

Also, in the past the order process for implementation of home telemonitoring resided with the physician. Without the PCP's order to place this device in the home it was not done. The usual protocol involving home health services after hospitalization was filled out at discharge. Nowhere on this form was telemonitoring noted. The PCP would have to write out, assessment for telemonitoring, if he chose this device to follow his patient. Visits to the home by skilled nursing would be initiated but it was then up to the case manager to call the PCP and obtain a specific order for home health telemonitoring.

Secondly, respondents indicated a greater emphasis should be placed on the screening process for the appropriate patient population. Both diagnosis and patient agility should be considered when assessing for the placement of a telemonitor in the home. Not all CHF patients are appropriate for these devices due to secondary diagnosis or inability to safely use the monitoring equipment. Sometimes it is a matter of the social support system in place, or lack thereof, which precludes the use of this device. Plus other patient populations exist within the agency aside from CHF that could benefit from closer monitoring.

Finally, technical training of field clinicians in the set-up, programming and operation of these devices needs to continue in order to ensure clinical comfort with telemonitors in the home. Refresher seminars can be offered as needed. Education across the entire spectrum of medical clinicians engaged in trying to ensure positive patient outcomes should be reinforced and ongoing.

This small study was of a limited duration and was not designed to statistically evaluate LOS or prevention of emergent care episodes at RHHS. Reports such as these exist anecdotally but not with statistical weight. Instances of clinicians alerted to patient measurements falling outside of specific guidelines have resulted in additional visits. Examples of positive outcomes can be cited. In one such case a patient was able to avoid prophylactic dialysis for fluid retention. Fortunately adjustments in diuretic therapy, initiated in response to weight gains, precluded the necessity of the more dramatic intervention that had been employed in the past.

The overall response was a favorable acceptance and an acknowledgement that telemonitors enhanced the standard of care, compliance and patient sense of well-being. Field clinicians agreed with statements indicating enhancement of patient management and home visit planning. Yet there was also a rogue response that panned the telemonitor system as cumbersome and adding additional work for the field clinician. With education and familiarization one would expect this type of response to wane.

The preliminary results of this study and the raw data were shared with the clinical specialist at RHHS in April, 2007, prior to the compilation of this report. Several of the suggestions were implemented by those championing this project with RHHS. The CHF/Telemed committee was meeting monthly to discuss the ongoing deployment of this device. And as a result of this project and internal analysis by clinical staff changes were implemented in the deployment of telemonitoring.

A heavily identified impediment to use had been the lack of physician orders. The decision was made to alter the referral form to specify this service. The referral form traditionally filled out by the discharging physicians when a patient is leaving the hospital was edited. It now includes a check box to indicate telemonitoring. Physician groups at St. Mary of Nazareth Hospital, which has the highest incidence of CHF discharge, in the RHHS system, where contacted individually and educated to this new addition and other home health services.

These small modifications to the telemonitoring program have had an immediate impact. The telemonitors available now, through RHHS, are deployed at full capacity and a waiting list has been initiated. The CHF/Telemed committee is meeting monthly to discuss diagnostic parameters for the use of home monitoring and the development of educational presentations for field staff. Hoping to maintain forward progress a clinical educator has assumed the role of chairperson to the CHF/Telemed committee.

The champions of this effort and RHHS hope that soon the discussion will change focus onto possible acquisition strategies to purchase additional units. As change evolves it is hoped that refreezing will take place and telemonitoring may become the standard of care for the management of complex diagnostic groups.

Change management is not an easy process. Steps can be laid out and followed judiciously but if others are not on board the ability to affect change will falter.

Simple details are ones often overlooked, but can become the obstacle to a new paradigm. Sometimes change happens very stealthily as a result of simple modification that goes mostly unnoticed. During the project described here an inference can be made directly, related to adding a checkbox onto the referral form, and educating the physician groups to this service. This simple idea resulted in a sense of inclusion for those PCPs who were unaware of the telemonitoring option.

The accepted norm in past treatment of CHF was that repeated hospitalizations were unavoidable. Lewin's change theory gives us a structure to measure this variable against a new technology, the home telemonitor. The telemonitor allows us to quickly respond to changes in a patient's status while still in the home. The intervention, directly correlated with the patient's condition, allows us to experience the means by which we can maintain that patient in his home. Through behavioral, educational or pharmacological intercession we can break the cycle of mismanagement that results in emergent care visits and additional hospitalization.

Irregardless of why the mismanagement occurred, telemonitoring adds to our tool box a method to respond proactively. Our experiences reveal to us a new logic. The patient can be managed in the community. Early intervention is a far superior and more cost effective method then the past response of rehospitalization. By reinforcing this new intervention we are able to refreeze our new response to chronic disease and enhance patient outcomes.

References

HomMed Company . HomMed Company of Brookfield, Wisconsin..

Kinsella A. Costs and reimbursement for home telemedicine services. Telemedicine Information Exchange.. (Link last checked on October 28, 2007) .

Knox D, Mischke L. Implementing a congestive heart failure disease management program to decrease length of stay and cost. Journal of Cardiovascular Nursing, October, 1999, 14(1): 55-74.

Kristonis A. Comparison of Change Theories. International Journal of Scholarly Academic Intellectual Diversity, 2004, 8(1): 1-7. (Link last checked on December 1, 2007) .

Prosser R, Watson G. Home telemedicine the future of healthcare in America. PowerPoint presentation presented at the meeting of the Resurrection Home Health Services Leadership Day. Skokie, IL., September, 2005.

Schneider NM. Managing congestive heart failure using home telehealth. Home Healthcare Nurse, October, 2004, 22(10): 719-722.

Leadership and management in nursing (4th Ed.) St. Louis: Mosby, Inc., 1999.

About the author: Kevin Cassin, RN, ACLS, AA, BS, MS, BSN Candidate is a Case Manger with Ressurection Home Health Services in River Forest, IL.