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News Roundup: April 28, 2014

Tablets Help Home Health Agency Boost Care Coordination, Cut Costs

Published by iHealthBeat
April 21, 2014

The use of tablet computers at a California-based home care and hospice agency has helped reduce costs and improve care coordination, according to a new case study by the College of Healthcare Information Management Executives, mHealthNews reports.

In 2012, Sutter Care at Home, an affiliate of Sacramento-based Sutter Health, adopted seven-inch tablets equipped with 4G mobile broadband access (Wicklund, mHealthNews, 4/18).

The agency includes more than 1,300 care providers who treat more than 100,000 patients.

Sutter Care at Home has seen several benefits from rolling out the tablets.

For example, the tablets allowed caregivers to access real-time, read-only data on patient hospitalizations, office visits and lab results from the system's Epic electronic health record software (McCann, Healthcare IT News, 4/18).
Once the tablets were rolled out, caregivers could complete documentation on patient visits in about 24 hours, compared with three days prior to the tablets.

Jennifer Brecher, Sutter Care at Home's project manager, said, "Tablets have sped up the flow of the process," adding, "In the past, if one of the clinicians went to see the patient on Monday and the physical therapist would go on Tuesday, the therapist would not have the electronic information about the Monday visit available. This is better from a productivity standpoint and better for the patient" (mHealthNews, 4/18).

In addition, the tablets include a standardized formulary for medical supplies, which made the ordering process easier and faster, Healthcare IT News reports.

In the first year, the use of the tablets, in combination with the formulary, helped cut medical supply costs by 20% per visit, according to officials.

Philip Chuang -- chief strategy executive and former director of information services for Sutter Care at Home -- said the tablets also helped improve wound care.

Home care nurses can use the tablets to take photographs of a wound and then securely transmit those photos to the patient's EHR, where they can be reviewed by specialists (Healthcare IT News, 4/18).

House Calls Are Making a Comeback

Published by New York Times
Milt Freudenheim
April 19, 2014

A relic from the medical past — the house call — is returning to favor as part of some hospitals’ palliative care programs, which are sending teams of physicians, nurses, social workers, chaplains and other workers to patients’ homes after they are discharged. The goal is twofold: to provide better treatment and to cut costs.

Walter Park, 68, of San Francisco says house calls prevented an expensive return visit to the hospital, where he initially stayed for seven weeks after a heart attack in 2012.

After his discharge, palliative care specialists from the University of California, San Francisco, were among those who visited his home to monitor his physical and emotional health. He got help with tasks as varied as household chores and organizing the 20 pills he takes daily for his heart and other conditions.

Confusion continues to exist over what palliative care is and whom it is for. Broadly, it is meant to ease symptoms and pain, and focus on quality of life for severely ill patients, who can choose between continuing or halting traditional medical treatment.

Dr. R. Sean Morrison and Dr. Diane E. Meier of the Patty and Jay Baker National Palliative Care Center at Mount Sinai Hospital. Credit Yana Paskova for The New York Times
Palliative care also occurs in hospitals, but an added emphasis on home care has been a selling point. A vast majority of patients would rather be at home than in a hospital anyway, said Dr. R. Sean Morrison, co-director of the new Patty and Jay Baker National Palliative Care Center at Mount Sinai Hospital in New York and director of the National Palliative Care Research Center.

Home care is generally cheaper than hospital care, and for more than a decade, government programs such as Medicare and Medicaid have worked to create incentives for hospitals to switch to less-expensive treatment. Recently, under the Affordable Care Act, Medicare has begun to penalize hospitals when, under certain conditions, patients are readmitted within 30 days after discharge.

Some insurers, including Medicare, pay for house calls by doctors and nurses specializing in advanced care. In cases where insurance does not cover this type of palliative care, hospitals are financing it themselves, sometimes with grants.

Dr. Steven Pantilat, an internal medicine physician who leads the palliative care program at the University of California, San Francisco, says his hospital subsidizes some home care because “there is sufficient improvement in quality and costs to make the investment a good idea all around.”

A 2007 study by Dr. Richard Brumley and colleagues, found that palliative care patients who received in-home, interdisciplinary care were less likely to visit the emergency room or be admitted to the hospital than those receiving more-standard home care, resulting in lower costs. The study, financed by the Kaiser Permanente Garfield Memorial Fund, covered terminally ill patents.

In Boston, palliative care doctors at Massachusetts General Hospital and at Brigham and Women’s Hospital make house calls. Nurse care managers, social workers and others also visit discharged patients in their homes or keep in touch by telephone as needed, said Dr. Timothy Ferris, who runs the Partners HealthCare accountable care organization.

Nurses from Partners HealthCare at Home, an affiliate with 900 employees, may also visit discharged patients. “The home care nurse is the eyes and ears and stethoscope in the patient’s house,” Dr. Ferris said.

Accountable care organizations, created under the Affordable Care Act, have the flexibility to pay for in-home palliative care services, he added, and his organization has done so.

Palliative care teams work with a patient’s regular doctors and specialists “to provide an added layer of support for people living with serious illness,” said Dr. Diane E. Meier, professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai Hospital and co-director of the Patty and Jay Baker National Palliative Care Center. They can address issues that someone who focuses intensively on a particular disease or organ system often cannot, she said — things like expert help with pain management, depression, fatigue and support for “exhausted and overwhelmed family caregivers.” They also offer practical help so patients can remain in their homes, she said.

While patients nearing the end of life can choose palliative care in a hospice setting rather than undergo expensive and risky treatment — many doctors say it is valuable for that very reason — it can also exist alongside efforts to treat and cure patients.

“There are a lot of people, including my mother, who don’t fit the criteria for hospice,” said Cameron Egan. In 2012, doctors told Ms. Egan’s mother, Jacqueline Andersen of San Francisco, that clearing her four clogged heart arteries would be unacceptably risky. Her health seemed fragile but fairly stable, and doctors could not estimate how long she would live.

Ms. Andersen, a retired high school English teacher, was clear that she did not want to spend more time in the hospital, said another daughter, Adrian King, who said, “She wanted to go home.” Ms. Egan moved in with her mother to care for her.

Dr. Pantilat helped oversee Ms. Andersen’s case, conferring with Ms. Egan, Ms. King and two other daughters on her care. He visited Ms. Andersen at home, and she received home visits from a spiritual counselor, who discussed her life, her fears and her attitudes about the end of her life, Ms. Egan said.

Ms. Andersen had an array of medical problems but “she was really with it,” Ms. King said. “There was no time that any of us thought she was diminished mentally.” Ms. Andersen died in February 2013, at 82, seven months after leaving the hospital. The day before, Ms. King said, she and her mother had “one of our classic Scrabble games.”

“She was in fine spirits when I left her, making sure I put the San Francisco 49ers flag in a vase in her window,” Ms. King said.

Dr. Pantilat said: “Without palliative care, it is likely Jackie would have been readmitted to the hospital, and the chances are 50-50 or more that she would have ended up having an operation. I also think her pain would not have been as well controlled.

“You can imagine what the cost of open-heart surgery would have been,” he said. “Tremendous. Avoiding even one hospitalization would have paid for all the palliative care she received.”

Proponents of palliative care say it can prompt people with terminal illnesses to face the future realistically. The focus is on making them comfortable, rather than exposing them to painful and expensive treatments.

But palliative care also seeks to extend life, Dr. Meier of Mount Sinai says. Several studies have shown that it “may be associated with a significant prolongation of life for some patient populations,” she noted in a 2011 article, adding that more research was needed to confirm whether these findings were applicable more generally.

Mr. Park, the heart attack survivor in San Francisco, said his plans had changed. In 2012, his palliative care team urged him to identify his short- and long-term goals. He said he wanted to attend the second Obama inauguration and return to his volunteer work at a nonprofit agency that helps older Americans. He was present at the January 2013 swearing-in, and later he resumed his volunteer work.

He is now looking forward to spending time with his two grandchildren, ages 8 and 11. “I used to plan only three years ahead,” Mr. Park said. “Now I really want to see my grandkids grow up and graduate.”

How telemedicine helps some elderly people stay home longer

Published by Catching Health
Diane Atwood
April 15, 2014

Rita, who is 79 years old, has congestive heart failure, a chronic health condition that lands many people in the hospital or nursing home. Telemedicine has allowed her to closely monitor important vital signs and stay in her own home.

According to the CDC, approximately 5.1 million people in the United States have congestive heart failure. Close to 1 million are hospitalized every year and 27 percent are readmitted within 30 days — the highest readmission rate of all medical conditions.

Congestive heart failure and its symptoms

Congestive heart failure develops when the heart can’t pump enough blood to the rest of the body. Symptoms include:

Cough
Fatigue, weakness, faintness
Loss of appetite
Need to urinate at night
Pulse that feels fast or irregular, or a sensation of feeling the heart beat (palpitations)
Shortness of breath when you are active or after you lie down
Swollen (enlarged) liver or abdomen
Swollen feet and ankles
Waking up from sleep after a couple of hours due to shortness of breath
Weight gain
After spending time in the hospital followed by a stay in a rehab facility, Rita returned to her home the end of January. She’s been able to stay there thanks to family, friends and home health care. She also relies on telemedicine (telehealth) to help monitor her congestive heart failure.

Something as routine as getting on the scale every day can be helpful in monitoring for early signs of congestive heart failure. Gaining just a few pounds could mean fluid is building up inside the body. It’s also important to keep track of blood pressure and oxygen levels.

Telemedicine

Androscoggin Home Care and Hospice in Lewiston provided Rita with a monitor, a scale, a blood pressure cuff and an oxygen meter that fits on the end of her finger. The monitor comes on at the same time every morning. “It tells me to stand on the scale,” Rita explains, “and then it gets your weight. Then I put the sleeve on my arm and it takes my blood pressure and the O2 meter on my finger.”

The data is transmitted to Rita’s nurse at Androscoggin Home Care. The monitor, which looks somewhat like an alarm clock, can plug into a phone jack or connect to a cell phone or special tablet provided by the agency. “Our registered nurses are seeing their patients’ vital signs every day,” says telehealth coordinator Shane Levasseur. “In addition, we can see vital sign trends. We could, for example, send a two week trend of vital signs over to a patient’s cardiologist for an upcoming appointment. It’s really powerful for doctor to have that information. Now a lot of physicians who send referrals for home care say they want telehealth.”

More and more hospitals and home care agencies in Maine and around the country are turning to telemedicine for patients. Levasseur says just three years ago Androscoggin had 25 monitors and only four were in use. Today it has nearly 250. Nearly all are being used and more will be purchased this year.

Putting in-home technologies to better use for the elderly

Earlier this year, the Governor’s Broadband Capacity Building Task Force issued a report outlining eight recommendations — number two was to help Maine’s elderly stay at home by better utilizing telemedicine.

“Use in-home technologies to reduce the proportion of elderly on MaineCare receiving long-term care in institutions from 65% to 40% by 2015, and to 20% by 2020. This will allow seniors to stay home longer — which is what they want — and at the same time save Maine taxpayers over $100 million in 2015, and over $250 million annually in 2020.”

Rita admits that, left to her own devices, she might not alert anyone right away if she noticed telltale signs of congestive heart failure. Her home care nurse doesn’t rely only on the monitor — she visits once a week — but if she notices something amiss, she’ll contact Rita immediately. “If I’m two pounds different from yesterday,” says Rita, “wow! Right way, the nurse wants to know if there’s a reason for that. Am I swelling? That’s a first sign of heart failure.”

On one occasion, the nurse decided she needed a trip to the emergency room. If Rita had waited, she might have been in big trouble. “I don’t really know sometimes if I need to go, but the nurse knew based on what the monitor said. She came to the house and said, ‘You’re going!”‘

Utilizing monitors like the one that allows Rita to stay home is only one example of new technologies that are already being used in Maine. You can read about some others as well as the remaining broadband use recommendations (not all health-related) in the full task force report or an eight-page version.