Remote Patient Monitoring For High Risk Patients

75-year-old Linda Pugh from Linnsburg, Indiana, is being monitored, and that's a good thing in her condition. With remote monitoring, high-risk patients stay healthy and out of the hospital.

Linda has been diagnosed with congestive heart failure, chronic obstructive pulmonary disease, and atrial fibrillation, so it eases her mind to know health professionals are keeping an eye on her daily.

Remote Patient Monitoring Technology

Linda's condition has sent her to the hospital countless times. Still, this time, after a minimally invasive procedure to insert a Watchman device - a device implanted in her heart to reduce her risk of stroke -- she went home with an armful of home monitoring technology.

Along with the Watchman device, she was left a blood pressure cuff and monitor, a scale and a pulse oximeter, and a tablet to record important information like her vital signs.

At-Home Monitoring Routine

Before heading home, Linda met with Teresa Schuster, an Indianapolis-based registered nurse from Franciscan Health's Accountable Care Organization, to learn about her new daily at-home routine as a patient of the Remote Patient Monitoring program.

Schuster explained that she'd be with Linda every step of the way once she was discharged, including updating Linda's health information on her tablet. At first, the two talked every day. When needed, Schuster would call Linda's doctors to get adjustments to her medication. She is also there to answer any direct messages Linda sends her way.

Often, the most minor things that patients might not immediately recognize can lead to more significant problems if not addressed.

"Sometimes, patients don't think to call the doctor and say, 'you know, I've gained all this weight.' The next thing, you know, they can't breathe and they're in the hospital," Schuster said. "But with us following them and watching that weight, we are able to say, 'hey, we need to get ahold of the doctor.' The medication gets increased, the weight comes off and they're still at home."

Linda's Experience With Remote Patient Monitoring

Linda later described her experience with the Remote Patient Monitoring program. She mentioned that she logged a blood pressure of 106/67, a blood oxygen level of 93, and a pulse of 75. She also answered the daily survey inquiring about her weight, among other things.

"My vitals were good. I won't get a call today," Linda said.

She admits that while her vitals were doing well, she's mildly disappointed that she hears from her newest friend, Teresa Schuster, less often these days. An unexpected side effect of the daily communication with Schuster was that she enjoyed their side conversations.

Reduction In Readmissions And Emergency Room Visits

The patient-provider relationships built during the program might seem like nothing more than a pleasant bonus, but it can prove to be a crucial element that can uncover gaps in care.

As an example, Schulter explained a simple follow-up call to different patients who had been recommended to be put on a continuous positive airway pressure or CPAP machine.

"During the conversation, his daughter told me no one nearby had a CPAP machine available," Schuster said. "So I made several phone calls and finally found a place that was in their area. They delivered it to the patient's address versus waiting three to four months before they could locate one."

Stories like this and the results of the Remote Patient Monitoring program have made Schuster a believer in its impact.

After 90 days, a significant reduction was noted in readmissions and emergency room visits among the home-monitored patients, according to Jessica Jones, population health project lead with the Accountable Care Organization. Jones said the 90-day readmission rate had dropped by 63 percent and emergency visits dropped by 48 percent.

Schuster says more than 100 people are monitored right now across Franciscan Health. The program is ideal for, but not limited to, patients with congestive heart failure, chronic obstructive pulmonary disease, diabetes, and end-stage renal disease.