Best Practice Intervention Package - Kansas Foundation for Medical ...

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PHYSICIAN ADVISORY GROUPUSING TELEHEALTH TO REDUCE READMISSION RATES IN CHRONICILLNESSESTelemonitoring is onecomponent of a diseasemanagement program. Using “Home care is an instrumental part of thetelehealth (phone monitoringchronic disease management model, andhome telemonitoring is an extension ofand/or telemonitoring) tohealth–care delivery in a patient’s homeenhance a disease management environment.”program can be effective. Sharewith physicians that telehealth is Polisena, Tran, Cimon, Hutton, McGill,one of the interventions used toPalmer, and Scott, 2010.effectively manage chronicillnesses. However, make sure to also include information on the othercomponents of your agency disease management program.Telehealth benefits to share with physicians include:• Daily monitoringo Vital signs, weight,blood sugar, pulseoximetry• Improved Quality of Lifeo Hospitalizations arereduced and diseaseexacerbations prevented• Improved access to health careserviceso Data monitoring allowsfor quickerinterventions• Electronic record of healthdatao Transmitted data maybe sent to physician“The frequent monitoring andtelephonic encounters associated withthe monitoring can reinforce topatients the impact of theirmedication and behaviors (such asThanks to Bayada Nurses for sharing informationon telehealth.- 50 -“Some physicians may see telehealth as causingan increase in paper work across their desk andare concerned about timely reporting by homecare agencies with abnormal results. By workingwith a trusted home care agency that is willing towork with the physician to develop protocols thatinclude panic levels, frequency of reportingresults to physician to streamline the process andprevent delays or cluttering of physician desks isthe key. Through the use of telehealth thephysician is able to improve the patients’ outcomeof chronic medical problems before they lead tocomplications and new health problems.” (For theentire letter for physicians click here)Joseph E. Gerhardstein, MD, FAAFPUniversity of KY Dept Family MedicineLexington, KYRebecca Cartright, MSW, MHADirector Central Baptist Home Care/Home InfusionLexington, KYdiet and exercise) on key health parameters like their blood pressure and weight.”(The entire excerpt from Dr. Landers is on the following page.)Steven Landers MD, MPHDirector, Center for Home Care and Community Rehabilitation. Cleveland Clinic
Promoting Telehealth as part of a Chronic Illness ProgramPhysicians should be aware that home telehealth monitoring is an emerging toolin health care that can help safely manage patients with serious chronic illness inthe comfort of their homes. Many home health agencies include telehealthmonitoring as part of their care model for patients with certain conditions. Thefirst generation of telehealth in the home care setting has typically involvedmonitoring of blood pressures, weights, other vital signs, and symptom scalesusing a device linked by telephone to a monitoring professional with anelectronic "dashboard" is alerted to patients with monitoring parameters outsideof normal values and then makes contact with the patient and/or their physicianor other appropriate caregiver. In the real world, there is variability inthe frequency and duration of monitoring and the content and context ofassociated telephonic encounters. Newer telehealth concepts are using cellularand broadband internet connections and may include two-way videoconferencing to the home, more customizable educational content and carepaths, and are increasingly similar in look and feel to the widely availableconsumer mobile devices such as Apple's iPad.Monitoring provides several potential benefits in reducing avoidablehospitalizations and improving clinical outcomes. Early identification ofconcerning scenarios (such as fluid retention in a heart failure patient) can allowfor early intervention before the condition warrants hospitalization. The frequentmonitoring and telephonic encounters associated with the monitoring canreinforce to patients the impact of their medication and behaviors (such as dietand exercise) on key health parameters like their blood pressure and weight. Forpatients doing well, the monitoring can sometimes provide reassurance about apatients' well being and success on a care plan so that scarce skilled humanresources can be triaged more appropriately.Because health care has been so focused on encounters, monitoring can bedisruptive in that it can generate data and "issues" outside of the context ofhistorical health care workflows. Thus, anyone considering using homemonitoring as part of their health care delivery must consider how workflows andcommunication patterns must change. In driving toward good outcomes theresourcing of the monitoring team with strong clinical leadership, theengagement of physicians and their office staff, and having resources forescalating care are all important aspects of a successful monitoring program.Ultimately, these factors are probably more important than the specific devices.The monitors are tools for a non-encounter based care team to use to manage tobetter outcomes, and to some extent the monitors are tools that can promote andsupport self management by patients and families. Over time the technology willchange and physicians should focus on sound care protocols, strong clinicalleadership, resources for managing problems in the home and coordinating care.Steven Landers MD, MPHDirector, Center for Home Care and Community Rehabilitation. Cleveland Clinic- 51 -
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Page 5 and 6: Quick Start GuideQUICK START GUIDE:
Page 7 and 8: Source: Wu, Shin-Yi and Green, Anth
Page 9: CHRONIC CAREIt may assist leadershi
Page 13 and 14: The Bottom LineLeaders must create
Page 15 and 16: DIABETESCenters for Disease Control
Page 17 and 18: SELF-MANAGEMENT: EMPOWERING THE PAT
Page 19 and 20: What is Patient Activation? How Doe
Page 21 and 22: TELEHEALTHTelehealth encompasses a
Page 23 and 24: Focus Section: Improving Care Trans
Page 25 and 26: Checklist for Agency LeadershipHow
Page 27 and 28: CHECKLIST FOR AGENCY LEADERSHIPASSI
Page 29 and 30: CHECKLIST FOR AGENCY LEADERSHIPASSI
Page 31 and 32: Motivational Interventions (CMI) Pa
Page 33 and 34: Tools/Resources available through W
Page 35 and 36: The four conceptual areas (referred
Page 37 and 38: and steps toward them.Self-Efficacy
Page 39 and 40: 1. Goals: Something you WANT to do:
Page 41 and 42: Conviction Ruler0 1 2 3 4 5 6 7 8 9
Page 43 and 44: Partnering with Patients and Famili
Page 45 and 46: Are You at Risk for Going to the Ho
Page 47 and 48: Call Me First!Stay safe and well at
Page 49: SUCCESS STORIESThere are three succ
Page 53 and 54: TRACKING DATA AND MEASURING PROGRES
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Page 57 and 58: Therapy Track: Focus on Improving C
Page 59 and 60: Home Health Aide Track: Focus on Im
Page 61 and 62: Coleman, E.A. (2003). Falling throu
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