Lessons from Geisinger: Operational Considerations When Implementing a Continuous Home Monitoring Program
In the early days of the COVID-19 pandemic, Geisinger at Home (Geisinger’s home-based model), one of their acute pulmonary clinics, the medical home case managers, and the COVID-focused emergency department team, stood up continuous in-home monitoring leveraging the Current Health platform. This care model focused on providing care for high-risk patients with COVID-19, those suffering from chronic obstructive pulmonary disease (COPD) and heart failure, and other patients considered to be at high risk for needing prompt medical attention.
By enhancing existing monitoring capabilities in the home, 24/7 monitoring allowed for:
- Continuous clinical monitoring of fragile and ill patients in their homes
- Earlier hospital discharge or discharge from the ED to home
- Identification of sudden or intermittent changes in a patient’s condition
- Greater patient comfort, safety, and satisfaction
- Avoidance of expensive emergency department visits and inpatient stays
The outline of the program was straightforward: first, identify eligible patients in designated clinics, in the emergency department, during care management follow-up, or at discharge. Then, ship a monitoring kit to their home that would provide continuous vital signs through a connected data platform, and use the real-time data and associated alarms to inform care. Access to real-time data would also allow members of the care team to proactively prioritize interventions which included patient outreach (e.g., a home visit or phone call) and/or scheduling an acute outpatient appointment with their provider when necessary. Access to enhanced home monitoring data also helped to inform changes to patient regimens: medications could be added or adjusted, particularly diuretics where dosing could be informed by oxygen saturation and daily weights, oxygen could be brought into the home or the flow rate modified, and one patient found to have heart block was brought into clinic for additional testing as an outpatient.
Operational Considerations to Launching a 24/7 Home Monitoring Program
Integrating an enhanced data stream into an established care model was a non-trivial exercise. In the early days of the program, the Geisinger teams identified a number of initial challenges to incorporating the new devices into their existing workflows:
- Data Access. Access to continuous vital sign data is typically only available in an ICU setting, and now it was available for patients at home. The team worked diligently to set up workflows to incorporate this data into daily patient management routines and found that access to vital sign trends over time allowed them to anticipate clinical events.
- Provider Adoption. Reminding clinicians that discharge with continuous vital sign monitoring was an option became a routine task. In weekly meetings, program sponsors Joann Sciandra, RN and Anthony Wylie, DO, reviewed successes and missed opportunities for broader provider adoption. Wylie worked the program into daily rounds and routine discussions with colleagues, educating them about the program and sharing early wins.
- Program Awareness. Especially with so many new workflows due to the pandemic, the various care team members were unaware that they could admit patients into a new program for continuous at-home monitoring. Case managers were critical to the program’s success, identifying inpatients or ED patients who might be eligible for the program on discharge. Ongoing education and feedback was required to keep this new option at the forefront of the care team.
- Kit logistics. The team had extensive experience in routine remote monitoring kit delivery. However, for the COVID-19 population or others that required continuous monitoring to allow for early discharge, there was a need to receive the kit quickly. The team could not wait 48 hours for home delivery so they arranged to stock monitoring kits on-site in several locations across their regions, including the ED, so they could be quickly deployed. There were a number of challenges with the logistics and managing the inventory of devices. For example, knowing what was available, getting them back/recycled/restocked and out to the next patient… Once the team worked through appropriate tracking and communication mechanisms, this became a much smoother process.
Program Impact at Six Months
COVID-19 consumed everyone’s attention, sapped energy, and made the implementation of all programs – new or existing – more difficult, so the three-month pilot was extended to six months. By that time, 139 patients had been admitted to the monitoring program, 65 per cent of them COVID-positive, and 37 per cent of them over 65 years of age.
When the Geisinger team set out to evaluate the pilot, they encountered the well-understood challenge that frustrates program evaluation: difficulty in identifying the right comparison group to use as a control. Of course, no one had wanted to randomize patients when they innately believed the remote continuous monitoring program would improve patient outcomes, experience and save dollars and lives.
The team did track the impact on enrolled patients and it was impressive: 23 patients had an averted emergency department visit, and 10 avoided an admission to the hospital or a skilled nursing facility.
Invariably, the stories that Sciandra’s and Wylie’s teams encountered over the course of the pilot influenced the way the team is thinking about the program as much as the data. Impact was seen across five broad categories:
- Admission avoidance. Three acute pulmonary clinic patients avoided inpatient admission because the team felt monitoring was the extra surveillance that was needed to assure their safety at home.
- Early diagnosis. One patient with COVID-19 developed atrial fibrillation that was diagnosed after home monitoring raised an alarm for bradycardia.
- Treatment Modification. One patient with COVID-19 was noted to desaturate at home overnight and was seen the next day in the clinic where their steroid dose and oxygen supplementation were modified, likely avoiding either admission or a catastrophe.
- Patient experience. Across the board, patients expressed appreciation for the peace of mind that came with knowing their healthcare providers were watching out for their well-being – even when they were at home.
- Peace of mind for patients and providers. Emergency Department physicians who might have admitted a COVID-19 patient newly placed on oxygen to keep eyes on them were comfortable sending patients home if continuous monitoring could be provided. Patients also liked the idea that their care team could keep tabs on them. In the words of program manager Meg Horgan, “they felt comfort knowing that someone was watching them.”
The program continues, and the team meets weekly to evaluate progress, improve the workflows as needed, and encourage appropriate utilization of the service. Current Health monitors utilization data daily and works with the Geisinger team to optimize the technology for the program and, at times, for individual patients. There’s a general sense, driven by a commitment to improve patients’ lives, that the program is making a difference.
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