April 4th, 2014
Editor’s note: For more on this topic, see the February issue of Health Affairs, which features a series of articles on connected health.
Remote care management (RCM) programs use telehealth technology to facilitate clinically driven, remote monitoring, care, and education of patients and are an absolute necessity for providers and payers striving to implement an effective population health management strategy. Historically, RCM programs have been viewed through a fee-for-service lens and, as a consequence, overlooked, because physicians would not be reimbursed for the time to monitor these patients outside the confines of their offices.
Yet the current shift to value-based care presents an imperative for health care providers to avoid costs by better managing the health of people with chronic conditions. This change will require more hands-on, effective support for patients that result in lasting behavior change.
Providers are working to keep the health of an individual from rapidly deteriorating once they develop a chronic condition(s). Two prominent barriers to providers’ efforts to keep their patients healthy are the providers’ intermittent contact with patients and limited access to clinical data. Remote care management addresses these barriers.
RCM programs have the potential to extend a provider’s reach and perspective into the daily lives of patients. Equally important, ample evidence, including a study of RCM within the Veterans Health Administration, demonstrates that RCM programs can improve patient knowledge and awareness, which are critical in facilitating early intervention, adherence to treatment plans, and appropriate utilization of medical services.
Maximize Value Through Patient Activation and Efficiency Gains
Patient activation is defined as “understanding one’s own role in the care process and having the knowledge, skills, and confidence to take on that role.” Relatedly, the patient activation measurement is a validated tool that assesses an individual’s skill, confidence, and knowledge for managing one’s own health and health care. One challenge for value-based payment models is to help patients with high-acuity health challenges and low health literacy become low-acuity, highly health literate populations.
Early intervention and patient activation support this goal by facilitating motivation, recognition, and patient understanding of when to take action and what action to take. When should an individual seek medical attention rather than take simple steps at home to address temporary shortness of breath? When is it more appropriate to make an appointment for an office visit rather than rush to the emergency room? These are common, mismanaged situations that may cause harm to patients, create avoidable readmissions, and lead to unnecessary ER use and higher costs.
In these situations, RCM programs can play an important role by helping educate patients and enabling clinicians to provide real-time clinical advice via video conferencing. Many studies have demonstrated the benefits of patient activation, showing that patients with high activation are more likely to adhere to treatment regimens, seek preventive care, and participate more in decisions about their care. A recent Health Affairs study also found that patients with the lowest level of activation had health care costs that were 21 percent higher than patients at the highest activation level.
RCM gives clinicians a better opportunity to effectively and efficiently connect with the high-cost, high-risk patients. With RCM, clinicians can monitor patients and provide “just-in-time” education to help them learn what causes exacerbated health conditions and what to do during subsequent occurrences. Additionally, RCM provides efficiency gains when compared to traditional primary care models that rely heavily upon in-person office visits and unprompted patient action. For example, in an RCM program, nurses can provide clinically facilitated care and monitor many patients, which frees up physicians and other advanced clinicians to focus on those patients who are in need of intervention or acute care.
RCM Gives Clinicians Daily Data to Better Manage Patients
RCM monitors patients and collects daily objective and subjective information. This longitudinal data provides clinicians a more complete view into the patient’s life. In most cases without RCM, clinicians only have access to sporadic data, which can make diagnosis and treatment more difficult and inefficient. For example, if a patient says he is tired and short of breath, twenty things may come to the clinician’s mind as potential causes.
However, if clinicians have that information combined with the patient’s weight, blood pressure, and symptoms recorded on a daily basis over a three-week period, potential diagnoses could be narrowed from twenty to two. This more complete picture puts nurses, who are monitoring patients remotely, and physicians, who are treating people in-person, in a much stronger position to deliver the best care. Pairing big data and analytics with RCM programs will ultimately translate the most value for population health management programs.
RCM Produces Positive Results
In 2010, as CMIO at St. Vincent Health in Indiana, my team and I designed an innovative research study with the goal of reducing hospital readmissions for patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) via RCM. The study was part of a $16.1 million government-funded Beacon Grant awarded to the Indiana Health Information Exchange.
During 2011-12, nearly 200 patients with CHF and COPD were randomized into the study immediately post-hospital discharge for a 30-day monitoring period. St. Vincent Health used RCM technology to facilitate clinical care from a nurse connecting to patients’ homes. Daily vitals were recorded automatically via the RCM technology, and nurses monitored the data for any red flags and opportunities for personalized education and/or videoconferences to intervene before clinical deterioration would occur.
Results from the study revealed a 60 to 70 percent reduction in readmissions compared to the national average. The study also found a statistically significant increase in the level of patient engagement for those in the RCM group when compared to the control group, indicating the potential for long-term improvements in health and the cost of care.
We must seize this opportunity to focus on new approaches to improve care coordination and facilitate early intervention. And we must continue to advance technology adoption and data integration. We’ll reach an important turning point when, just moments before walking into an exam room, every physician will easily be able to reference key data points obtained from the home (such as a patient’s daily weight and blood pressure), along with various information from other data sources (such as EHR or HIE) through the same access point.
The study I led at St. Vincent, along with Julia Smalley, Carrie Queenan, Mark Smith, Jason Cadwallader, Justin Morea, and Christopher Weaver, demonstrated a clear association between RCM and fewer hospitalizations and healthier patients. Yet, in conversations, my team and I have found some health care systems reluctant to embrace such findings and this new care model because they are predominantly reimbursed in a fee-for-service model.
While we understand the financial implications today, we believe providers need to adopt virtual care strategies now to prepare for the future, which will likely be characterized by decreased reimbursement, more financial risk for providers, and an uneven physician distribution nationally.
Virtual care strategies, such as using video conferencing to establish a stronger connection between clinicians and patients, will play a larger role in caring for patients. Using technology to enable nurses and therapists to improve interaction with high-risk patients allows for personalized care that can translate into better health, and in turn, reduced costs.Email This Post Print This Post
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