This tablet-based app used by nurses and health coaches in a follow-up care program reduced hospital readmission rates among at-risk Medicare patients by nearly 40 percent.
One in five Medicare patients are readmitted to the hospital within 30 days of discharge according to the Robert Wood Johnson Foundation. Preventable hospital readmissions cost the U.S. health care system at least $25 billion annually. One of the ways in which insurers and hospitals attempt to lower the cost of readmitting patients is through chronic care disease management, discharge follow-up and health coaching.
Nurse care managers and health coaches have traditionally used home visits, telephonic interaction and e-mail to reach out to patients after discharge. Increasingly, they have been using mHealth apps to better connect with patients during home visits and help them manage their conditions.
The Care at Hand tablet app is one of these apps which have been shown to significantly cut readmission rates. During a six-month program, health coaches at Elder Services of Merrimack Valley in Massachusetts used the app during each visit and telephonic contact with 561 medium-risk and high-risk Medicare patients who have just been discharged from the hospital.
“Patients at medium or high risk for readmission receive an in-home visit within 48 hours of discharge and a weekly phone call for each of the next three weeks. During each encounter, the coach uses a tablet-based application that provides suggested questions written in lay language based on the patient's diagnoses, treatment, and overall risk profile,” stated an Agency for Healthcare Research Quality (AHRQ) Innovations Exhange Report.
The app prioritizes the type of questions to ask depending on the most recent diagnosis or symptoms that could lead to a readmission. For instance, a patient with heart failure may be asked about breathing difficulties or sudden weight gain − factors that could get them readmitted if not addressed promptly.
According to the paper, “If the answers indicate a decline in health status, the system sends a real-time alert to a nurse care coordinator, who subsequently uses a different component of the software to help the patient and coach address the issue within 24 hours, including arranging for any needed services.”
The app can send a mild, moderate or high alert to the nurse coordinator, who then uses clinical judgement to arrange and schedule the patient for either primary/specialty care, a medication change, a home visit from a nurse, and/or an emergency department visit.
Using the Care at Hand app during the six month program reduced the 30-day readmission rate by 39.6 percent compared to the previous 18 months when they did not use it.
The software also lowered all-cause readmissions for all Medicare patients enrolled in the program by 5.9 percent. Moreover, the app helped save an average of $109 per patient for each month of the six-month program − resulting in net savings of $370,000 and gross savings of $600,000, according to the report.
“The use of health coaches supported by the tablet-based software significantly reduced readmissions among at-risk Medicare patients, as compared with use of health coaches without the software. This reduction generated substantial cost savings for partner hospitals and the health care system as a whole,” the report concluded.
According to the National Priorities Partnership (National Quality Forum), utilizing mHealth and telehealth technologies can help care providers manage clinical information seamlessly to connect and communicate with patients in managing chronic conditions and ultimately reduce hospital readmissions. Because U.S. hospitals face stiffer penalties from CMS for readmissions (2 percent in 2014, 3 percent maximum penalty in 2015), they will continue to explore new healthcare and information technologies to curb the trend.