Effectively managing risk alerts is one of the keys to success with a telehealth and RPM program. While the end goal is the patient achieving the highest level of self-management, risk alerts guide the actions and interventions of the overseeing clinician. Those interventions in turn, inform the patient of appropriate actions and reinforce self- management.
Management of risk alerts creates an effective clinical workflow and allows the maximum number of patients to be monitored. If a program is mired in addressing risk alerts, perhaps the alerts are not properly set.
Risk alert settings can include biometric data such as BP, T, P, Pulse Oxygen, BS and weight. Other risk alerts include disease-specific symptom surveys, activity and medication adherence. Clinicians have several key metrics available to make good assessments and inform next steps. The next steps may be as simple as asking the patient to resend information, notifying the provider for additional orders, or advising the patient to seek emergency care. Good information interpreted with excellent critical thinking skills leads to positive outcomes for patients including reduced unnecessary emergent care and hospitalizations.
Establishing Risk Alerts Standards
Establishing your risk alert parameters may depend on your targeted patient population. Heart Failure, COPD, Diabetes, Hypertension and Cardiac Surgery are the most frequently monitored populations. It is important to develop organizational clinical standards that determine your risk alert setting. For example you may set a risk alert for a systolic BP > 150 for all of your monitored patients. However, a hypertensive patient may be consistently as high as 160. It would be appropriate then to notify the provider and ask for a modification of your organization's standards. Should the provider order only to be notified of a systolic BP > 162, your risk alerts may significantly reduce and your workflow becomes more efficient. So while your organization has appropriate clinical standards, it must ultimately be patient specific when indicated. For HRS partners, our Client Success Team can help you establish condition-specific biometric parameters.
Triaging Risk Alerts
Protocols for responding to risk alerts provide guidance to clinicians, however, it requires a skilled clinician with sound critical thinking skills to absorb and interpret the complete patient picture and take the most appropriate action. No single alert is cause for alarm, but does require further investigation. HRS has developed best practices to help your team appropriately respond to risk alerts.
1. Verify and validate the reading with the patient or caregiver:When receiving a reading outside the patient’s normal parameters, it’s important to confirm that the reading was accurately recorded. Perhaps the patient took their blood pressure while standing in the kitchen talking to their family or their partner stepped on the scale to check their weight before the patient. Reaching out to the patient or caregiver to verify the reading is essential as it will determine your next steps in responding to the alert. If the reading was taken accurately you will likely have the patient retake the reading and move to step two. However, if the recording was taken incorrectly, you would educate the patient on the proper use of the equipment and how to take the most accurate readings.
2. Confirm accurate medication regimen was followed on that day and previous days:Medication non-adherence is a significant cause of unnecessary emergent care and hospitalizations. HRS offers medication reminders for patient ease, but for patients taking multiple medications several times per day, it’s still possible to miss or skip a dose or more. When validating the patient’s vital signs, it may be necessary to confirm all their medications were taken not just that day but previous days. For example, the effects of missing several days of blood pressure medication may not always appear immediately. Educating the patient on the importance of compliance with their medications might be necessary before escalating the issue to their physician for a medication change.
3. Check for abnormal symptoms.HRS’ daily symptom surveys give clinicians deeper insight into the patient’s current health status. Review the patient’s survey answers and, if indicated, query the patient further. For example, if the patient reports he is more short of breath today than yesterday, review the key biometrics and ask the patient about any other symptoms. Is pain perhaps contributing to the increase in SOB? Keep in mind that a patient might not be feeling any symptoms. For example, a patient with extremely high BP may not have any symptoms at all.The patient’s self reported symptoms should be assessed in combination with any key biometric alerts to get a more clear picture of the patient’s status.
A virtual visit is ideal when a visual assessment is indicated. The ability to assess the degree of distress, the patient’s color, demeanor and appearance adds exponentially to the assessment. A clinician can also assess the level of extremity swelling, the current wound status and even watch the patient withdraw and administer their insulin dose correctly or use their inhaler properly. A virtual visit combined with biometric readings and symptom surveys provides the most comprehensive assessment outside of an actual home visit and preserves valuable staffing resources.
5. Escalate to the necessary intervention, if necessary.This step is going to vary based on the risk alert and the patient. As stated above, escalation may simply require notifying the physician and requesting a change in medication or sending a nurse to perform an in-home visit. However, if severe symptoms are present, escalation could require advising the patient to go to the emergency room. Every situation will be different, but the earlier the intervention, the better the result.
6. Document the intervention.This is one of the most important steps in high alert intervention. In ClinicianConnect, HRS’s clinician-facing portal, notes automatically pull in the patient’s biometric readings at the time the note is saved. HRS also integrates with a number of EMRs to reduce double documentation and reduce clinician burden. If your organization does not have an EMR integration, we recommend documenting in HRS first and then copying the note into your EMR.
When documenting the assessment and intervention it is important to paint the full picture. Start with your observations that include related biometrics, specific survey questions, visual findings and any germain comments from the patient or their caregiver. From that you would detail the assessment of your findings. The intervention based on your findings may be to contact the provider for further orders or to ask the patient to submit additional data later in the day. It is important to document the follow up planned after the intervention. If there was a medication change it is critical that the patient understands the change.
Establishing a protocol to respond to risk alerts will allow you and your organization to better manage your patients on a day-to-day basis, improving your outcomes for your organization, patients, and their families.