Overview
Community Nurse’s Telehealth and RPM Program Reduces Hospital Readmissions and Care Costs
Community Nurse Home Care (CNHC) is an independent, non-profit healthcare agency, serving communities across Southeastern Massachusetts. CNHC’s team of skilled nurses, therapists, home health aides, and social workers coordinate with patients, families, and physicians to ensure patients receive the comprehensive, quality care necessary to recovery in the comfort of home.
Challenge
Across the country, medical costs related to chronic diseases will continue to soar over the next decade, as the number of Americans living with one or more chronic diseases rises exponentially. According to the Partnership to Fight Chronic Disease, in the state of Massachusetts, health care expenditures for chronic disease treatment are projected to cost the state an average of $41 million per year by 2030.
Reducing care costs requires behavioral changes on the part of patients and treatment advancements on the part of providers, including:
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Improved education offered to patients, explaining how to recognize and proactively address symptoms.
Increased patient engagement in their care plans and therapies, supporting long-term behavior change.
Enhanced communication between patients, family caregivers, and healthcare providers.
Early identification of exacerbations to prevent unnecessary ED visits and hospitalizations.
Solution
Community Nurse Home Care partnered with Health Recovery Solutions beginning in 2019 and launched a telehealth and remote patient monitoring (RPM) program, targeting high-acuity patient populations. To improve patient outcomes and decrease care costs, CNHC enrolled patients with one or more chronic diseases and a history of hospitalization or non-compliance. Patient populations identified for the telehealth program included CHF, COPD, diabetes, and hypertension.
Placing communication and care coordination at the center of their telehealth and RPM program, CNHC deployed a centralized model of monitoring in which a telehealth coordinator monitors patient vitals signs and symptoms, performs virtual visits, reviews educational materials, and coordinates care plan and medication changes with patients’ physicians.
A Centralized Telehealth and RPM Model Enables CNHC to Improve Patient Care and Reduce Care Costs
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Daily biometric monitoring and risk alerts enable CNHC to identify exacerbations in real time to be addressed through an in-person or virtual visit to prevent potential hospitalizations.
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Symptom surveys help patients identify a change in their health status and allow the telehealth coordinator to address concerns timely.
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Condition-specific educational videos and teach-back quizzes engage patients in self-management, learn about their condition(s), and prepare them to live more independently in the future.
- Patient-level reporting enhances communication between CNHC and physicians to ensure every patient receives comprehensive, quality care.
I feel RPM is an invaluable tool for both patient and provider. With this virtual method, a relationship is developed with the patient to assist with self-care monitoring and to establish transfer of the data to the provider, thereby decreasing hospital visits.
Heidi Gonsalves, LPN, Tele Med Nurse
Community Nurse Home Care
Patient Adherence Average Rate in 2023
Patient Satisfaction Rate in 2023
Patients that Reported Feeling Stronger Support in 2023
Results
Since launching the program in 2019, Community Nurse Home Care has treated more than 1,300 patients through telehealth and RPM. To assess the success of the telehealth and RPM program, and its impact on reducing health care utilization and care costs, CNHC evaluates several key metrics: patient adherence, patient satisfaction, and hospital readmissions.
A core goal of the telehealth and RPM program is to engage patients in their care plan and increase their understanding of their condition(s), symptoms, and treatments. The telehealth program has significantly increased patient engagement and boasted an average 88% average adherence rate during 2023. In the same year, 96% of telehealth patients agree they are more involved in their care after being enrolled in the telehealth program.
Not only are telehealth patients more engaged in their care on a day-to-day basis, but over 93% of patients feel more supported by their healthcare team due to the additional monitoring and support provided by telehealth and RPM.
Finally, CNHC has substantially reduced hospital readmissions among telehealth patients, allowing these high-risk patients to recover in the comfort of their home. To provide the most accurate outcomes data, CNHC partners with Strategic Healthcare Programs (SHP), a leading performance improvement software company supporting home health benchmarking. Through the partnership with SHP, CNHC has the ability to compare readmission rates between its high-acuity, telehealth patients and its global patient population.
The Acute Care Hospitalization Scale, developed by SHP and using over 163 different risk factors, assigns patients a risk score on a scale of one to nine. Since launching the program in 2019, CNHC has utilized telehealth and RPM to target high-acuity patients with vital signs and symptom monitoring, as well as custom education and care planning. This intensive care has resulted in a significant reduction in hospital readmissions, particularly among high-risk patients with multiple comorbidities and a history of hospitalization.
Across all risk levels, and between January 2022 and December 2023, CNHC telehealth patients recorded a 17% reduction in their average 60-day ACH rate when compared to non-telehealth patients. The majority of the telehealth patients in the CNHC program were enrolled with an SHP risk score of two, three and four. Among these patients specifically, CNHC telehealth patients recorded a 23% reduction in their average 60-day ACH rate when compared to non-telehealth patients.