Healthcare providers have been going the distance to cut the huge costs associated with the growing epidemic of chronic diseases and a quickly aging population, but the answer to improved care coordination and reduced hospitalizations might be much closer to home than previously thought.
For some patients at Banner Health, a 28-hospital chain based in Arizona, sophisticated chronic disease management can take place right in their living rooms, thanks to a combination of telehealth and home monitoring technologies that are backed by a dedicated, integrated team providing expertly coordinated care.
Two years into its Intensive Ambulatory Care program, Banner Health is seeing big results from its emphasis on care coordination for patients with long-term, complex health needs. By providing more extensive care in the home, Banner has been able to reduce the number of unnecessary hospitalizations experienced by these patients by 45 percent, while cutting overall related service costs by nearly a third.
Remote monitoring and centralized clinical documentation technologies have played a major role in these improvements, but Dr. Hargobind Khurana, Senior Medical Director of Health Management at Banner Health, was quick to point out that a strong, coordinated, informed multi-disciplinary care team is the real foundation of any effective population health management initiative.
“The idea is that we can identify patients who have higher needs, such as those who have chronic conditions, those who have multiple hospital admissions, or who come into the emergency rooms multiple times – patients who require more of a proactive approach for managing their care,” Khurana said in an interview with HealthITAnalytics.com. “We use technology for that, but more important is our care team which is involved in taking charge of these patients.”
“We try to engage patients while they’re in the home with telehealth and remote monitoring,” he added. “We use a tablet which has Philips software on it, and through that tablet, people can connect through audio and video, or have information sent to them. They can read some educational materials; they can answer questions about how they feel on a daily basis. The data is sent back to a central location where the care team can look at it.”
Once identified as a participant, a patient is matched with nurses, pharmacists, social workers, and physicians who review the data collected from medical devices and other self-assessments. “So think about all that vital information – the blood pressure, the heart rate – coming in from the patient’s home, being run through algorithms,” he said.
“You might not have to look at every single data point, but if there is an absolute number that is not okay, or if there is a trend that is not acceptable, that gets highlighted and our nurses will evaluate it. They will call the patients, get an assessment of what’s going on, and connect with a pharmacist, physician, or social worker depending on what the issue is.”
Patients participating in the program also receive visits from Banner’s health coaches to strengthen and maintain a meaningful connection. The coaches become the team’s “eyes and ears” within the home environment,” Khurana says. “The health coaches can provide help with the tablet or help set up a video visit. We help them become comfortable with the technology, which hasn’t been much of an issue. We have 102-year-old patients, or 90-year-old patients, grandmas and grandpas, who are very comfortable using the tablet and the technology. It’s not a problem at all.”
“The health coaches also observe the home and see how patients are behaving and what they’re doing that might be affecting their health,” he continued. “In general, they keep in touch and become a conduit to keep patients engaged with the healthcare system.”
These strategies have reduced hospitalizations among the target population from 11.5 admissions per 100 patients each month to just 6.3, Banner Health says. This includes significant decrease in long-term care facility admissions, which have dropped from 3.9 per 100 patients per month to just 1.4. Acute and long-term care costs have deflated accordingly: Banner can boast a 32 percent reduction in spending related to these events.
In addition to Banner’s own assessment of its program’s results, there is mounting evidence across the industry that higher levels of patient engagement, telehealth use, and care coordination can significantly improve outcomes, forestall hospitalizations, and cut costs for patients with complicated conditions. But healthcare providers must first identify the patients who would benefit most from these activities – and produce the most return on the investment for their providers.
“When we talk about risk stratification and identifying patients for the program, we’re basically using the presence of chronic conditions and frequent utilization of healthcare services as a predictor of continued higher risk,” says Khurana.
“So if the patient has four or five chronic conditions, has been in the hospital two times in the last six months or a year, been in the ED a few times in the last few months…there is probably some complexity to their condition, whether it’s a social, behavioral, or medical need, that requires additional support. We’re getting better at identifying patients who could benefit from the program.”
Once identified, enrolled, and provided with the right technology, the next challenge is ensuring that the patient’s health issues are being adequately addressed by the entire care team. Pharmacists must be aware when physicians change dosages; nurses need to stay up to date on potential side-effects from new regimens. Social workers must be aware if the health coach has found a danger in the home or if the patient needs to be connected to supportive community services. To tackle these potential communication problems, Banner turns to technology again.
“Everybody on the team is creating documentation in the same software system, which keeps all the information together,” Khurana explained. “When the health coaches go to the patient’s home, they document it in that system, and the whole team can see that note. So when the physician gets a call about that patient, he can take a look at the file and say, ‘All right, when the health coach went to the patient’s home, this is what she found; these are the changes that the pharmacist made, so here’s what is going on.’ It’s all standardized and it’s all in one platform, so the communication is very robust within the team. It’s very reliable.”
Face-to-face communication plays a part in ensuring adequate care coordination, as well. “It’s a team that really communicates,” he said. “So the health coach calls the social worker on a daily basis, and she will go with the coaches once in a while to conduct home visits with them. Then the social worker sits down with the centralized team – the pharmacist and the physician and the nurses are all sitting next to each other. So you can have a great technology platform, but when you’re sitting in the same room, communication can really reach the next level.”
The program operates with the hospital as the hub, but most patients have their own primary care providers that may or may not be directly affiliated with Banner Health. No matter how well the Banner care team communicates internally, they must also keep data flowing to their patients’ other providers.
That has been a challenge for the program, notes Khurana, which has encountered some of the same health data interoperability problems that have plagued the rest of the industry in its attempts toreduce fragmentation and make health information exchange more of a routine reality.
“We have interfaces with some EHRs, and we share data on these patients that way when we can,” he said. “We have a standard form of communication that goes through the EHR interface, so when an external primary care provider sees the patient, they know what happened and what we’re doing at Banner. And if they don’t have an EHR or they don’t have a system we can connect to, we still pass that information over to the office in whatever way makes sense. So we make a significant effort to make sure that the entire care continuum is involved.”
The idea is to give patients more choices about how and when they receive necessary care, and to do whatever it takes to increase access for those with the most pressing needs. That includes providing nearly round-the-clock clinical availability for these high risk patients. “You can call or be connected to a physician or pharmacist or a social worker or nurse within minutes, and that doesn’t happen in most PCP offices for obvious reasons,” Khurana added.
While patients are free to call their own primary care providers if they wish to discuss their health status, Banner hopes to remain their first choice. “We do ask them to call us directly if they have an issue, but they can and they do call their own primary care providers if they have issues they want to discuss with them,” he said.
“I think the more communication we can create, the better it is, and it’s getting better and better over time. In general, I think patients prefer to call us first because of the availability we offer. That kind of access is generally not available with most of their other physicians.”
This expanded access to care, coupled with the dedication of a well-coordinated care team and an increased reliance on a comprehensive stream of patient health data from home monitoring devices, is “very new for healthcare,” Khurana points out, and represents an important opportunity for providers to develop much more effective population health management techniques.
“We have been used to patients who come to the hospital, go home., see their primary care provider a week or two later, and then a few months later, they’re back in the hospital again,” he said. “That’s a lot of time without having a connection to that patient. The patient may have no idea that something is wrong.”
“But when we can be proactive as a team, we can collect information from the patient at home. And not just objective data, but subjective information as well, like from our mood surveys. If their blood pressure is 180/100 for five days in a row, they are potentially going to end up in the hospital, sure. But there’s a belief that you have a better sense of your health than your blood pressure does. If the reading is totally normal, but if you’re not feeling well, something else might be wrong that needs to be taken care of.”
“So taking that holistic approach and having a significant amount of touch points with these patients, provides enough data on a timely basis that we can take proactive steps to manage the problems,” Khurana concluded. “We can change some medications, help them through some symptoms, or catch something that is exacerbating a problem and hopefully change the course of that condition.”
“It makes a difference when you can build trust with a patient and have a central team which is solely responsible for managing or helping these patients on a timely basis. That makes a difference in how they use healthcare and whether or not they end up in the hospital.”
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