January 02, 2012

By Leslie A. Grant, Ph.D.

If patient telemonitoring seems like futuristic speculation or science fiction, when it comes to addressing the needs of long-term care residents, it’s not. The largest and widest-scale deployment of any such technology is currently under way in five states – and it’s being done among seniors living in assisted living facilities or at home.

LivingWell@Home is a demonstration project by the Evangelical Lutheran Good Samaritan Society – the largest nonprofit provider of senior care and services in the United States – in Iowa, Minnesota, Nebraska, North Dakota, and South Dakota. With an $8.1 million grant from a private philanthropic trust, the society is working with WellAWARE Systems, Philips Lifeline, and Honeywell HomMed to test the efficacy of three telemonitoring systems: sensors, telehealth monitors, and personal emergency-response systems. All three are integrated through an online reporting system that alerts nurse specialists (registered nurses) to emergent health problems among at-risk seniors.

The sensor technology, from WellAWARE Systems, monitors client safety by sending wireless signals indicating sleep patterns, motion, falls, bathing, toileting, cooking, and other activities of daily living.

The personal emergency-response system, from Philips Lifeline, involves a pendant with a button that a client can press to summon help. The system has an “auto-alert” function (using a built-in accelerometer) that sends a signal to the Lifeline call center should someone fall and be unable to press the button.

The telehealth monitors, Genesis from Honeywell HomMed, prompt clients to take vital signs, which are sent to the nurses via landline or cellular phones. This system also asks the client disease-specific questions and provides educational content to the seniors living in their homes.

The nurse specialists are trained in how to identify and respond to potential seminal health events these systems pick up, such as by monitoring the frequency of toileting. If the frequency deviates above a threshold that is considered normal for that person, the online reporting system alerts the nurse specialist. In turn, the nurse specialist contacts a housing manager at an assisted living facility, a nurse at a home health care agency, or another responsible party to contact the physician who can order a lab test and follow-up.

Goals for Service and Research

For the Good Samaritan Society, the LivingWell@Home program has the following objectives:

► Expand the use of sensor technology, telehealth monitoring services, and personal emergency response systems.

► Study how these telemonitoring technologies can help seniors.

► Evaluate potential cost savings associated with these services.

► Secure public and private reimbursement for these services.

► Develop business models to sustain LivingWell@Home as a major service going forward.

 

But the telemonitoring systems can potentially achieve a number of other, related and interrelated clinical goals:

► Enhancing patient adherence to treatment regimens.

► Improving care coordination across key stakeholders including patients, family caregivers, and clinical teams.

► Providing information to clinical teams so they can intervene proactively to improve clinical processes.

► Monitoring clinical and nonclinical parameters on an ongoing basis to assure safety from a distance.

► Identifying seminal health events remotely and communicating the need for action to care providers at the point of service.

I lead a research team from the University of Minnesota, Minneapolis, that is collecting longitudinal data in a randomized trial to evaluate the cost-effectiveness of these technologies. Our hypotheses are that these technologies reduce overall health care costs; reduce utilization of health care services (for example, hospitalizations and admissions to nursing homes); lead to better out- comes in health status, quality of life, functional status, and client satisfaction; and support “aging in place.”

Our study has two phases. In phase one, qualitative data from focus groups made up of nurse specialists, housing managers, and other key stakeholders have been telling us how these telemonitoring systems affect organizational and clinical processes. Meanwhile, quantitative data are being collected in diaries, telephone surveys, and in-person surveys. Parameters include utilization of medical services, health care costs, sleep patterns, adverse medical events, quality of life, health status, and client satisfaction.

During this first phase, 1,600 at-risk seniors will be recruited and randomly assigned into an experimental group that is receiving telemonitoring services or a control group that is not. Primary data collection started in February 2011 and will run through March 2013. Each research subject will be followed for 12 months.

Research participants are in four groups, each comprising 200 experimental and 200 control subjects. The groups are assisted living facility residents; recently hospitalized, dually eligible Medicare-Medicaid beneficiaries participating in Medicaid waiver programs; patients being discharged into community settings from inpatient hospitals; and residents being discharged into community settings from postacute nursing facilities.

Phase two of the study will start in October 2013 and run through September 2014. This work will assemble data retrospectively from Medicare, Medicaid, and third-party claims files to compare health service utilization and costs between the 800 experimental and 800 control subjects in the four groups described.

A major goal of LivingWell@Home program is to demonstrate how telemonitoring systems can be used to curb the overall cost of health care and persuade public and private insurers to provide reimbursement for these technologies, to make them more affordable for seniors. The study is examining potential cost savings associated with telemonitoring technologies across a group of seniors who are at risk for high medical expenditures. The research is also evaluating how telemonitoring can ensure safety and improve clinical processes for better chronic disease management.

Early Lessons Learned

Evaluation of the economic value of telemonitoring has been limited to date, and our LivingWell@Home research has not progressed far enough to reach clearcut conclusions about cost or other potential benefits. Nevertheless, some early lessons can be gleaned from a focus group that we conducted with nurse specialists in June 2011, about 6 months into phase one of the research.

Because these technologies represent innovations that have not yet diffused widely into long-term care settings, these nurses responsible for monitoring these systems are experiencing a daunt- ing “learning curve.”

One nurse specialist described her early experiences, “It’s challenged me as a nurse to think outside of my normal parameters. It has by and large [been] one of the most challenging things I have ever done as a nurse.”

A major challenge, she said, is to learn how to use telemonitoring systems to help inform clinical decision making. The Good Samaritan Society is currently developing user guides for nurses about how to use telemonitoring effectively. Another challenge is to understand how to make clinical inferences from nonclinical data, such as when a senior stays in bed during much of the day, does not bathe regularly, spends an extraordinary amount of the night in the bathroom, or sleeps very erratically.

It is likely that the deployment of any telemonitoring device, in and of itself, will not lead to significant improvements in clinical processes. What will be equally important is figuring out how to make effective use of these technologies to assist other members of clinical teams (such as home health agency nurses, nurse practitioners, and physicians) who often are at the point of service for chronic-disease management.

Workflows and other processes are being redesigned at the Good Samaritan Society to provide greater opportunities for clinical teams to intervene when alerted by telemonitoring. At the same time, improvements are being made to the telemonitoring devices and the online reports they generate.

Some early examples of clinically meaningful events captured by these telemonitoring systems include falls, urinary tract infections, sleep irregularities, negative reactions to medications, positive responses to adjustments in medications, and difficult behaviors. The LivingWell@Home project is still in an early phase, so research must continue before empiric conclusions about economic or clinical benefits or disadvantages from the telemonitoring of seniors can be reached.

Dr. Grant is an associate professor and director of the Center for Aging Services Management at the University of Minnesota School, Minneapolis. His research interests include environmental design for seniors and the financing, organization, and delivery of long-term care. BILL KUBAT, LNHA, director of mission integration for the Evangelical Lutheran Good Samaritan Society, coordinates this column.

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