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Remote Monitoring of High-Risk Patients: Telehealth Protocols for Chronic Care Management
Remote Monitoring of High-Risk Patients: Telehealth Protocols for Chronic Care Management
Remote Monitoring of High-Risk Patients: Telehealth Protocols for Chronic Care Management
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Real-time remote management of high-risk populations curbed hospitalizations, hospital readmissions and ER visits for more than 80 percent of respondents and boosted self-management levels for nearly all remotely monitored patients, according to 2014 market data from the Healthcare Intelligence Network (HIN).

Remote Monitoring of High-Risk Patients: Telehealth Protocols for Chronic Care Management profiles a successful eight-year initiative by New York City Health and Hospitals Corporation's (NYCHHC) House Calls Telehealth Program that significantly lowered patients' A1C blood glucose levels.

The following outcomes are attributed to NYCHHC's House Calls Telehealth Program, an innovative hybrid of technology and human touchpoints, over a two-year period:

  • 76 percent of 769 monitored patients experienced improved A1Cs almost every three months;
  • All A1Cs over 13.1 were reduced to 10.2;
  • Ninety-one percent of individuals with A1Cs between 11 and 13 experienced an improvement.
While the House Calls Telehealth program targets diabetes, NYCHHC's innovative approach provides a template for organizations wishing to impact key metrics in at-risk populations, particularly individuals with congestive heart failure (CHF), hypertension, chronic obstructive pulmonary disorder (COPD), and even medication non-adherence, the top targets of 2014 Remote Monitoring programs.

In this 25-page resource, Susan Lehrer, RN, BSN, CDE, associate executive director of the telehealth office for NYCHHC, shares key aspects of the real-time monitoring program, including the following:

  • How the NYCHHC House Calls model blends telehealth, electronic medical records, electronic communication with providers and direct communication with patients by nurse case managers;
  • Case loads, skill sets and work environment of the nurse case managers at the heart of the program;
  • Profile of NYCHHC House Calls Telehealth Program participants, including the seven realities of high-risk patients;
  • Six behavior change basics for telehealth participants;
  • Detailed analysis of patient outcomes and improvements;
  • Guidelines for evaluating telehealth vendors and selecting remote management services;
  • Advice for overcoming challenges to remote monitoring, including unreachable patients, clinical intertia, the non-engaged member and language and literacy barriers;
and much more, including insight into staff training, frequency of client contact and hallmarks of high-performing patients.

Table of Contents:

  • Diabetic Telehealth Monitoring: The Impact of Real-Time Data on High-Risk Patients
    • NYCHHC Background
    • Program Admission Criteria
    • Outcomes and Impacts from House Calls
    • Evaluating Telehealth Vendor Services
    • Case Study in Remote Patient Monitoring
    • Overcoming the 8 Barriers to Remote Patient Monitoring
    • Lessons Learned from the House Calls Model
  • Q&A: Ask the Experts
    • Initial Intake Interview
    • Nurse Case Loads
    • Frequency of Patient Contact
    • Member Alerts
    • When Patients Are Unreachable
    • Caregiverís Role in Remote Management
    • Hallmarks of High-Performing Patients
    • Telemonitoring Training for Case Managers
    • Management of Comorbidities
    • Program Integration
    • Impact on ER Visits and Readmissions
    • Depression Screening
    • Home Health and Telehealth
    • Case Manager Skill Sets
    • Plans for Program Expansion
    • Work Environment for Telephonic Case Managers
    • Graduating from the House Calls Telehealth Program
  • Glossary
  • For More Information
  • About the Contributor
Publication Date: February 2015
Number of Pages: 25
ISBN 10: 1-941329-62-4 (Print version); 1-941329-63-2 (PDF version)
ISBN 13: 978-1-941329-62-7 (Print version); 978-1-941329-63-4 (PDF version)
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