Check Point – Remote Monitoring Equipment Helps Patients Connect the Dots

Every morning at exactly 10 a.m., Barbara Kobak weighs herself, takes her blood pressure, attaches a clip to her finger that measures her oxygen-saturation rate, then answers a series of computerized questions specific to her condition, which are presented out of sequence from one day to the next to ensure she thinks carefully about her response.
Within two minutes, the results are transmitted electronically to a registered nurse at Porchlight Visiting Nurse Assoc./Home Care in Chicopee, who calls the 84-year-old if anything doesn’t fall within the parameters Kobak’s doctor set for her.
The service is called telemonitoring, and Porchlight brought the equipment to Kobak’s home in January after she was released from the hospital. She had been diagnosed with congestive heart failure, and after an initial meeting with a nurse liaison in the hospital, a registered nurse spent several days in her home making sure she understood how to use the technology.
Home visits were spaced farther apart as time went on, which is typical; the goal is to help the person learn to manage their disease by recognizing potentially dangerous symptoms, making changes in their diet, and taking all medications prescribed for them.
“The equipment is really easy to use; I depend on it and don’t know what I would do without it. It’s reassuring to have someone call me if my blood pressure is up,” she noted, adding that there have been days when her pressure has been high in the morning, but when she puts the cuff on later in the day, she is relieved to see it has returned to normal.
The Chicopee octogenarian is one of a growing number of people who are benefiting from telemonitoring services. The equipment is made by a variety of manufacturers, and it allows healthcare providers to keep a close watch on the patient from a remote setting.
“We call new patients every day until they become comfortable with the equipment,” said Sandra Peret, a registered nurse at Porchlight and associate director of intake/community service. “We tell patients to use it at the same time every day, but if they are not feeling well, they can recheck the values.”
Telemonitoring is typically used to treat people with congestive heart failure or chronic obstructive pulmonary disease (COPD), which can make it difficult to breathe, although an additional module can be added if the person is diabetic and doesn’t have another reliable method to measure their blood-sugar levels.
Experts say it is valuable because people who are newly released from the hospital can feel overwhelmed when they get home due to the trauma of their diagnosis, the amount of information presented to them, and the lifestyle changes they must make to keep their condition from exacerbating, which can lead to rehospitalization.
“These conditions require a lot of self-management and usually include dietary changes such as cutting down sodium intake,” said Melissa Pouliot, a registered nurse and Porchlight’s intake/telemonitoring manager, noting that telemonitoring helps the patient see a direct correlation between their behavior and their health. For example, if someone eats Chinese food, their weight is likely to rise the next day due to its high salt content.
When that happens, a registered nurse calls the patient and conducts an assessment by phone to determine if the doctor needs to be notified. In some cases, there is no need for alarm, while in other instances, the person’s physician may be called to see if medication changes are in order.
However, patients sometimes don’t follow instructions given to them, which can have a direct effect on their vital signs. For example, they might fail to weigh themselves at the same time each day or wear heavy shoes or clothing while they are on the scale.
In any case, the patient is followed closely, and if the weight gain continues, the doctor is contacted. “The ultimate goal is to keep the patient from having an acute attack,” said Sue Pickett, director of Mercy Home Care, adding that patients track their symptoms themselves on a calendar even though the results are stored in the computer.
“Telemonitoring is a wellness proactive measure that allows us to catch symptoms early before they exacerbate and become a crisis,” she told HCN. “The reason why these programs are so important is because hospitalization is very common for people with congestive heart failure. We have patients who have been in and out of the hospital every other week.”

Nuts and Bolts
Major advances have been made in telemonitoring equipment in recent years, said those we spoke with.
In the past, people needed a landline to transmit information remotely, but today Bluetooth, cellular, and satellite technology make it possible to provide the service whether or not the person has a phone in their home.
The equipment patients receive from the VNA or home-healthcare service usually includes a blood-pressure cuff, an oxygen sensor that is clipped onto a finger, and a scale, which is plugged into a monitor with a touchscreen that not only transmits the information, but stores it, although there are some variations according to the company producing the equipment.
Pouliot said people tap the screen on the monitor Porchlight uses, and when a voice asks them what they want to do, they hit the corresponding icon. When they are finished with their reporting, which takes less than 10 minutes, a voice on the monitor asks the patient a series of questions which can range from “has the doctor changed your medications?” to “do you want someone to call you?” as well as reminders to take their medication.
However, these systems are not appropriate for some, including people with dementia or individuals with a disability who don’t have a caregiver.
“The person has to want to do this and be able and willing to use the equipment every morning,” said Sheryle Marceau, manager of clinical practice for Mercy Home Care.
The remote monitoring is combined with education that takes place during visits to the person’s home. Mercy’s patients are given printed materials with valuable information including symptoms that should not be ignored by people with congestive heart failure. They include unexpected or rapid weight gain; weakness or fatigue; dizziness or faintness; swelling of the legs, ankles, feet, or abdomen; more frequent visits to the bathroom at night; chest pain; and other signs.
“Exacerbation can be prevented, but people need to know what they can do every day, which includes reading food labels, taking their medication, and eating foods low in sodium,” Marceau said.
She added that hospital stays are usually short, so the staff doesn’t have time to teach patients all they need to know. In addition to the goal of keeping them from returning to the hospital, they want patients to be able to maintain their quality of life and stay active in the community.
So, while the technology is important, it’s what people do with the information gleaned from daily readings that makes a difference. “It helps patients connect the dots,” said Maura McQueeney, president of Baystate VNA and post-acute executive.
For example, if a patient has a big holiday dinner and their blood pressure and weight rise the next day, it will trigger a call from the nurse who will discuss what they have eaten and determine whether the doctor needs to be involved.
Medication is critical, but unless patients understand the importance of each drug prescribed for them and know exactly what it does, they may take it inconsistently or fail to get it refilled, particularly if they are on a fixed income.
“We try to update each patient’s medication list because the physician may make changes during an office visit, and monitoring allows us to see if the new medication is working,” McQueeney told HCN.
Baystate typically uses telemonitoring for patients who have experienced congestive heart failure. They usually keep the equipment 30 to 45 days or until the nurse feels the patient is capable of caring for himself or herself and has learned the association between symptoms that may indicate their disease is getting worse.
Insurance doesn’t pay for telemonitoring, but local visiting-nurse associations find it so valuable, they do not charge patients for the equipment or the service.
“It’s a tool that provides us with consistent information,” McQueeney said, adding that Baystate began tracking the effectiveness of telemonitoring in high-risk patients about 18 months ago and found their rates of rehospitalization are lower than the national average.
“If a patient calls at 8 p.m., we can have them slip on the blood-pressure cuff and the oxygen clip and get on the scale, which gives the nurse valuable information,” she noted.
In many cases, people have more than one chronic condition, which complicates matters, but a registered nurse has the ability to discern whether pain from a surgery or anxiety is likely the cause of shortness of breath, heart palpitations, or other complaints.
It takes a long time for most chronic diseases to become apparent, but there are points at which the disease progresses.
“Without monitoring, it can seem that the disease got worse overnight, but when a patient can chart their vital signs on a daily basis and know they are being watched by a registered nurse, trends can be identified that alert them to changes that require the doctor to become involved,” McQueeney told HCN. “Telemonitoring is a tool that helps keep people out of the hospital. It involves education and a collaboration with the patient, the registered visiting nurse, and their physician.”
As a result, the service can make a critical difference in a person’s life.
The American Health Care Assoc. reports that the majority of people with chronic heart disease or COPD are elderly, and being readmitted to a hospital increases the risk of complications and infections during their stay as well as the likelihood that their functioning will be decreased when they return home. In addition, every hospitalization exacts an emotional toll on the patient and increases the cost of Medicare, since people are living longer and the incidence of chronic diseases has increased dramatically over the last three decades.

Weighing In
Before nurses discharge patients from home-based services, Marceau said, they make sure they have absorbed what they need to know and have a blood-pressure cuff and scale so they can continue to weigh themselves daily. “We have purchased scales for people who are unable to afford them and teach people when to call their doctors,” she noted.
However, Porchlight has found some patients or their families opt to pay for the telemonitoring service even when the person no longer needs it because it gives them peace of mind.
“It’s great for family members who are concerned about a loved one,” Pouliot said, adding that the service costs about $100 per month, and people on fixed incomes can apply for reduced rates.
Kathleen Stezko agrees. “People get nervous and aren’t sure who to call or whether they should call anyone if they don’t feel well. But telemonitoring provides them with reassurance; they know someone is checking on them each day and will get in touch with them and their physician if it is necessary,” said Porchlight’s vice president of clinical services, adding that people using the equipment can call at any time of the day or night if they have concerns.
Indeed, the peace of mind and patient learning that results from telemonitoring is so important that most VNAs and home-care agencies that use it keep adding more equipment, which helps patients and also ultimately reduces the cost of healthcare.
Kobak can attest to the comfort it provides. “When my friends visit and see this,” she said, “they are so impressed.”