Care Pathways, Telemonitoring Foster Self-Management

Thursday, July 30th, 2009
This post was written by Melanie Matthews

As part of its successful medical home pilot, Geisinger Health Plan (GHP) has crafted patient education tools that support nurse case managers in their care coordination efforts, whether conveyed to the patient telephonically or face to face, explains Janet Tomcavage, R.N., M.S.N., GHP’s vice president of health services.

“For example, there’s no better way to teach foot care to diabetics than to have them take off their shoes and socks when they come into the office and show them the parts of the feet that they need to look at. Then, get a bottle of lotion and teach them where the feet tend to get dry and how to protect their feet. Teach them how to look at the inside of their shoe and the types of socks that leave ridges in their toes and cause areas of friction that can then cause open areas or pressure sores.”

Geisinger reinforces these patient education efforts with telemonitoring, such as in the case of heart failure patients whose homes are equipped with Bluetooth® scales. “We teach them to step on that scale. They get up and go to the bathroom in the morning and before they do anything else, they step on that scale.”

That scale automatically transmits their weight to a Web portal that monitors daily weight. “If we notice a two- to three-pound weight gain overnight or a five-pound weight gain over five to seven days, the nurse is then alerted so she can reach out to that patient,” Tomcavage explains.

Similarly, diabetic patients are taught to check their blood sugars at home and look for patterns identifying the extremes of when they should be calling in to the clinic. “Symptom monitoring is very critical in chronic disease. For example, asthma patients learn how to do peak flows and know their normal peak flow. “If their peak flow is dropping, which usually means they’re getting a little more restrictive in their breathing, they have an action plan to respond.”

Tomcavage said that even though the medical home pilot population is largely rural, with few patients having Internet access, GHP is starting to see more seniors surfing the Internet or using EHRs. Also, she notes, family members of the Medicare patients love the patient portals.

“We have many nurses who communicate with the patient’s families, who are often the caregivers, who work during the day. The portal is an easy way for them to communicate with us.”

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