Remote Care Management: Self-Monitoring Enhances Care Transitions

Thursday, May 14th, 2015
This post was written by Patricia Donovan

Encouraged by reductions in hospital readmissions and almost universal patient satisfaction from its small remote patient monitoring pilot, CHRISTUS Health scaled up the initiative to more 170 participants. Luke Webster, MD, vice president and chief medical information officer for CHRISTUS Health, and Shannon Clifton, CHRISTUS director of connected care, describe the patient’s responsibility in remote monitoring.

During the daily monitoring portion, the patient will do the daily self-care tasks. That includes their biometric readings, and answering questions related to their care plan, such as, how did they feel that day? Did they sleep well? Are they able to ambulate and get through their day normally or in good health? As long as they stay within those normal parameters, they will continue on with the daily monitoring and self-help management as they go.

Most patients monitor themselves in the morning, within 30 minutes of waking up. Some are directed to monitor themselves throughout the day depending on their risk: whether they’re low, medium, or moderate to high risk. That’s determined ahead of time by the nurse coach and/or the physician.

If for some reason there is an alert—such as a two- to three-pound weight gain, the patient’s not feeling well, or ran out of their prescription—any of those cues will alert the nurse that something has fallen outside that patient’s wellness parameters and their care plan. The nurse coach, at that time, will review all of the data; then the patient is called and the nurse coach will coach the patient back to their care plan.

We’ve had great success with that process; having all of that data has made the care transitions program more efficient, especially because the nurse coach has access to that day-to-day information; whereas before, our care transition program consisted of the nurse calling up to five times within 30 days.

Source: Remote Patient Monitoring for Chronic Condition Management: Leveraging Technology in a Value-Based System

remote monitoring

Remote Patient Monitoring for Chronic Condition Management: Leveraging Technology in a Value-Based System chronicles the evolution of a remote patient monitoring pilot by CHRISTUS Health. This 25-page report reviews the multi-state and international integrated delivery network’s impressive early returns in cost of care, 30-day readmission rates and patient satisfaction from remote patient monitoring, as well as the challenges of program expansion.

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