Telehealth is enabling improved patient care transitions, care coordination, and chronic disease management to take place in many communities. This can take place when a patient leaves the hospital to go home or to a skilled nursing facility and sometimes even back to the hospital. Poorly managed transitions can affect the patient’s health and at the same time increase costs that can result in billions of dollars in wasteful spending.
Three companies Broad Axe Care, Riverside Health System, and iTelehealth Inc. took part in a session stressing effective care transition and coordination utilizing technology at the Mid-Atlantic Telehealth Resource Center (MATRC) Summit 2014 held March 30 to April 1 in Fredericksburg, Virginia.
Lindsey Koshansky MSN, RN, Coordinator for the Broad Axe Care C3 program at www.broadaxec3.com reports that the C3 program has three components such as Care Transition, Care Coordination, and Analytics & Reporting. The C3 program is successfully working with the University of Virginia’s Medical Center and handles 1000 patients a year.
According to Koshansky, “The Care Transition component can be challenging and so we need to have a friendly conversation with the patient to enable the patient to completely understand the changes that are going to take place. At this point, the patient needs to trust the coordinator and take ownership of the situation while the Care Transition team needs to establish the home setup.
The Care Coordination component includes setting up any remote monitoring equipment needed and then coordinating the patient’s care with the primary care physician. Lastly, the third component provides for analytics and reporting to develop information on outcomes and how to improve the process.
Vickie O. Morgan, RN, Clinical Director of Operations for the Home Care Division within the Riverside Health System at www.riversideonline.com works mainly with older adult patients unable to access regular medical care. Physicians and nurse practitioners trained in primary care are working together to develop and design a plan for the care. They are determining if telemonitoring can be used effectively so that a smooth transition from the hospital to the home can be achieved.
“Technology used such as a watch device or a tablet can acquire health data by the minute”, notes Loretta Schlachta-Fairchild, PhD, RN, retired U.S Army and now President and CEO of iTelehealth Inc. at www.itelehealthinc.com.
She added, “Both the watch worn 24/7 and the tablet can analyze health trends, monitor locations, and provide physiological status in real-time indoors or outside. An emergency call button is provided so that if there is a problem, than the patient, family, or medical provider is alerted. In addition, iTelehealth is partnering with AFrame Digital to help veterans monitor their PTSD episodes.”
Schlachta-Fairchild pointed out that the next generation telehealth technology driven care will not only continually collect data, but also provide real-time analysis. Devices will be able to tailor medications and determine what is normal for the patient’s body, determine population health risks by disease, and monitor new products and services to help with specific medical conditions.