Feasibility and acute care utilization outcomes of a postacute transitional telemonitoring g program for underserved COPD patients Cecile Davis MSN RN Jason Broad MBA, Miriam Bender PhD RN , Tyler Smith PhD Intervention Population/Setting • Sharp Grossmont Hospital • • • • 540 beds in East San Diego county Largest COPD population in SD county Part of Sharp HealthCare integrated health system R l Real-world ld setting tti • Population criteria • Adult patients admitted to Sharp Grossmont Hospital with primary diagnosis of COPD • Underserved status defined by Payor • Unfunded, Medi-Cal, County Medical Services, unassigned Medicare • Patient discharged to home, board and care, or assisted living • Needed to be able administer their own medications Measures • Primary outcomes were 30, 90 and 180-day acute care utilization – Data D t obtained bt i d via i Sh Sharp H HealthCare lthC d data t warehouse h • ED use, readmission rate • Any Sharp HealthCare hospital • Health status at enrollment and discharge using the Clinical COPD Questionnaire (CCQ) – Validity and reliably have been determined to be acceptable for COPD population • Program satisfaction with Centura Telehealth patient satisfaction tool – Identifies older adults’ perceptions and beliefs about health technology – addresses key issues such as privacy concerns, time of use, involvement in one's healthcare, and quality of care Program Details: Home Visits • Baseline home visit by program coordinator – – – – – Self maintenance education Telemonitoring setup and training Patient received pillbox and medication reconciliation Baseline CCQ administered Establish medical home for patients: follow follow-up up visit planned and method of transportation secured • 90 90-day day program – Evidence: 90 day time period for new behavior learning to become routine • Second and final home visit by program coordinator – – – – Collection of telemonitoring equipment Final CCQ administration Satisfaction tool administration Final self maintenance education Program details: Telemonitoring Equipment • • Wireless machine (built in Wi-Fi hotspot) Biometrics captured daily – – – – • Patient a e ca can call ca program p og a manager a age o or nursing u s g se service ce p provided o ded with telemonitoring equipment at any time – • Pulse Oximetry and Heart Rate Weight if patient had CHF comorbidity Daily report of symptom management: preset yes/no question Education vignette that rotated every week We chose to use nursing service for the pilot Triggers for clinician intervention – – Daily report showed 20% increase in symptoms Automatic telemonitoring trigger • – – Severe SOB, fever, chest pain, confusion Patient call-in with problem Non use for 3 days Results: Sample p Size Hospitalized patients not identified for mHealth Program Eligible participants identified via program manager (n=80) Declined to participate (n=11) Control Group (n=550) Control group Matched by: Hospital Admission type (IPE, IPR, OPI) Discharge date range COPD ICD-9 codes (first 3) Discharge disposition to home Payor (underserved) Enrolled into mHealth Program (n=69) Intent to treat analysis Program follow-up information Completed 90-day program Lost to follow-up Death before program end Dis-enrolled patient request Dis-enrolled (unable to meet requirements) Propensity Matching on 15 indicators Final Control group: N=130 Final mHealth group n=65 n=58 n=2 n=2 n=5 n=2 Patient Satisfaction Outcomes Question Mean score (n=57) SD 4 99 4.99 .11 11 4.99 .11 The training and support team from Sharp HealthCare helped me understand how to operate the equipment. The Commander Flex was easy to use. Since using the Commander Flex monitoring, I am more motivated to monitor my health. The Commander Flex equipment helped me improve my health. 4 56 4.56 .83 83 4.40 .89 I was uncomfortable usingg the Commander Flex technology. gy 1.05 .27 The Commander Flex took too much time to use. 1.12 .46 I worried about my privacy with Commander Flex technology. The h Commander d Flex l Technology h l h helped l d me b become more involved l d with h my health care. The care I received with Commander Flex technology was just as good as having a nurse come to my house. I would recommend this telehealth program to others. 1.05 .28 4.36 .99 4.36 1.04 4.86 .45 (1) No definitely not. (2) I don't think so. (3) Maybe yes, Maybe no. (4) Yes, I think so. (5) Yes, definitely. Health Status Outcomes Clinical COPD Questionnaire score Mean Std. Dev. Min Max Pre-CCQ total score Post-CCQ total score TOTAL SCORE DIFFERENCE 3.82 1.90 1.93 0.947 0.991 1.03 1.6 0.1 5.7 4.2 Pre functional status Post functional status FUNCTIONAL STATUS SCORE DIFFERENCE 3.37 1.94 1.43 1.37 1.04 1.30 1 0 6 4 Pre Mental Health Post Mental Health MENTAL HEALTH SCORE DIFFERENCE 3.87 1.79 2.08 1.74 1.80 2.06 0 0 6 6 Clinically meaningful change in status is difference of .4 or greater Acute care utilization outcomes Control Tele-monitoring (n=135) n % (n=65) n % Percent reduction (%) p 30-day ED utilization 11 8.5 5 7.7 9 .45 60-day ED utilization 31 23.9 14 21.5 10 .63 90-day ED utilization 40 30.8 20 30.8 0 .82 30-day all-cause readmission 20 15.4 6 9.2 40 .61 90-day all-cause readmission 40 30.8 19 29.3 5 .88 180-day all-cause readmission 56 43.1 24 36.9 14 .43 Implications • Telemonitoring may be a promising tool for providing services that bridge the gap between supply and demand to improve the health of underserved COPD patients • Our feasibility study suggests telemonitoring in the context of a post-acute post acute transitional care model may reduce nearnear term admissions by 40% through promotion of selfmanagement in underserved COPD patients • More rigorous and long-term investigation is warranted – What is an optimal timeframe for transitional program? – Outcomes and cost analysis