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Service Delivery Innovation Profile

Daily Nurse Review of Key Health Indicators Reduces Inpatient and Emergency Department Use for Patients on Dialysis


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Snapshot

Summary

Using home-based monitoring equipment, end-stage renal disease patients with or at risk of comorbid conditions such as diabetes and high blood pressure track health indicators each day. A nurse remotely monitors the indicators at least once a day and follows up with patients, caregivers, and physicians as needed to discuss incomplete or abnormal data, offer advice, and suggest needed followup care. Compared to similar patients not receiving home-based monitoring, the program has reduced hospitalizations, inpatient days, and emergency department visits and charges, and improved quality of life.

Evidence Rating (What is this?)

Moderate: The evidence consists of a nonrandomized study that compared key outcomes in participants and similar patients not receiving program services; metrics include inpatient admissions and days, emergency department visits and charges, and quality of life.
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Developing Organizations

Liberty Dialysis; Queen's Medical Center; University of Hawaii
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Date First Implemented

2008

Problem Addressed

End-stage renal disease (ESRD)—permanent kidney failure resulting in the need for dialysis or transplant1—is a common condition that frequently leads to the need for expensive inpatient and emergency department (ED) care. While tools such as home monitoring equipment can identify problems early and potentially avoid complications, very few ESRD patients have access to such support.
  • A common, complex, and costly condition: In 2007, more than 525,000 Americans had ESRD.2 Many of these patients have up to four comorbidities (e.g., diabetes, congestive heart failure, high blood pressure) at the onset of dialysis, and about 40 percent will develop a walking disability during dialysis treatment.3 Due largely to these comorbidities and related complications, ESRD patients frequently require inpatient care. In 2008, for example, the average patient on dialysis was hospitalized 1.9 times.4 Some patients end up being hospitalized repeatedly over short periods of time; in fact, 11.2 percent of discharged ESRD patients get readmitted within 7 days, 20.4 percent within 15 days, and 31.6 percent within 30 days.5 Not surprisingly, high use of inpatient care translates into large expenditures—in 2007, for example, Medicare expenditures for ESRD patients totaled $24 billion, representing 5.8 percent of the entire Medicare budget.6
  • Unrealized potential of home-based monitoring: Many ESRD-related admissions and readmissions are unrelated to dialysis treatment and can be prevented if the underlying problems are identified and addressed in a timely manner.3 Many dialysis patients, however, do not have access to home-based tools, such as monitoring equipment, that can identify potential complications early.3

What They Did

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Description of the Innovative Activity

Using home-based monitoring equipment, ESRD patients with or at risk of comorbid conditions such as diabetes and high blood pressure track health indicators each day. A nurse remotely monitors the indicators at least once a day and follows up with patients, caregivers, and physicians as needed to discuss incomplete or abnormal data, offer advice, or suggest needed followup services. Key program elements include the following:
  • Identifying those who can benefit from monitoring: University of Hawaii researchers use an internally-developed tool called an infirmity index to develop a risk score for ESRD patients based on their age, comorbidities (e.g., diabetes, congestive heart failure, high blood pressure), ability to perform activities of daily living, and nutritional state. The score is used to identify patients who can likely benefit from home monitoring due to their risk of complications and their ability to use the technology effectively. Researchers provide lists of eligible individuals to nephrologists, who then inquire during office visits if they would like to participate in the program; in addition, clinical managers at each of the dialysis units were introduced to the project and provided names of patients they believed would benefit from the program. A nurse (known as a "remote care nurse") contacts those who express an interest to describe the program and schedule a visit to the patient's home.
  • Individualized care plan: The nurse and physician jointly develop a care plan for each patient that includes specific measures to be monitored and the appropriate range of normal values for each measure.
  • Initial home visit: The remote care nurse and a trained technician travel to the patient’s home to set up and demonstrate the self-monitoring equipment.
    • Equipment components: The home monitoring unit includes a blood pressure monitor, scale, pulse oximeter, and glucometer, along with a video camera and headset to enable videoconferencing between patient and nurse. The unit is calibrated to indicate abnormal parameters as dictated by the care plan.
    • Patient/caregiver training: The nurse teaches the patient and/or caregiver how and when to use each component of the unit. The nurse emphasizes that she will be checking the patient’s values every day and will contact the patient in case of an abnormal value.
  • Daily tracking by patient: Each day, patients use the equipment to take their health measurements according to their customized care plan. (Analysis from a pilot study suggests that two-thirds of patients take their measurements at least 75 percent of the time.) Measurements include weight, blood pressure, oxygen saturation, and pulse rate. In addition, patients use the monitoring unit to answer 10 preprogrammed health questions about their health and functioning; sample questions include “Are you feeling sick today?”, “Are you having any new pain?”, and “Have you skipped any medications?”.
  • Ongoing nurse review: All data are automatically transmitted to a secure Web site. The nurse signs onto the Web site at least once each day to review all incoming data, with abnormal or absent values being highlighted in red.
  • Nurse and physician response to abnormal data: The nurse phones patients/caregivers when data are incomplete or outside the normal range. Based on that discussion, the nurse may suggest an intervention (such as a dietary change), advise the patient to contact his/her physician, or contact the physician directly (via telephone call or faxed report). As appropriate, the physician provides needed medication changes or other interventions. The need for followup varies greatly across patients; some patients require a call once or twice a week, while others may not need to be contacted for several months at a time.

Context of the Innovation

Located in Honolulu, the 500-bed Queen’s Medical Center is a private, nonprofit, acute facility affiliated with the University of Hawaii. The largest private hospital in the state, Queen’s has more than 3,000 employees and more than 1,200 physicians. Liberty Dialysis is a for-profit organization that owns and operates more than 100 dialysis clinics across the United States; its 15 clinics in Hawaii treat approximately 1,500 of the 2,600 patients on dialysis in the state. The impetus for this program came from Dr. Steven Berman, an infectious disease specialist at Queen’s who has worked with dialysis patients for many years. Dr. Berman began realizing that the vast majority of infectious illnesses in ESRD patients were not related to dialysis. As a result, he thought that tracking these frail patients on nondialysis days could help identify potential problems early, thus allowing clinicians to intervene and prevent avoidable complications. Liberty Dialysis nephrologists concurred and agreed to allow the university to test the model with their patients.

Did It Work?

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Results

Compared to similar patients not receiving home-based monitoring, the program has reduced hospitalizations, inpatient days, and ED visits and charges, and improved quality of life.4
  • Less inpatient use: Program participants had only one-third of the hospitalizations of similar patients who did not participate (1.8 versus 5.6 admissions over the course of 1,000 days). Similarly, participants had only a quarter the number of hospital days (8.2 versus 35.5 inpatient days per 1,000 days).
  • Fewer ED visits, lower ED charges: Program participants had less than one-sixth as many ED visits as nonparticipants (0.3 versus 1.9 ED visits per 1,000 days) and roughly one-third the ED charges ($114 versus $322 in ED charges per day).
  • Better quality of life and high satisfaction: Quality of life, as measured by the Short Form-36, decreased slightly for nonparticipants but remained constant for participants. Anecdotal reports indicate that patients appreciate having a nurse monitor their well-being on a daily basis.

Evidence Rating (What is this?)

Moderate: The evidence consists of a nonrandomized study that compared key outcomes in participants and similar patients not receiving program services; metrics include inpatient admissions and days, emergency department visits and charges, and quality of life.

How They Did It

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Planning and Development Process

Selected steps included the following:
  • Selecting cost-effective model: Dr. Berman discussed the idea of providing home-based support to dialysis patients with his colleagues at the University of Hawaii and Queens Medical Center. These conversations led to the realization that daily home visits by a nurse would be prohibitively expensive, and hence they decided to pursue a technology-based approach through remote monitoring.
  • Identifying and purchasing monitoring units: Through hospital contacts with the U.S. Army, Dr. Berman and colleagues identified a vendor and purchased monitoring units at a discounted rate.
  • Introducing program to dialysis center representatives: Dr. Berman discussed the idea with Liberty Dialysis administrators and nephrologists, who readily agreed to participate.
  • Hiring and training remote care nurse: Program developers advertised for and hired an experienced individual to serve as the remote care nurse. They provided her with basic training related to program goals and use of the remote unit. (She did not require additional clinical training.)

Resources Used and Skills Needed

  • Staffing: The program required the hiring of an experienced nurse to monitor patients on a daily basis; a full-time nurse can handle approximately 35 patients.
  • Costs: Upfront costs include purchase of the remote units (roughly $3,500 each). Ongoing expenses consist primarily of the salary and benefits for the nurse. Hawaiian Telecom provides free Internet service to the homes of participating patients.
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Funding Sources

U.S. Army; Queen's Medical Center; Hawaiian Telecom; Hawaii Medical Service Administration
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Adoption Considerations

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Getting Started with This Innovation

  • Select patients carefully: The best candidates for this program are those at high risk of declining health, including individuals with one or more chronic conditions (such as diabetes) that should be monitored daily. Participants should also be willing and able to use the technology.
  • Emphasize patient responsibility: To engage patients, the remote care nurse should emphasize the patient's responsibility for his/her own health, but also stress the important support that the nurse will provide on a daily basis.
  • Select reliable equipment: Choose equipment from a vendor with a track record of reliability.

Sustaining This Innovation

  • Monitor and share data on program impact: Objective evaluations that demonstrate the program's impact on patient outcomes and utilization can convince administrators to continue supporting the program.
  • Expect most meaningful impact to occur early: Patients will benefit most during the first few years of their participation in the program as they learn to manage their condition. 
  • Build trusting relationships: The program's success depends in large part on the ability of the nurse to develop and maintain trusting relationships with patients, as such relationships improve adherence to the daily measurement regimen and encourage patients to accept greater responsibility for their own health.
  • Update technology as needed: Technology improvements come out each year, and would-be adopters need to be prepared to update equipment and systems as necessary. For example, program developers expect that technological advancements will eventually enable patients to transmit self-monitored data via mobile phone.

More Information

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Contact the Innovator

Steven J. Berman, MD
John A. Burns School of Medicine
University of Hawaii at Manoa
1380 Lusitana Street #810
Honolulu, HI 96813-2444
Phone: (808) 524-0066
E-mail: sjberman@gmail.com

Dayna Minatodani, PhD, RN
University of Hawaii-Leeward Community College
University of Hawaii-West Oahu
2226 Liliha Street, Room B115
Honolulu, HI 96817
Phone: (808) 547-6208
E-mail: daynaminatodani@gmail.com

Innovator Disclosures

Dr. Berman and Dr. Minatodani have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Berman SJ, Wada C, Minatodani D, et al. Home-based preventative care in high-risk dialysis patients: a pilot study. Telemed J E Health. 2011 May;17(4):283-7. [PubMed]

Footnotes

1 American Kidney Fund. End-stage renal disease [Web site]. Available at: http://www.kidneyfund.org/kidney-health/kidney-failure/end-stage-renal-disease.html
2 National Institute of Diabetes and Digestive and Kidney Diseases. National Kidney & Urologic Diseases Information Clearinghouse. Kidney and urologic diseases statistics for the United States. Available at: http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/
3 Berman SJ, Wada C, Minatodani D, et al. Home-based preventative care in high-risk dialysis patients: a pilot study. Telemed J E Health. 2011 May;17(4):283-7. [PubMed]
4 United States Renal Data System. 2010 Atlas of CKD and ESRD. Volume 2, Chapter 6: Morbidity and Mortality. Available at: http://www.usrds.org/2010/pdf/V2_06.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
5 Mackiewicz R. Admitting to a readmit problem. The Hospitalist. October 2008. Available at: http://www.the-hospitalist.org/details/article/187645/Admitting_to_a__Readmit_Problem.html
6 2009 USRDS Annual Data Report. Costs of ESRD. Available at: http://www.usrds.org/2009/view/v2_11_econ.asp
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Original publication: February 01, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: February 12, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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