Care Navigation Services – CASE STUDY: Mobile Health & Telehealth RN Coaching

Patient Background: Seventy-eight-year-old, Female Patient admitted to Skilled Nursing Facility (SNF) following Trauma – Total Hip Replacement Surgery. Identified as high-risk for an acute readmission once discharged to home due to having four chronic conditions, lives alone, and takes 5+ medications. Patient non-compliant with medication plan (diuretic) while in SNF and complains of shortness of breath and swelling.

Intervention: Patient identified as ideal candidate for at-home mobile health and RN coaching intervention pilot. Provided with AT&T’s remote patient monitoring solution in which patient would be asked to respond to customized health survey questions and take daily biometrics over a 60-day period. Care Navigation Services’ Telehealth RN would be alerted to responses that indicated a decline in health status and implement innovative coaching techniques to educate patient on long-term self-health management. During the first 10 days of participating in the Pilot, patient responses triggered 16 high alerts to the Care Navigation Services RN. In addition, the patient’s Daily Health Score dropped to a low of 42 (based on a 1-100 scale, where 100 represents ideal health status).

Outcome: 

Patient responded very well to program. Specifically, over the 60-day intervention pilot:

• Patient experienced 23% improvement in health status
• Patient lost 27.8 pounds
• Patient learned the importance of medication adherence and how not taking diuretic caused excess fluid retention, swelling and weight gain
• On Day 60, patient’s Daily Health Score climbed to 92
• Patient understood the importance of limiting daily liquid intake and the correlation her addiction to cranberry juice has with her shortness of breath

Patient Testimonial:

“I now understand how to manage my health…I used to fear that something was really wrong and would go to the ER. I no longer have that fear because I now understand my disease process and signs and symptoms that it is worsening.”

Overall Pilot Results

• 0% readmission rate
• 13% improvement in health status
• 96% mobile health program compliance rate
• 100% mobile health program satisfaction rate