Care Navigation Services’ Mobile Health Study Demonstrates Improved Health Status of High-Risk Patients
Patients discharged from a skilled nursing facility remain a very vulnerable population. Even with the assistance of home health services, these patients often experience a decline in health status during their first two-weeks at home and return to the acute setting. Since data demonstrates that most of these readmissions are avoidable, innovative strategies to decrease these unnecessary, yet costly interventions, should be a priority amongst post-acute providers.
Care Navigation Services, in collaboration with AT&T, is conducting a study to identify if innovative post-acute coaching techniques not only reduce the readmission rate amongst skilled nursing patients discharged to home, but also improves their health status. Utilizing AT&T’s remote patient monitoring solution, skilled nursing patients identified as high-risk for an acute readmission are discharged to home with a fully-managed home-based “kit” that includes a wireless tablet and paired biometric devices. Patients are asked health survey questions customized to their health condition (and co-morbidities, if necessary) and utilize the devices to measure blood pressure, heart rate, oxygen saturation and weight. Should any of the patient’s responses indicate a negative change in health status, Care Navigation Services’ Telehealth RN receives an alert via a portal and initiates a phone call to the patient and provides unique coaching techniques focused on engaging the patient in their own health improvement and recovery process.
To-date, the results demonstrate that Care Navigations Services’ efforts have a very positive impact on patients’ health status. When comparing patients’ Daily Health Scores (a daily score assigned to patients utilizing the remote patient monitoring solution that measures the number of alerts triggered by their health survey responses and biometric readings) during their first 10 days of the study to their last or most recent 10 days of the study, patients experienced a 13% improvement in health status. Some patients had improvements of 25% or more! The combination of remote monitoring technology affording the platform to provide near-time alerts and Care Navigation Services’ Telehealth RN providing needed coaching and education has greatly impacted these high-risk patients who are now well-equipped to successfully manage their health long-term.