At Home With Nursing Informatics

A man who has experienced heart failure wakes up one morning and weighs himself.

Within 10 minutes he receives a phone call on his cell phone, because his home phone line is temperamental. He answers a set of questions assessing his weight and well-being for the day and is off the phone, back to his morning routine within 5 minutes.

A short time later, a case manager checks her EHR and notices a trigger has been set off on her screen. The patient she is in charge of is heavier than usual, according to data readily available to her via Bluetooth wireless technology inside his scale. She calls him to check up.

This is a familiar scenario at Geisinger Health, Danville, PA, thanks to new technologies adapted to help better monitor their patients and reduce the risk of re-hospitalizations.

Partnering with AMC Health, Geisinger Health Plan uses an interactive voice response system (IVR) and other remote patient monitoring technologies partnered with an increased case manager participation in monitoring patients transitioning from hospitals in the Geisinger Health System in eastern and central Pennsylvania to their homes.


Geriatric Telemedicine

Nurses capitalize on technology to help older patients obtain a new level of independence.

The system has accounted for a 44 percent reduction in 30-day readmissions compared to a control group.


“We knew we needed to do something different to touch the population,” said Joann Sciandra, BSN, RN, CCM, director of case management and strategic planning at Geisinger.

“We really felt that an increase in touches would increase patient-nurse interaction and could impact our outcomes. So the more we could touch a patient the better that should be in the long run.”

Improving Quality of Care

In 2006, Geisinger started an internal program with medical management associates making follow-up calls to patients post-discharge.

As the volume of patients increased and Geisinger decided to begin a heart failure program, the expansion became too much to manually complete.

In 2008, the company partnered with AMC Health to integrate technology systems and Bluetooth technology to better monitor patients. Three different programs, including post-discharge, heart failure and hypertension, use the software to monitor the status of patients. More programs are under development.

The technology was designed to be simple and reduce patient fatigue, but also to be helpful, not a burden, to the case managers. All the questions require yes or no answers that patients can verbally respond to or use their keypad for.

The questions were designed using a branching logic as to prevent false alerts, or triggers, that will highlight the patients name in red for the nurses to easily identify. The aim of the technology, in part, was to create frequent contact with the patients while also giving RN case managers time to complete other duties.

“It’s helped me manage patients,” said Pam Berns, RN, a Geisinger case manager. “Being able to manage them outside of the hospital has been beneficial.”

First Call

Before a patient is released from the hospital, the case management team and create a discharge plan. But the most important part of the system is the first call, which occurs between 24 and 48 hours post-discharge.

Post-discharge check-ups consist of one IVR phone call a week for 4 weeks. The focus of the first call is to explain the post-discharge process and what will be happening in the next month. This is done to help the patient understand the purpose of the calls.

Questions asked include the following:

  • Have your pre-hospitalization medications been reordered?
  • What do the discharge meds look like?
  • Were your meds filled by the pharmacy, and can you afford them?

The rest of the call is focused on the discharge itself and if the patient will be seeing her primary care doctor within 5 days of release.

If home health is involved, the case manager will make sure everything is in place. All these procedures are ways to “tuck in” the patient with the first calls said Sciandra.

Later, calls include questions checking for shortness of breath; or, if surgery was involved, wound care and medications. After completing 4 weeks, the case manager may still feel the need to follow up on the patient and the services are still available.

The last question always asked in the IVR is if the patient would like to be contacted by their nurse.

Case managers check their EHR and portal where trigger details can be found frequently throughout the day, but some patients have learned to trigger that question for regular phone calls from their nurses.

If patients find the system difficult, they can directly speak with their case manager to create a different plan.

Overall, case managers have found this system helpful.

Flexible Technology

The heart failure program includes the Bluetooth-enabled scales placed in the patients’ homes to track their weight and record it into a web portal. Case managers have the ability to create graphs tracking weight changes that can be shared with primary care physicians. Geisinger has about 800 members using the scales.

With the improved quality of life for patients with heart failure, Geisinger hopes the reduction rates will lead to a reduction in not only readmissions but costs, which is good for all parties involved.

IVR technology is also helping patients with hypertension via Bluetooth-enabled blood pressure cuffs that track their progress. The goal is to prevent kidney disease related to hypertension.

Two new programs are in the works for Geisinger. First is a glucose monitoring machine for patients with diabetes, along with using the blood pressure cuffs and video monitoring. The idea behind the monitoring is to help the case managers see the patients and help patients who have transportation issues still receive the attention they need.


Consumer Driven Healthcare

Patient engagement is critical to meeting quality initiatives.

Meanwhile, Geisinger is looking to build questions around patients suffering with COPD. The goal is to help this population identify if patients who are exasperating sooner.

The flexibility of the Bluetooth systems used allows patients who travel to warmer climates in the winter to easily take their scales with them and continue with the IVR calls.

However, not every person is the right candidate to receive IVR calls. A full general case management assessment is done to check for hearing or memory problems.

Case managers ultimately decide which patients would be best for the system “because you know that patient, you know the family situations because you’re the one talking to them for the first time,” Berns explained.

The technology has had “growing pains” said Sciandra, but case managers recognize the enormous advantage the system provides in keeping patients at home.

“If we are able to respond to early indicators that these patients are in trouble, and get a plan in place and address it early,” she said, “we’re going to improve their quality of life.”

Elizabeth Adams

is an editorial intern at ADVANCE.

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