Leaving the hospital is good news, yet it can be difficult for patients to manage their own care at home. The task may be especially challenging for elderly patients who have complex medical issues.

University of California Irvine Health (UCI) recently piloted a program to improve transitions of care for older patients. UCI’s focus on care coordination with remote home monitoring helped improve outcomes for participants.

UCI shared its story at our recent annual user group event, Population Health University. “We wanted to make sure patients were getting the care that they needed,” said UCI’s Senior Project Manager of Health Reform Joan Hoppe, RD, CDE.

Addressing needs of a growing elderly population

UCI serves the people of Orange County, California, where the population is aging. In 2010, there were 360,000 seniors, and that number will double by 2030. One in four patients will have at least one chronic disease. Many communities around the world are facing the same clinical challenges.

UCI piloted a remote home monitoring initiative in response to California’s Delivery System Reform Incentive Payments (DSRIP) program. The goal was to reduce readmissions and emergency department (ED) visits by enabling patients to use iPads to communicate regularly with UCI caregivers.

UCI began planning the project in January 2012, and launched the six-month pilot study one year later.

One of the most critical steps: determining eligibility

A UCI team of clinicians and information technologists set patient eligibility criteria, including:

Need:  Did the patient have more than one inpatient visit in the past 12 months or more than one ED visit in the past 6 months? If so, this patient is at a higher risk for readmission.

Language: Will the patient be able to communicate with pilot program clinicians? The first group would need to speak either English or Filipino, the languages spoken by clinical staff involved with the pilot.

Capability: Is the patient able to learn and use iPad videoconferencing? Some are more tech savvy than others.

Connectivity: Does the patient have a strong enough wireless 4G signal at home?

Clinicians identified potential candidates for the program upon discharge from the hospital. Sunrise by AllscriptsTM  generated a list for UCI’s Senior Health Center (SHC).

How the program worked

Using the established criteria, UCI built an assessment in Allscripts Care DirectorTM. Patients who answered “yes” to the questions above were considered eligible. A simple, graphic user interface in Care Director enabled clinicians to track patients as the pilot moved forward.

Once they obtained patient consent, SHC clinicians provided an iPad and instructions. They held their first iPad sessions within 48 hours of enrollment, to engage patients as quickly as possible.

During an iPad session, patients and clinicians can discuss medical issues, perform assessments, and schedule follow-up sessions or appointments. Clinicians documented session details in Sunrise as an ambulatory clinical note or phone note. The monitoring period lasted about 30 days, depending on patient need.

Pilot program resulted in positive outcomes

Eighteen UCI patients received home monitoring services via iPad. Of those patients, only one had an inpatient visit during the monitoring period—and that episode could not have been prevented by remote monitoring. Clinicians reported the benefits far exceeded their expectations, as they were able to address medical questions and concerns in real time.

Hoppe reports that patient feedback regarding remote home monitoring was positive, offering comments such as:

– “I have peace of mind knowing that someone will call.”

– “Great program I wish we can be on iPad monitoring longer.”

– “Great for my dad, he likes talking with you on the iPad.”

“Patients like knowing they’re not alone, that somebody is going to call them, that their providers are accessible,” Hoppe said. “If they have a problem, they know that somebody cares and they’re going to get their problem solved.”

UCI is currently assessing the success of the pilot and investigating opportunities to expand and make the program more broadly available in the future. Have you tried population health management programs like this one? If so, please share your experience in the comments below.

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About the author

Arian Bichsel is a director of solutions management focused on care coordination products, including Allscripts Care ManagementTM, Allscripts Referral ManagementTM and Allscripts Care DirectorTM. In this role, she works cross-functionally with the Sales, Solutions Development, Support and Services organizations to develop an integrated strategy and roadmaps for these solutions. Since joining Allscripts in 2006, Arian has held increasingly responsible positions in solutions development, client support and professional services. Prior to joining Allscripts, Arian was with ECIN (Extended Care Information Network) where she provided project management, education and sales support. Arian holds a Bachelor of Science degree in Marketing from the University of Illinois at Chicago.


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