`
`The monthly guide to quality,
`cost-effective senior care
`
`
`{feasts1145;121:607“
`» OCTOBER199912-21;.
`
`
`WW
`
`High-tech alternatives
`help providers manage
`chronically ill seniors
`
`One of the biggest challenges facing health
`care providers is managing the more than 90 mil-
`lion Americans who live with chronic disease.
`
`Caring for such individuals -— the majority of
`whom are seniors -- is estimated to cost as much
`
`as $400 billion per year, more than half of the
`total health care tab. Yet, even with sizeable
`investments in sophisticated DM programs,
`many senior patients fall through the cracks.
`The problem is the continuous monitoring
`required for many chronically ill patients who
`remain at home. Home health visits, daily phone
`calls, effective patient education, and active fam-
`ily involvement are all needed in order to pick up
`sudden health declines or lapses in patient com-
`pliance before they deteriorate into larger prob-
`lems.
`
`To shore up —— and in some cases replace —-
`traditional modes of patient management, a
`flurry of computer-age tools have been devel-
`
`oped Specially designed pagers, electronic pill-
`boxes, and interactive television are among the
`new options available to providers to help keep
`tabs on chronically ill seniors. While many of
`these high--tech approaches come with a high
`price tag, there is evidence that some information
`technology improves efficiency and, in some
`cases, actually lowers management costs.
`
`Online service developed for seniors
`
`Rather than reinventing traditional DM pro-
`grams, one new tool seeks to revolutionize and
`therefore improve the communications compo—
`nent. By providing an online infrastructure
`through which providers can communicate daily
`with senior patients, Mountain View, CA-based
`l-lealth Hero Network (HI-IN) believes it can
`streamline the monitoring process required for
`optimal care of the chronically ill.
`While HHN’s approach can be used with
`patients of all ages, the company's founder and
`CEO, Steve Brown, developed the system with
`senior patients in mind. ”We learned that the last
`people computer companies, cable companies,
`and interactive TV companies were going to
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`serve were the seniors. So we decided it was
`
`worth it to turn everything on its head and focus
`on technology that works with seniors,” explains
`Brown.
`
`More than anything else, Brown believes
`seniors want a system that fits into their daily
`routine. ”They don’t want a bunch of compli—
`cated technology that gets in their way. They
`want something that is convenient, simple, and
`focused .
`.
`. where the technology is almost invisi-
`ble,” he notes.
`To fit the bill, HHN developed the Health
`'Buddy -- a simple appliance with a screen and
`four buttons that can be placed on a night stand,
`a kitchen counter top, or just about anywhere the
`patient finds convenient. Depending on the DM
`program involved, patients use the device to
`anSWer a series of questions daily. For example, a
`CHF patient might be asked the following ques-
`tions:
`
`0 How are you feeling today?
`0 Did you gain any weight?
`0 Did you take your medicine?
`0 Do you have any difficulty breathing?
`Using the four buttons on the device, the
`patient answers the questions. Depending on the
`answers, additional questions may be asked. The
`device also can be used to provide patient educa-
`tion in the form of dietary recommendations or
`other reminders, and it can offer feedback such as
`”good job.”
`Ideally, patients are instructed to answer the
`questions at the same time every day, most often
`in the morning or the evening. The information is
`then downloaded via the Internet to HHN’s web
`server so it can be accessed by an assigned nurse
`or care manager who reviews the data daily.
`”When the data comes back, it is automatically
`risk—stratified, so the nurse can see who is in the
`’red zone,’ the ‘yellow zone,’ and the ’green
`zone,” stresses Brown, explaining that these
`parameters are determined by the provider and
`the DM program being used. ”The medical direc-
`tor usually decides what the three zones mean.
`We provide the structure and basically the oper-
`ating system for someone to create that kind of
`program. ”
`
`Pilot targets noncompliant CHF patients
`
`One of the first groups to implement the
`HHN service was Santa Clara County Individual
`Practice Association (SCCIPA), a San lose-based
`medical group with more than 800 physicians,
`serving approximately 125,000 members enrolled
`in 12 HMOs. The group had been outsourcing
`disease management for CHF patients to another
`company. ”We identified the patients, and [the
`
`DM company] essentially did case management
`by calling patients and doing follow-up,”
`explains Lawrence Bonham, MD, president and
`CEO of SCCIPA. ”That program wasn’t a com—
`puterized system like HHN. The new approach
`actually brings everything back in-house, which
`was one of my goals.”
`Before implementing the HHN program,
`SCIPPA had to develop protocols and questions to
`be employed in the project. To accomplish that
`task, a medical director assigned to disease man—
`agement worked with nursing staff and cardiology
`consultants who are part of the SCIPPA network.
`Once the protocols were established, patients
`and physicians needed to be informed about the
`upcoming changes in procedure. During a series
`of meetings patients were informed about the
`HHN program and were given opportunities to
`see and use the Healthy Buddy device. ”It is not
`just something you would hand out in a box,"
`says Bonham. ”It needs careful explanation, and
`with any kind of new technology for seniors, they
`have to be convinced that there is a reason they
`should learn this and understand it. We are
`
`already targeting noncompliant people with the
`devices, and it is always risky to leave them on
`their own to manage a new device. A hands—on
`training program is always better. ”
`
`Alerts help managers respond, intervene
`
`Instrumental in the development of protocols
`for the CHF program, Julie Wahlig, RN, MA,
`quality improvement disease case manager for
`SCCIPA, now manages the program, which
`includes 50 patients involved in a six-month data
`test. ”I go in every morning and check the
`patients and see what lights correspond to their
`names, and then I follow up patient by patient,
`beginning with the red lights first,” explains
`Wahlig.
`SCIPPA set up its program so that a red light
`indicates a high-risk response. For example, if a
`patient indicated through the Health Buddy that
`he had gained four pounds overnight, that would
`show up on Wahlig's computer screen as a red
`light. If a patient gained two pounds in the last
`day, that would show up as a yellow warning
`light. A green light indicates a smaller risk, such
`as a one-pound weight gain. If there is no prob—
`lem With the patient’s responses Via the Health
`Buddy, then no light appears.
`Beginning with the highest-risk responders,
`Wahlig calls each patient to get details and gather
`data. She then prepares a message that explains
`her assessment and faxes it to the patient’s physi—
`cian. SCCIPA developed three categories of faxes
`that are not officially part of the HHN program,
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`

`but that have been devised to work with it: an
`FYI, or information-only fax, a possibly urgent
`fax, and an urgent fax. That way, the physician
`can tell whether the faxed message needs imme-
`diate attention.
`.
`Once the physician has reviewed the fax, he
`notes what action he wants Wahlig to take and
`returns the form to her. For example, he may pre-
`scribe a change in medication and ask that an
`appointment be made for the patient in the next
`couple of days. Wahlig then calls the patient and
`explains the new instructions. ”I am a link
`between the physician and the patient, and when
`I see that the physician responds to my original
`fax, I am satisfied, because I see the system work—
`ing,” she says. ”My goal is to prevent a crisis, and
`CHF is such a sensitive disease that someone
`
`could gain weight gradually, and if you don’t
`catch that trend, they can end up in the hospital
`within three or four days."
`
`Personal interaction still important
`
`Having worked in traditional disease man-
`agement programs, Wahlig was concerned that
`the personal approach to care she preferred
`would be compromised with the HHN system.
`”My model has always been hands—on, she says.
`”I like to meet with the person. In the program I
`was doing previously, people came in for
`appointments every three months. I didn’t know
`how receptive seniors would be to the
`phone /computer interaction, because I know
`seniors like to communicate in person.”
`However, Wahlig found that she still could make
`a personal connection during the initial informa-
`tional sessions. She also connects with patients
`during regular CHF classes.
`”Consequently, the phone and the computer
`have not been a real barrier to developing a
`nurse-patient relationship,” stresses Wahlig. ”In
`fact, with our daily conversations, I feel like I am
`getting to know these people intimately. ”
`Wahlig also was concerned that seniors might
`be intimidated by the technical nature of the pro-
`gram. ”Even getting a phone answering machine
`can be intimidating to some people, but the Health
`Buddy is so simple to hook up .
`.
`. that I only had
`to visit two people in person because they could-
`n't operate it,” says Wahlig, adding that a handful
`of seniors elected not to participate by simply fail-
`ing to hook up the Health Buddy appliance.
`With the HHN system, what is lost in face-to—
`face contact may be more than made up for in
`regular contact. ”The seniors have interaction,
`and they see that someone cares about them.
`Also, I have noticed that the approach makes
`them more accountable. The Health Buddy asks
`
`them to check their weight and check their blood
`pressure, so I have lots of positive feedback,”
`notes Wahlig. ”Seniors like to know they are not
`alone. They like to know that someone is watch—
`ing over them, but we make it real clear not to
`use the Health Buddy as a 911.”
`
`Positive survey results
`
`About three months into the pilot program, a
`patient satisfaction survey produced positive
`results, indicating that patients better understood
`how to manage their disease, and they felt more
`confident about their ability to care for them-
`selves as a result of the HHN program. (See
`Figure 1 on page 158.)
`Another plus with the HHN program is it
`that can dramatically improve efficiency over tra—
`ditional DM programs. Only the people in need
`of contact are highlighted, and much of the infor-
`mation needed is gathered electronically before
`the nurse manager ever picks up the phone.
`How well the system works in terms of out-
`comes is still being analyzed. However, Wahlig
`points to several incidents where hospitalizations
`were prevented. In one case, a woman who had
`endured frequent hospitalizations reported
`severe shortness of breath over a three- to four~
`
`day period. Wahlig notified the physician by fax,
`and he prescribed a new medicine. The next day
`the woman felt much better, and she hasn’t been
`hospitalized since.
`In another case, a woman who reported high
`blood pressure received immediate treatment as a
`result of the HHN approach. ”She now says that
`she has never felt better, and I attribute that to
`the physician seeing a day-to-day trend in her
`blood pressure. Usually physicians only see
`blood pressure when the patient comes in to visit,
`which is once every few weeks or few months, so
`I think being able to see the trend on a day—to-day
`basis was important,” says Wahlig.
`
`New patients being recruited
`
`While SCCIPA’s initial pilot project is near-
`ing completion, the HHN/CHF program is
`already being expanded to include many more
`patients. The patients at highest risk -- the phase
`3 and phase 4 CHF patients ~- are the key targets
`for the program, particularly patients who are
`not compliant. ”We search our database for infor-
`mation relative to multiple hospital admissions
`or multiple ER visits,” explains Bonham. "We
`also get information from PCPs and cardiologists,
`and we ask them to identify high—risk, noncom—
`plaint patients. We don’t want to enroll someone
`who has never been to the ER, who is very com—
`
`October 1999
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`Senior Care Management
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`3
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`

`

`anyone in the group requiring home health. That
`program was pretty much in place, so it seemed
`like a logical testing site [for the Health Buddy.]”
`To implement the study, researchers first
`needed to develop the questions and protocols
`that the Health Buddy would use, based on the
`care management program already in place. The
`system focuses on 10 of the most common symp—
`toms these patients typically experience in the
`weeks following surgery, including shortness of
`
`Figure 1: Patient Satisfaction Survey Results
`
`Do you believe you have a better understanding of
`heart failure and how to manage your condition
`based on this program?
`93% Much or Somewhat Better
`Understanding
`/”\
`
`
`
`
`
`
`
`
`
`
`Somewhat
`
`No
`
`Not sure
`
`
`Responses
`
`
`I Satisfaction Survey, Month 3, Day 1(n=4_11l
`
`Do you feel more confident in taking care of
`your condition as a result of this program?
`88% Much or Somewhat
`More Confident
`
`
`
`
`
`
`
`
`
`
`PercentageofRespondents
`
`PercentageofRespondents
`
`
`
`pliant, and who always takes his medications. We
`want to capture patients who don’t manage
`things very well, or at least have had some prob-
`lems managing themselves and would be helped
`by an educational intervention.”
`,
`There are significant costs aSSociated with
`implementing an HHN/DM program, including
`the cost of the nurse manager, regular online fees,
`protocol development costs, and the cost of a
`consulting cardiologist to help manage patients
`during emergencies and other urgent
`situations. However, Bonham stresses
`that it is still less expensive than out—
`sourcing DM. "It is enormously more
`beneficial to have the flexibility to
`have a real-time View of what is hap—
`pening and real—time assessment of
`patients' responses rather than wait-
`ing for a report and having to ask
`somebody else to modify the pro-
`gram.”
`
`Study looks at effectiveness
`
`While it is clear that an online
`
`approach, such as HHN’s service,
`offers an efficient alternative to more
`
`traditional modes of monitoring, clin-
`icians are eager for scientific proof
`that such an approach can be as effec—
`tive or more effective than typical DM
`programs that rely solely on tele-
`phone and in—person contact.
`That is one issue being looked at
`by researchers at the University of
`Nebraska Medical Center in Lincoln,
`NE. They are evaluating how patients
`using the Health Buddy compare
`with patients who are being moni-
`tored in more traditional ways.
`For the study, researchers are
`working with a population of seniors
`who have undergone coronary
`bypass surgery. ”It has become appar-
`ent over the years that these patients
`are going home earlier and earlier,
`and basically sicker, from the hospi—
`tal,” explains Lani Zimmerman, PhD,
`RN, the principal investigator on the
`study and an associate professor at
`the University of Nebraska Medical
`School._ ”We were studying symptom
`management in these patients, look-
`ing for complications on follow-up
`telephone calls at two weeks, four
`weeks, six weeks, three months, and
`six months post discharge. We had set
`up a care management program for
`
`Yes, somewhat
`Yes, much
`more confident more confident
`
`No
`
`Responses
`I Satisfaction Survey. Month 3. Day 1 (n=41
`
`Source: Santa Clara County Individual Practice Association, San Jose, CA.
`
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`HHN primarily is being used to monitor
`chronic diseases. However, Brown notes that two
`groups are using the service in a more general
`way to monitor frail elderly individuals. Also,
`while most users of the service are currently large
`provider groups, Brown suggests that the service
`is a viable option for smaller providers as well.
`”Since this is an Internet—based program, anyone
`on the provider side should be able to go to the
`Internet and get access to it, and get a Health
`Buddy to someone who needs it,” says Brown.
`”Ultimately, we would like for family members to
`be able to monitor and essentially case-manage
`elderly parents as well.”
`Editor’s Note: For more information on the
`Health Hero Network, access the company’s website at
`www.healthhero.com. 2g
`
`breath, incision pain, fatigue, sleep disruption,
`angina, swelling in the legs, rapid heart rate,
`appetite problems, anxiety, and depression.
`
`Answers prompt more questions
`
`Blocks of questions were built around those
`symptoms and then programmed into the Health
`Buddy at appropriate intervals. For example,
`if a patient indicated that he was experiencing
`shortness of breath, the Health Buddy would
`then present another series of questions probing
`how frequent and how severe the problem
`was. There might be some health tips pro—
`grammed into the sequence. For example, The
`Health Buddy might remind the patient to take
`frequent rest periods or to watch the sodium in
`his diet.
`
`With the first group of patients using the
`Health Buddy, researchers mainly worked to
`refine and improve the questions and informa-
`tion provided by the appliance. Clinicians were
`trained by HHN to handle the programming
`aspect of the service so that it could be done in—
`house; however, Zimmerman emphasizes that the
`”scripting” phase was a huge task. ”It is very
`labor-intensive to write these algorithms, because
`you have to think ahead,” she says. ”If the
`patient replies 'yes’ to a question, then you
`have to establish What the next logical questions
`are, so it is an algorithm of drop~down ques—
`tions.”
`
`With revisions in the program completed,
`researchers are now enrolling patients for the for—
`mal study. Patients in the control group will be
`asked the same questions at the same intervals as
`patients using the Health Buddy, but the control
`group will be contacted by phone at the standard
`2-, 4—, and 6—week intervals, plus at three months
`and six months. The patients using Health Buddy
`will have daily reinforcement of the information
`from the appliance.
`
`Expansion planned
`
`Data from the study will not be available for
`some time. However, Zimmerman notes that
`patients have been receptive to the appliance,
`and researchers already are developing programs
`where the appliance will be used to monitor
`patients with other chronic diseases, such as dia—
`betes.
`
`”The majority of physicians have been
`impressed with the system, and the home health
`people have responded favorably as well,” notes
`Zimmerman. ”They absolutely want the data. It
`has major implications for them on resource allo-
`cation."
`
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