Objective

To use ambulatory monitoring devices so that:

1. providers can more closely monitor at-risk, high-utilizing (or all) patients
2. patients have greater, more timely access to health care and advice
3. high risk patients can avoid worse outcomes

Background

We often ask patient with heart failure (daily weights) and diabetes (blood glucose) to collect frequent clinical data that providers only analyze every few months. This results in many missed opportunities to intervene on patients who have poor control of their illnesses. 

As the healthcare system evolves, the office visit becomes highly valued real estate. Interactions with healthcare providers need to be high yield and care that can be provided by other members of the healthcare team or in other settings will likely move to being provided in those ways.

Brief description of intervention

In many regards, this is similar to the “HIPSTER” proposal but expanded for other diseases that can use this model.

Heart failure:

Heart failure is one of the most common causes of readmission. Due to changes in Center for Medicare and Medicaid Services reimbursement models, hospitals have begun to feel financial pressure from high readmission rates. While some patients have disease that cannot be well managed in the outpatient setting, there are many who don’t know how to manage their disease well as an outpatient.

This proposal focuses on providing a subset of patients with heart failure with a scale that automatically records and sends the patient’s weight to his/her providers. This device could also be synced with this patient’s cell phone, email, and/or landline. This would enable primarily two interventions:

If the patient’s weight exceeded set parameters dictated by the patient’s providers:

a)     an automatic reminder would be sent (via SMS, email, and/or automated phone call) to increase the patient’s diuretic dose (much in the same way that providers currently provide instructions)

b)     a notification could be sent to designated team members to check in with the patient and determine a need for a face-to-face encounter

Diabetes

We also often ask our patients with diabetes to check their blood sugars on a frequent basis. We then review this data every three months and provide suggestions about how to better control a patient’s sugar. As we move towards a bundled payment system, this will become an increasingly poor use of the face-to-face time between patients and providers. This is especially true if at least some of the teaching and instruction can be provided outside an in-person interaction.

This proposal suggests providing a subset of patients with diabetes with blood glucose monitors that automatically record and send this data to the patient’s providers. This device could also be synced with this patient’s own cell phone, email, and/or landline. This would enable again two similar interventions:

a)     patients could receive suggested insulin titration doses via email, SMS, or phone call based on automated insulin titration that could be pre-approved by a patient’s provider

b)     patients with blood glucoses outside a designated range (either too high or too low) would receive a reach-out phone call from a provider

References

Levy N, Moynihan V, Nilo A, Singer K, Bernik LS, Etiebet MA, Fang Y, Cho J, Natarajan S. The Mobile Insulin Titration Intervention (MITI) for Insulin Adjustment in an Urban, Low-Income Population: Randomized Controlled Trial. J Med Internet Res 2015;17(7):e180. http://www.jmir.org/2015/7/e180/

Kulnik et al. Evaluation of Implementation of a Fully Automated Algorithm (Enhanced Model Predictive Control) in an Interacting Infusion Pump System for Establishment of Tight Glycemic Control in Medical Intensive Care Unit Patients. J Diabetes Sci Technol 2008; 2(6): 963-970. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769812/

Inglis SC, Clark RA, McAlister FA, Ball J, Lewinter C, Cullington D, Stewart S, Cleland JGF. Structured telephone support or telemonitoring programmes for patients with chronic heart failure. Cochrane Database of Systematic Reviews 2010, Issue 8. Art. No.: CD007228. DOI: 10.1002/14651858.CD007228.pub2.