Saint Francis Medical Center - Staying Well at Home

Overview

The Staying Well at Home program helps elderly residents live independently, avoid frequent re-hospitalizations, and maintain a high quality of life. This is accomplished through the on-site education and telehealth monitoring stations that record vital signs. The monitors are conveniently located at three senior centers in small rural communities and at Saint Francis Medical Center’s cardiac/pulmonary rehabilitation center. These stations, available for public use at no charge, transmit data to a Home Care Services nurse at Health Connect at Home and provide data that the individuals can share with their personal physicians. The nurse coordinator trains individuals in how to monitor their vital signs (weight, blood pressure, oxygen levels, and heart rate) and provides information on what those signs mean. The system may also be programmed to include some customized elements based on an individual’s health status. It was anticipated that the telehealth monitoring, which began in 2006, may alert patients and their physicians to potential problems prior to the need for hospitalization and thus reduce the 30-day readmission rate.

Impact

Nearly 200 individuals are currently enrolled in the program. Enrollment in the program is increasing, and there has been a slight decrease in 30-day readmissions for Medicare patients with the same diagnosis. The hospital’s outpatient rehab program has seen the most growth in the last couple of years. Information on vital signs that is transferred to a nurse at Saint Francis Home Health is trended; if vital signs change or something looks concerning, individuals are encouraged to contact their primary care physician for follow-up before their symptoms become critical. Monitors are also available for use in people’s homes. Saint Francis’s discharge planner is the source of many referrals. Individuals with chronic heart failure often use the monitors following discharge from the hospital. The consistent monitoring alerts them to changes in their condition, hopefully before re-hospitalization becomes necessary. By knowing their vital signs, individuals become more proactive in taking care of themselves. For example, a change in blood pressure may cause an individual to be more diligent in following medication dosage or nutritional recommendations. Frequent readings of vital signs are important, especially for cardiac patients, but are helpful for all older patients with chronic diseases. Trended data can help physicians make better treatment decisions if they are able to look at several readings over a period of time rather than just one reading.

Challenges/success factors

The telehealth monitoring project is a preventative program; as such, it is sometimes difficult to document positive outcomes. A coalition, composed of representatives from Saint Francis, critical access hospitals, and senior centers, was established to implement this health care service. The participating senior centers have been a tremendous help in making this service available in their community. A room is provided at each site for the monitor and other necessary supplies. The centers promote the program, and about one-third of enrollees are referred by the senior centers. A newspaper article on the program increased awareness and resulted in new enrollees.

Future direction/sustainability

Funding for Staying Well at Home was provided by the Saint Francis Foundation and a three-year grant from the Health Resources and Services Administration (HRSA). Those funds helped with startup costs such as obtaining computer equipment, monitors, and the salary of the nurse coordinator. HRSA grant funds expired in 2010; alternative grants and donations are being explored.

Advice to others

Initially, on-site generic education was provided by the nurse coordinator to groups at the senior centers. It has been shown that individual instruction, relevant to the individual’s health issues, is more effective in getting individuals to monitor their vital signs and become more proactive in taking care of themselves.

Contact: Cathy Ferguson, RN
Health Connect at Home
Telephone: 308-398-2604
E-mail: Catherine.Ferguson@chs.trihealth.com