Coordinated Care Management

June 08, 2010

SeniorBridge Uses Telemonitoring to Help Seniors Stay Independent at Home

SeniorBridge was founded in 2000 to provide integrated care to people with complex medical problems and to seniors who need assistance to stay healthy at home. Dr. Erik C. Rackow has served as SeniorBridge President and CEO since 2007. Rackow has more than 35 years experience in healthcare, including a position as Professor of Medicine at the New York University School of Medicine. In this exclusive MedHealthWorld interview, Rackow discusses how SeniorBridge is integrating both telehealth monitoring and telecare to provide a coordinated and cost-effective home health care service.

Mary Cronin: What are the major challenges in providing home healthcare services for seniors?

Dr. Erik Rackow (pictured below): SeniorBridge has evolved to a company that focus on the most chronically ill seniors who need to have care managed at home in order to stay out of hospitals and nursing homes. That's a very challenging population to serve, since treatments for chronic illness including acute care and hospitalization represent a very large proportion of the overall healthcare expenditures in the U.S. For example, as much as 85% of the overall annual healthcare costs for the insured represent spending on people with chronic illnesses. A lot of that cost comes from providing acute care in emergency rooms and in hospitals. To add to the challenge, it's estimated that about one third of currently uninsured people who will be covered under the new healthcare act also suffer from chronic illness. If we want healthcare providers and the system as a whole to stay solvent, we have to break the cycle of repeat hospitalization chronic illnesses and make a paradigm shift to deliver cost-effective home health care rather than focusing on acute care. This is especially important for chronically ill seniors where hospitalization can lead to institutionalization in a nursing home environment.

SenorBridge aims to stabilize the health of seniors living at home and help them and their families to avoid hospitalization. We provide home care with an integrated practice to manage chronic illness including family, social nutrition, to keep seniors functioning at home at the healthiest level possible. But a lot of this home care requires face to face interaction with providers. It's time consuming and expensive. So we incorporate technology enabled care solutions that work best for the care management team, the senior and the family to deliver cost effective services.

MC: What types of health technology are you finding to be most effective?

ER: SeniorBridge has adopted 2 primary techniques in telehealth. The first is telemonitoring. As part of coordinating home health care with the family and with other professionals in the health system, the SeniorBridge care manager will help to set up the types of home monitoring recommended for each patient. These may include sensors that monitor blood pressure, glucose levels, oxygenation of blood any fluctuations in weight, and other indicators that are relevant for the treatment of that individual.

Since the sensors and monitors are wireless, they can upload the data collected to a central in-home station and report results daily or even more frequently. The nurse or other health practitioner can review the reports remotely and decide when the results indicate that a visit to the home or a change in medication levels is needed. SeniorBridge serves as the coordination point for telemonitoring. The actual monitoring devices and data systems are provided by CardioCom, Philips VRI and other technology partners so that we can provide the most appropriate and advanced monitors to fit the health profile of our client.

SeniorBridge has also introduced aspects of telecare, in which we use Skype or other video phone capabilities to support interaction with the person receiving home health services for communication and interaction with the SeniorBridge team as well as with other healthcare providers and with families. The SeniorBridge professional care manager may help set up the communication link and initiate the call from the patient in the home-or the care manager may be in other location using the video and audio connection with the patient for counseling and answering questions as needed. This type of face to face visualization and communication with the patient can provide important indicators of the overall well-being of seniors who are living alone, and it can be a great way to keep family members in distant locations in direct touch with the senior.

We are starting to implement this SeniorBridge Skype program in New York to complement home visits. Video telecare in combination with telemonitoring data is also a very promising alternative for some types of doctor visits. It is an enormous effort for many chronically ill seniors to get to a doctor's office and the cost of such visits contributes to the high cost of treatment that I mentioned earlier. But regular monitoring and consultation with the care provider is needed to avoid emergency care situations. Use of telehealth as part of a coordinated care plan benefits the patient and also helps to reduce costs.

MC: What changes in the health care system are needed to enable broader adoption of technology-enabled healthcare services?

ER: We need to adopt a more patient-centered approach to the health care record, including Electronic Health Records. Implementation of an Electronic Records system is a national priority, with the expectation that EHR will improve patient outcomes as well as helping to reduce costs of treatment. But right now most patient health records and records systems are centered on the care provider (the doctor, the healthcare specialist, the hospital, and so on) rather than patient centric. When a patient moves from one care provider to another, that records isn't integrated. This has to change to support a patient centered record that can be integrated into different records systems to span all the different care providers who are involved in treating chronically ill patients and that will be available to the patient. It's a big challenge, but it is essential if we are going to move forward with an integrated health system.

At SeniorBridge, for example, we try to serve as the hub of information for various health providers. So we have developed a web-based information and record system designed around a patient centered record that makes it easier to for different providers to access and to coordinate the care among all the specialists. We want to connect that record even more broadly, so if a patient goes to hospital it is updated to make all the hospitalization and discharge information available to home care providers.

We are working with a multitude of professionals in the healthcare system -families and doctors and other coordinated care providers. A patient-centered health record can enable much more effective care coordination to support a holistic hub of care that addresses all aspects of well being for that individual patient.
Dr. Cronin is a Professor of Management in the Information Systems Department at Boston College. To read more of her articles, please visit her columnist page.

Edited by Michael Dinan
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