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Study suggests telemonitoring does not reduce hospital readmissions

April 18, 2012
by Sandra Hoban
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Telemonitoring, which has been discussed with increased frequency as an option to reduce patient rehospitalizations, doesn’t work as intended for older patients, according to the results of a recent study published this week in the Archives of Internal Medicine.

The study, conducted by researchers at the Mayo Clinic and Purdue University, found telemonitoring had little effect on people age 60 years and older in significantly reducing readmissions or emergency department visits.

Preventing hospital readmissions and emergency department visits is an important focus of the Affordable Care Act that will affect Medicare payments for services beginning in 2013.

In the controlled study, people over 60 years of age and at high risk for rehospitalization were broken into two groups. One group used telemonitoring to follow each individual’s health status with daily input (symptom reporting, biometrics and videoconferencing), while the other group experienced routine care.

At the study's end, the telemonitored group did not significantly reduce its hospitalization or ED visits as compared with the group that received usual care. The mortality rate for the telemonitored group (14.7 percent) however, was higher than the usual care group (3.9 percent). The reasons for this discrepancy are unknown.

While this study did not show a significant benefit in reducing ED visits and hospital readmissions, other studies have concluded otherwise, such as the Geisinger Health Plan investigation that found success with patients using the technology. However, that study was not limited to older adults.

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Comments

I am a nurse executive for a large long term care management company. Hospital readmissions is perceived to be a significant problem in our company, with approximately 70 rehospitalizations out 8,000 over all census. From the operations/marketing perspective, this is an enormous threat to revenue and the exodus must be stopped!

The company has bought into the idea that such intrventions as INTERact II and telemedicine will prevent discharges. Every week, countless hours are spent on conference calls to discuss census and develop contests to reward facilities with the least discharges.

The nursing perspective is quite different. First, recognize that this is a very low hospitalization rate! Organizations should perform root cause analysis to identify the reason for the rehospitalizations. It is not because the nurse doesn't exude self-confidence to the physician. It may be because the physician does not feel secure leaving a patient with a change of condition in a facility that is staffed with 1/10 the number of RNs as a hospital med surg unit and 1/3 the number of direct care nurses (LPN rather than RN, and 1/2 the number of nursing assistants! Seriously, how could a physician rationalize that it is safe to start IV's, new drugs and treatments, intense monitoring (without electronic monitoring equipment)?

Staffing is only one part of the problem. Another significant consideration is the organizational workflow. Starting at the top, the Director of Nurses does not function independent of the Administrator. The Administrator has veto power over everything except what happens on nights, weekends and holidays - when it is then the DON's responsibility to manage both the Administrator's function and the DON function. At the same time, direct care nurses are left to maintain housekeeping, maintenance, laundry and dietary, social services, admissions and smoking activities. Remember, they are staffed at 1/3 the level of a hospital! This amounts to workflow malpractice which the DON is powerless to correct, but which has direct impact on patients and nurses - and census!

Facility design also contributes to hospital readmissions. Most facilities (none in my company) do not have a designated area where patients with significant changes in condition can be moved so that their care can be managed efficiently by a designated nurse and other specially trained caregivers. Instead, patients endure their changing condition in exactly the same care situation as when they were well! Nurses can and do work harder, longer, and give much more of themselves in these conditions, but they are set up for mistakes and very short careers due to burn out and injuries.

Then there is the convenience factor. I love doctors. Like nurses, they are altruistic - not "in it for the money". BUT, they, like nurses, are entitled to a "life". Physicians do not have to be on call 24/7 if their patient is in the hospital, tended by hospitalists. They can see more patients in a condensed setting such as a hospital, and they get paid more money (yes, money is important) to treat the same patient in a different environment. More convenient, more money, less time and work - who wouldn't choose that!

The answer to rehospitalizations is to increase funding for caring for patients with temporary changes of condition, and create hospital-like environments and work flow models in the LTPAC. It is not to try to get more blood out of Nurse Turnip!

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