A remote monitoring program implemented by Geisinger Health Plan using interactive voice response (IVR) and other telemonitoring technology to aid case managers has shown a 44 percent reduction in hospital readmissions.

The Geisinger Monitoring Program (GMP) uses a range of technologies from remote monitoring and telehealth company AMC Health designed to increase the number of interactions patients had with caregivers post-discharge.

“That first week or two post-discharge is when you really see readmissions happening,” said Joann Sciandra, director of case management and strategic planning with Geisinger Health Plan. “Having the ability to have a couple more touches or encounters with that patient makes this a very valuable tool. From a case management standpoint, it gives the case manager a little bit more time they may need with more complex patients.”

The two-year old program was designed to see if the use of IVR technology for a population of Geisinger patients would produce significant improvements in hospital admissions rates compared to patients who did not receive IVR follow-up.

Patients in the program would receive scheduled calls using the IVR technology to answer questions specific to their case about their progress and how they were feeling. Their answers are captured both online and in the patient’s EMR and determine whether a nurse or case manager should follow-up directly with the patient.

“Our success in leveraging AMC Health's technology to reduce readmissions underscores our belief that providing clinicians with the right data, at the right time, to drive the right interventions is critical to driving the best patient outcomes,” said Jim Peters, system vice president at Geisinger Health System and head of Geisinger's strategic industry partnering activities.

Geisinger first began the remote monitoring project in 2008 focused on roughly 900 patients in its complex care heart failure program. In this iteration, patients were provided with Bluetooth-enabled scales that would feed daily weight data to Geisinger. Customized, pre-set triggers on weight fluctuations as well as trend data along with IVR calls that allowed Geisinger to collect additional symptom data helped determine which patients might be at risk and could benefit from either call from a nurse or a visit to their doctor. The compliance rate for the heart failure patients exceeded 85 percent.

In a survey of case managers active in the Geisinger program, 96 percent said the telehealth technology allowed them to monitor heart patients more efficiently, and 85 percent believed that the combination of the telehealth technology and closer monitoring of patients helped reduce hospital admissions.

Based on the success of the heart failure program, Geisinger Health Plan broadened the use of IVR to include patients with hypertension and diabetes.

“These patients are among the most challenging to manage,” said Janet Tomcavage, RN, MSN, vice president of health services for Geisinger Health Plan. “The acuity of their condition requires constant surveillance to detect emerging exacerbations. If left unaddressed, this inevitably leads to increased emergency department utilization and costly hospital readmissions.”

In Sciandra’s view, the GMP has helped fill a gap in care that exists for most patients after they have been discharged from the hospital.

“We really wanted to do something around transitions in care. It wasn’t a question of people doing a bad job, they weren’t,” Sciandra stated. “But it is the system that sets us up for failure. By having someone to hand off the patient to for outpatient (management) we are able to prevent some of those problems we had in the past.”