Trinity Health has 94 hospitals across 24 states. 

In 2017, the health system – which has 100 continuing care locations, including home care, hospice, PACE programs and senior living facilities – was in a bind, facing double-digit hospital readmissions of 16% across its high-risk Medicare population.

THE PROBLEM

Trinity needed to reduce readmissions to single digits. The plan was to offer remote patient monitoring to Medicare patients across its 14 home care sites to avoid preventable hospitalizations and unnecessary visits to the emergency department.

In doing so, Trinity also hoped to receive readmission incentives from the Centers for Medicare and Medicaid Services, avoid penalties, and reduce costs as it transitioned to value-based care reimbursement.

Further, Trinity knew that reducing readmissions was the right thing to do. Entering the hospital, or even going to the ED, is tremendously disruptive to the lives of patients.

PROPOSAL

Trinity Health would use RPM in two ways: RPM for Trinity Health at Home, called Home Care Connect, focused on skilled home care patients; and RPM for at-risk patients following a home-care episode of care, or who do not meet skilled home care eligibility, with support of Trinity Health's Virtual Care Center.

"With the help of an innovation grant, Trinity Health at Home – Trinity's home health business unit – launched a 30-day RPM pilot to 55 patients," said Karen Joyce, RN, vice president of clinical and virtual operations at Trinity Health at Home. "The program, using vendor Vivify Health's connected care platform, aimed to reduce readmissions."

"After hours and on weekends, the Virtual Care Center acts as a triaging nurse to Trinity's home care and hospice patients across the U.S., managing more than 4,000 patients."

Karen Joyce, RN, Trinity Health at Home

"With only one patient returning to the hospital, the proof of concept was a success, and Home Care Connect, Trinity Health at Home's nationwide virtual care program, was born," she added.

Trinity selected Vivify Home, a self-contained RPM kit that offers chronic-condition pathways, high-quality video and a home care kit that addresses diagnosis-specific needs. Patients receive a 4G-enabled tablet and connected health devices, including a weight scale, pulse oximeter and blood pressure cuff.

"Vivify's RPM technology was simple enough for a centenarian to understand and use with little to no assistance, increasing the likelihood of compliance and satisfaction with the program," Joyce noted. "Indeed, patients enrolled in Home Care Connect are 29-107 in age, with 77 being the average age."

The connected health vendor offers a virtual care package that includes 24/7 support with a virtual care nurse, a user-friendly interface and a strong education component, which was essential, she said.

MEETING THE CHALLENGE

Trinity Health started with a 30-day RPM program for patients transitioning from hospital to home. These patients encompassed 80% of Medicare episodic discharges, meeting specific criteria.

"The program includes eight weeks of automated digital conversation aligned to a patient's care pathways, which address specific chronic conditions," Joyce explained. "The patient follows the tablet's voice and text instructions, and device information, to self-report vital health information and answer condition-specific questions. The more the patient learns, the more compliant the patient becomes, ultimately driving better outcomes."

RESULTS

The RPM program produced immediate positive results. In less than a year, 30-day readmissions dropped from 16% to roughly 8% and eventually to 6%. These results alone enabled Trinity Health to improve revenue by taking advantage of CMS incentives while reducing its costs.

Trinity Health's patient compliance and patient satisfaction numbers remain high at 85% and 96%, respectively, illustrating the importance of continuous positive patient engagement, easy-to-use technology, highly trained clinicians and first-class health education, Joyce said.

"Other critical factors also played a role in the program's early and continuing success, including strong support from Trinity's executive leadership team and the organization's commitment to caring for high-risk patients at home, where they are most comfortable and more likely to thrive," Joyce noted.

As the RPM program has matured, Trinity Health is pursuing new opportunities to expand its reach across the Trinity Health at Home footprint and beyond.

"In 2017, Trinity launched its Virtual Care Center, which has a 24/7 all-RN staff and is licensed in 17 states to provide RPM services," Joyce said. "The Virtual Care Center allows us to offer remote monitoring, answer alerts, and provide additional education and care coordination to more patients who are at risk.

"Also, after hours and on weekends, the Virtual Care Center acts as a triaging nurse to Trinity's home care and hospice patients across the U.S., managing more than 4,000 patients," she added.

The Virtual Care Center has expanded RPM services to patients with a chronic illness who are in need of short stays in home care and are no longer homebound. There is definite value with continuing to monitor patients after a home care episode, Joyce noted.

"More recently, Trinity Health started offering RPM services outside of the organization," she said. "We expanded our virtual care offerings in response to a need we saw outside of Trinity Health. ACOs and other commercial payers found us to be efficient and effective with virtual care monitoring.

"Payers are starting to come on board, as well," she continued. "We asked payers across the country to consider paying for monitoring beyond the home care episode of care. Several decided that remote monitoring should become part of that rising-risk, high-risk population's plan of care. Currently, these payers reimburse 30, 60, 90 and 180 days of RPM via Home Care Connect."

ADVICE FOR OTHERS

"Define your scope: Outline key stakeholders, assumptions, processes and constraints, what the project is about, what is included, and what is not," Joyce advised. "Document all of this essential information in a scope statement.

"Select measures of success," she continued. "Our success metrics included: 30-day readmissions in the single digits, lower preventable hospitalizations and unnecessary visits to the ED, patient satisfaction, provider satisfaction, population health clinical outcomes, and avoid readmission penalties and receive CMS incentives."

Continuously evaluate the program, she added.

"RPM for Trinity Health at Home is a very robust program that is constantly changing," she explained. "We push each other to excel and think of new ways to use remote monitoring in this world. What's next? Trinity is looking at how RPM can serve patients who want to age in place. We're exploring how RPM can work in senior communities, so we can keep them at home and out of assisted living or long-term care."

Finally, she advised her peers to collect user satisfaction data.

"96% of patients enrolled in a Trinity RPM program today say the technology is easy to use," she concluded. "Nurse satisfaction has improved, as well, due to a decrease in after-hours visits with nurses who had already worked a full day."

Twitter: @SiwickiHealthIT
Email the writer: bsiwicki@himss.org
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