Remote Patient Monitoring - vital signs at home

[Keywords: home AMC ]
GLFHC has a Remote Home Monitoring program for patient vital signs.  You can refer appropriate patients, they will receive the equipment and help they need, and data will flow into the EMR!

Summary:

• Make an internal referral to: "INT - Remote Home Monitoring (vital signs)".
• Check off the things you want to monitor (BP, glucose, O2Sat etc.).
• If you include glucose, the patient MUST have a FreeStyle Lite, FreeStyle Freedom Lite, or OneTouch Ultra glucometer - or you must prescribe one.
• Equipment (other than glucometer) will be sent to the patient.  The team will provide help setting it up.
• Data will flow into the EMR each week as a document.
• This is NOT for real-time monitoring, as no alerts are raised for abnormal readings; it is just for gathering data between visits.
• If a patient has questions or problems with equipment, have them call AMC (or help them call): 877-262-2240

Details:

Who can I refer?

You can refer anyone, any insurance.  Just PLEASE MAKE SURE the patients knows what is happening and is willing to try it.

How do I refer?

Use the Internal referral: "Remote Home Monitoring (vital signs)".  You can find it by searching for "monitor", "remote",  "vitals" etc.  Then check off the vital signs you want to monitor in the referral.

What vital signs can be monitored?

Blood Pressure, Glucose, O2Sat, Temperature and Weight

How does my patient get the devices?

Devices, except glucometers, will be shipped to the patient from a company called AMC, within a few days of the referral.  
NOTE: If you want to monitor glucose, the patient must have their own FreeStyle Lite, FreeStyle Freedom Lite, or OneTouch Ultra glucometer.

How do we get the data?

The patient receives a tablet that connects to the devices and transmits the data.  Data arrives in the clinician EMR Inbox every week.  The patient does not need Wi-Fi, a computer, a Smart Phone, or anything else!

How tech-savvy does the patient need to be?

We have designed a tiered system for helping patients get set up.  It starts with assistance by phone, then via nursing visit, and even involving a home visit if necessary.  Once they are set up, taking readings is straightforward.  All assistance is bilingual.

What if readings are abnormal, or CRITICAL?

This is not a system for real-time monitoring of acutely ill patients.  It is for gathering data in-between visits.  There is no alerting system for abnormal readings. Think of this as an alternative to patients taking their own home readings, but with major advantages:

• The clinician receives all the data
• The data is accurate
• Every reading has a date and a time
• Data arrives weekly, so we can respond faster than waiting for the next visit

When does monitoring stop?

We are piloting this as a three-month program.  After three months, equipment will be recalled and enrollment ended.  This will happen sooner if the patient is unable or unwilling to use the equipment (after assistance).  We may change the duration and conditions in the future if appropriate.

How is it paid for?

Grant money is supporting the cost of patient enrollment and equipment, and this will last for at least several months.  Once the program is operating successfully, we will explore Massachusetts billing models to make it sustainable when the grant runs out.