Care Dimensions Improves Quality of Life for Hospice Patients Using Telehealth

Publisher: The Insight Partners

Care Dimensions has achieved an average 30-day hospital readmission rate of 1.38% over one year for hospice patients enrolled in the telehealth program. In 2018, Care Dimensions partnered with Health Recovery Solutions (HRS), a nationally recognized telehealth provider, to expand its telehealth program and extend telehealth services to more patients.

Care Dimensions launched its telehealth program to provide an additional layer of support to both palliative and hospice patients, ensuring patients' physical, emotional, and social well-being. In Massachusetts, Care Dimensions is one of the first healthcare providers to offer the advanced support of telehealth and remote monitoring to hospice and palliative patients and their families.

All patients referred to Care Dimensions with a cardiac or respiratory diagnosis, such as COPD or CHF, are evaluated for the telehealth program. Patients with a history of frequent ED visits or requiring focused weight and medication management are enrolled in the telehealth program to receive the additional support telehealth provides.

Patients enrolled in the telehealth program receive a 4G tablet, pre-loaded with the HRS software, in addition to Bluetooth biometric monitoring devices to record their vital signs including, blood pressure, weight, and heart rate. Via the tablet, patients receive medication reminders, educational videos, and daily symptom surveys, all seamlessly upload to the clinician's dashboard, allowing the patient's clinical team to track their health status 24/7. HRS' telehealth software also enables communication between clinicians, patients, and caregivers through text messaging, voice calling, and video conferencing platforms.

Care Dimensions employs an interdisciplinary approach to patient care, with a team of RN case managers, social workers, chaplains, hospice MDs, hospice aides, and volunteers coordinating patient care and assisting primary caregivers. The telehealth program operates as a centralized model, facilitating care coordination across the interdisciplinary team. Upon receiving a patient risk alert, telehealth nurses contact patients to verify their biometric readings, offer care plan recommendations, and schedule a home visit or virtual video visit, if necessary. The telehealth nurse coordinates care across the patient's care team, tracking the intervention, contacting the patient's primary case manager, and ensuring data is transmitted to the Care Dimensions' EMR to inform all providers on the interdisciplinary team.

Pain management, education, and engagement are fundamental aspects of hospice and palliative care, not only to reduce hospitalizations but to improve patient quality of life. Careful monitoring of patient vitals and symptom surveys enables the Care Dimensions team to control symptom burden and patient discomfort. Care Dimensions' inpatient hospice houses are utilized to assist patients whose symptoms have worsened and require continuous assessment and interventions to ease their symptoms. Utilizing hospice houses, instead of emergency rooms and hospitals, Care Dimensions provides additional comfort to patients through symptom exacerbations.

In addition, Care Dimensions' interdisciplinary care team leverages the educational videos and quizzes available on the HRS platform to teach patients and caregivers how to manage symptoms best and demonstrate emotional coping skills.

"Care Dimensions' clinical team recognizes the importance of engagement, from both patients and caregivers, and prioritizes this when enrolling and teaching new patients," said Devon Wetter, Client Success Manager at HRS. "Their commitment to patient and caregiver engagement has resulted in patient adherence rates of nearly 90% and has been essential to their reduction of hospital readmissions and ED visits."

In the coming months, Care Dimensions' clinical team will further expand their use of virtual visits, scheduling virtual visits following patient enrollment and installation to answer questions and ensure patient and caregiver comfort with the telehealth program.

"The use of telehealth has enabled our team to personalize care to each patients' needs and provide daily updates to the patient's care team," said Lisbet Sanchez, Care Dimensions' Specialty Programs Manager. "We are looking forward to expanding the use of virtual visit calls to manage patient symptoms and assist in providing recommendations for the patient's care plan."