Integrated Remote Patient Monitoring - Qualitative and Quantitative Data

Integrate remote patient monitoring into existing Transition Care Programme services to provide an end-to-end solution that combines:

  • Physical care and health services in the home, 
  • Algorithmic analysis of qualitative notes and data left by:
    • Care workers
    • Family
    •  Individuals
    • Allied Health Professionals
  • PROMS (EQ5D) and PREMS
  • Quantitative data from integrated medical devices such as
    •  Pulse-oximeters
    • Glucometers
    •  Blood Pressure
    • Temperature
    • Weight Scales
    • 24/7 Telehealth Availability
  • Voice-activated welfare checks/questions
  • 24/7 monitoring nursing team
  • Real-time feedback of a patient’s condition and wellbeing data to the consulting specialist

To work effectively, the pre-admission should assess discharge requirements in the home and pre-order aids, equipment AND monitoring technologies to be ready for discharge.

The discharge report should:

  • Trigger a transport pick up if required.
  • Schedule the initial home clinical nurse assessment. 

This initial in-home visit should also include:

  • The configuration of any devices needed, and a Telehealth device (BYO phone, iPad or supplied by the program for the duration of recovery).
  • An initial EQ5D and PREM should be captured electronically at this point.
  • A review of the patient's future home care funding options with relevant applications and/or assessments booked in.

An appropriate multidisciplinary care plan would be created that prescribes the target software analysis of care worker notes and quantitative data logged by the relevant devices.

Any concerns the monitoring algorithm identifies should be brought to the attention of the 24/7 monitoring nursing team for investigation. They would be able to contact and consult with the patient directly using using the Telehealth tools available.

All data and insights would be sharable with the consulting specialist so they can provide additional advice and recommendations. This would also better inform the consulting specialist when patients return for follow up consultations.

After the typical transition period, the formal care services may no longer be required, but low-cost devices and 24/7 monitoring may be extended with planned Telehealth appointments until additional funding is secured.


Why the contribution is important

It is possible to achieve high-quality outcomes for people in their own home, and drive value from the health spend by combining an individualised mix of skilled people in the home, integrated devices, analysis and remote monitoring.

Remote Monitoring can identify early changes that can lead to care changes to avoid re-admission.

Remote monitoring can be delivered at scale from anywhere 24/7 so makes health professionals readily accessible to vulnerable patients in the night who may have simple questions, be frightened or immobilised.

If integrated into the admission and discharge processes, it will enable faster and safer discharge into a highly monitored environment. This frees up beds for those who need to be cared for in an acute setting.

This solution would deliver greater value out of existing funding models such as Transition Care Programmes and Home Care Packages where available but the cost would be significantly lower than in hospital regardless of the funder.

It is of particular importance because this solution exists today in Queensland and is already being used to support people ageing in place. It makes sense to leverage the model for post-acute in-home care. 

by fivegoodfriends on May 28, 2019 at 12:17PM

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