PAM Scores

As per the HERSA grant which is funding the expansion of Telehealth into Central Oregon, patients are required to complete pre- and post- Patient Activation Measure scores.

One challenge with this process is that some patients are reluctant to complete the surveys.  Others fail to return their completed surveys.

A second hurdle has been sorting out how to keep track of the scores.  When COTN first launched Telehealth in Prineville in 2013, the process involved scanning the completed forms so that they were accessible electronically.  Once scanned, the forms were saved in in “other orders” – this was prior to there being a specific place in EPIC for the forms to call home.

Heading forward, the scores will be saved in the “referral” section in EPIC, and pre- and post- scores will be entered into an Excel Spreadsheet as they are collected.

COTN Highlighted in Regional Newspaper

The launch of Telehealth in Prineville and Redmond has created a buzz around Central Oregon.  On October 8th, COTN was featured in the health section of the Bend Bulletin.

The article provided an overview of the Telehealth program, including the successes of the project thus far.  Two currently enrolled Telehealth patients were interviewed, and lent their opinions regarding their participation in the program.  Andy Eck, Clinic Manager of Mosaic Medical Prineville, and Aimee Priest, Mosaic's RN Care Coordinator, were also interviewed.

The following link will direct you to the Bend Bulletin website, where the article may be read online:
http://www.bendbulletin.com/health/2465399-151/patients-learn-to-monitor-own-vital-signs?entryType=0

Balancing Equipment and Demand

In general, patients enrolled in Telehealth participate in remote patient monitoring for a standard three months.  This amount of time has been found to be effective in determining whether a patient will benefit from further monitoring.  However, not all patients show much progress in the initial three months.  After this time period has passed, it is up to the provider to extend the referral, requesting for further remote patient monitoring. Some patients participating in the Central Oregon Telehealth Network (COTN) have been enrolled for nearly a year, and depending on specific health issues and provider concerns, this may be necessary.

For patients who are not ready or willing to make lifestyle changes, continuing to monitor their health from afar may not be helpful to their care.  Due to a potential increase in demand for equipment, especially with new sites being added to the COTN, it may be necessary to distribute limited equipment to new patients who may use the feedback from their daily readings to proactively take charge of their health.

While this balance of equipment with patient demand is an issue to be aware of, it is a challenge that program administrators believe will balance itself out as they continue working with providers to ensure that patients involved in remote monitoring are benefiting from the program.  

Patient Interview, Sep. 10, 2014

A 69-year-old patient reports that her experience with Telehealth has been “an eye opener,” helping her to be more accountable for her own health.  The patient has been on the program for eleven months.  It is difficult for her and her spouse to get to the hospital due to the remoteness of their home and the unwieldy road leading to and from it.  The task is insurmountable during Central Oregon’s severe winter storms - twelve-foot drifts of snow have been known to isolate their home from thoroughfares for up to three months at a time.

The patient has experienced multiple health complications, and has recently undergone a successful gastric bypass.   Telehealth has helped her to feel more at ease being active following the procedure.  During hot summer months, the pulse oximeter helps her to know if she needs to wear an oxygen pack while working outdoors.  She states that she “feel[s] more secure knowing that my blood pressure is not going out of whack, if my oxygen level is good or bad.”  Further, the patient has become more prudent regarding her diet, knowing that loading up on salty foods will be reflected in her readings. 

While her experience with Telehealth has been very positive overall, she has had trouble with the equipment.  At times, she takes her blood pressure two to three times before receiving a reading.  When her pulse oximeter failed to read accurately, she was unable to receive a new one in a timely manner due to incline weather.  Despite equipment hassles, she is hopeful that she will continue to benefit from Telehealth, and is grateful for the relationships that she has cultivated via the program - “it’s good to know that I am in reach of medical care.”      

Patient Interview, Aug. 26th, 2014

            A 65-year-old male was referred to Telehealth for weight and blood pressure monitoring.  The patient refused a remote weight scale, but willingly accepted a kit containing a blood pressure cuff and transmitter pod.  Since July 25^th, the patient has consistently transmitted blood pressure readings to the Mosaic Medical Prineville Clinic, performing checks up to five times per day.  He is confident that he will complete the three months of monitoring initially ordered by his provider, and looks forward to the possibility of continuing use of the Telehealth equipment past the scheduled discharge date.

            When questioned regarding his intention to remain in the program, the patient stated: “I like it because I can keep track of my blood pressure instead of having to worry about it.  I don’t have to find some place to go check it.”  The patient explained that prior to enrolling in Telehealth, he would seek out places to check his blood pressure, making extra visits to his provider, or driving to a pharmacy.  This posed an inconvenience, as he lives in a remote area.  Having just begun a new medication, he was increasingly concerned about keeping track of his blood pressure - Telehealth allows him to do so conveniently.  The patient has traveled with his equipment, independently trying different locations for transmitter placement when in a new area to ensure that the readings are sent.    

            The patient’s only concern about the program is leaving for extended hunting trips, when he will be unable to plug in the transmitter cell pod.  Such a concern may be addressed by suggesting that a patient continue to monitor their blood pressure under such circumstances, even if they are not transmitted to the clinic.  Telehealth has enabled this patient to monitor his own blood pressure regardless of his location, encouraging him to experience greater self-efficacy regarding the management of his health.

           

Patient Referral

During a recent installation, a patient inquired as to whether their spouse could use the blood pressure cuff newly installed in their home to monitor his own blood pressure.

Although the answer was no, this is one example of a positive referral being made by a program participant due to their own involvement with and enthusiasm regarding the possibilities of remote monitoring.  It has not yet been determined whether this patient's spouse will be recommended for the program by their PCP, but this demonstrates the value that some patients place on being able to monitor their health independently.

Patient Investment in Remote Monitoring

Despite a consolidated team-wide effort, maintaining patient buy-in throughout their planned course of involvement in the program continues to be of concern. 

To ensure that patients are well informed regarding the benefits and potential challenges of daily monitoring from home, primary care providers explain the process to patients in office, when the initial recommendation is made.  During installation, the RNCC and Team Care Assistant follow-up on this information, targeting other potential challenges that may arise during the home visit, and repeating the reasons for referral. 

Although there has been much success in the program thus far, patients occasionally agree to participate in the program only to request equipment removal in a short amount of time – as little as two days, in some cases.  There are a few possible explanations that we have seen thus far.  Patients may simply agree to participate when it is recommended by their PCP in the office, viewing their PCP as an authority to whom they should comply, but re-thinking it when the reality of the program sets in.  Even with authentic buy-in initially, the demand of maintaining a consistent schedule and taking readings when necessary could pose too troublesome of a challenge.  Patients also may not be emotionally prepared to see their own readings each day, triggering anxiety and feelings of hopelessness when faced by the experience of daily weight or blood sugar checks, for example. 

Each case presents a different outcome, sometimes resulting in the early removal of a specific instrument or all equipment from the patient’s home, and other times with the patient retaining the equipment but refraining from using it regularly.  In the latter circumstance, keeping the instrument nearby may be a practical solution.  In the case that a PCP may unexpectedly require a specific reading, a simple phone call may be made to request that the patient comply at that time, even though readings are not taken daily.  Such a compromise may be a logical way for the program to continue to assist in the monitoring of patients who are not fully invested.

Increase in Patient Contact

Telehealth monitoring has given us the opportunity to be in more frequent contact with our patients and the ability to recognize their needs in a timelier manner.  This has enabled us to make more referrals and obtain equipment that the patient may have needed. Meeting the patients’ needs leads to better health care and patient satisfaction.