Build your own: Northwell's app for patient monitoring

Northwell Health, formerly North Shore-LIJ Health System, is participating in three new Medicare bundled payments programs that are making its 21 hospitals responsible for patients' outcomes from the time they enter the hospital through 90 days after discharge.

Managing a patient throughout this period, dubbed the “episode of care” in the Comprehensive Care for Joint Replacement Model, the Cardiac Rehabilitation Incentive Payment Model and the Bundled Payments for Care Improvement Initiative, will be a significant undertaking, especially because of the system's size.

This year, Northwell is overseeing episodes of care for about 3,500 Medicare fee-for-service patients, who have either received a hip or knee replacement or cardiothoracic surgery. That number is likely to grow to about 5,000 in 2017 when Northwell begins working with patients recovering from heart attacks, coronary bypasses and hip and femur fractures.

Northwell's strategy for handling each episode is pretty straightforward. It involves intensive social work and developing new technology to monitor and engage patients after discharge.

“Hospitals have traditionally had this very paternalistic view that every solutions sits within the intensive care unit,” said Dr. Zenobia Brown, medical director for advanced illness management at Northwell Health Solutions. The episodic payment models force health systems to acknowledge that people are “much more complex.”

For elective joint cases, Northwell starts with a pre-operative phone call from a social worker trained in motivational coaching. The call is designed to gain patients trust and identify social factors that could inhibit their recovery, such as being afraid to use home health care because of the physical condition of their home or holding tight to what Brown describes as falsely held beliefs.

“A patient may chose a rehabilitation center because they want to hold onto their independence and not ask a family member for help,” said Brown. A social worker could explain that they could maintain more of their independence, plus lower their risk of infections, if they were discharged straight home.

Medicare fee-for-service patients can chose where to go after they are discharged and often pick post-acute care facilities like a skilled nursing facility or rehabilitation hospital. But that model drives up costs with, very often, little bearing on outcomes or the overall quality of care. Low quality post-acute care providers can be significant drivers of readmissions while mounting up half the cost of an episode of care.

In the hospital, nurse practitioners, who act as care navigators, follow up with patients, making face-to-face contact. This ideally creates a relationship that will be critical during the post discharge period.

“It's one of the lessons learned,” said Brown, adding that about 40% of patients had turned away health workers pursuing a home visit because they had never met them before.

Once a patient is discharged, care navigators call patients within 24 hours and make house visits within 72 hours. At this point they can reassess risk and reconcile any medication issues.

Medication reconciliation is a big issue. Patients can have medication from before they went to hospital, new medications at the hospital and then a separate list of medication from a rehabilitation center. Navigators are nurse practitioners and can prescribe any missing medication, spot drug-drug interactions or identify other medication errors.

For elective surgeries social workers and physicians can work with patients pre-operatively and plan their care path before they are even admitted into the hospital. But many patients who qualify for the episodic programs, especially the cardiovascular program, are likely to be admitted through the emergency department, creating another issue: how does the hospital identify patients who qualify for episodic programs as soon as possible.

“If someone comes to emergency department with shortness of breath, it could be COPD (chronic obstructive pulmonary disease), pneumonia, heart failure or influenza,” said Brown, adding that a hospital could lose days waiting for the DRG to drop.” (A DRG is the diagnostic code that hospitals use for billing and that Medicare uses to determine who qualifies for the new programs.) By that time a patient could be discharged or ready to leave.

To find these patients, Northwell built a system called Care Tool, a platform that coalesces information from multiple sources: admissions, surgical scheduling, electronic medical records, and (within the next year) pharmaceutical databases.

“We needed to have some sort of technology that could anticipate the most likely DRG,” she said.

After discharge, care navigators and physicians use Care Tool to see updated list of medications, track patients through different post acute care facilities or even if they show up in emergency room of another hospital in the region.

With the overarching systems in place, Northwell is now piloting a new application designed for orthopedic patients, called Force Therapeutics. The pilot, which began in January, currently involves eight physicians, three hospitals and 660 cases, though that is expected to grow by the end of the year.

The app, which is designed to be intuitive, provides updates that ensure patients have essentials like transportation to the hospital on the day of surgery. It also allows patients to watch a video instructional featuring their orthopedist or nurse running through topics like pre-surgical or post-surgical routines and exercises.

During the hospital stay patients are encouraged to continue to use the app, reporting items like pain level. This helps maintain continuity and reinforces the apps relevance. Once a patient is discharged the app again provides instructional videos, updates and asks questions that enable clinicians to monitor the patient's progress.

The app can also be used to text questions to the care navigator or physician, depending on the physician's preference. Some physician offices are equipped to monitor alerts from the app directly while other chose to use Northwell's care navigator team.

For example, one patient concerned about her wound sent a picture to the doctor, who quickly determined it was fine and kept her regularly scheduled appointment. “The interaction took less than five minutes,” said Brown, adding that without the technology the same interaction would have taken a lot longer.

The pilot saw 88% of its Medicare fee-for-service patients to sign up for the app; About 70% of those patients completed tasks like answering a survey prior to surgery; 30% used it to send electronic messages. About 3% of patients generated a post-operative alert.

Northwell is looking at other applications to serve patients with chronic conditions like heart failure, who have very different needs and may require an intervention that is structured differently. Brown is unconcerned about trying different companies since the technology is so new she expects it to evolve very quickly.

“Year over year, the apps are getting better, faster and easier to integrate,” she said.

In part six, learn about the importance of identifying metrics when piloting patient monitoring apps.

Lisa Ward is a freelance writer based in Mendham, N.J.