by Marki Flannery, Former President and CEO
For fragile older Americans living at home with multiple chronic conditions, the road to better health and safety is increasingly paved with new innovations. This can include novel technologies for real-time, remote monitoring and intervention, as well as data and analytics that can help us predict and mitigate risk for vulnerable populations.
It’s important to note, however, that these new technologies and evidence-based insights are only as insightful and effective as the people who put them into practice day in and day out. We still need, as we always have, expert teams who are skilled at communication and are able to deliver high-quality, patient-centered care, whether it’s delivered remotely or in-person.
At the not-for-profit Visiting Nurse Service of New York, we’ve recently launched a new division that harnesses the power of preventive and predictive technologies and analytics, along with the talent and compassion of our clinicians, to connect the most vulnerable seniors to the right care at the right time in the right place. This new division, VNSNY’s Care Management Organization (CMO), works with insurers to provide extra support to people living at home with seven, eight, or more chronic illnesses. The goal is to help them manage their many conditions at home and avoid the downward spiral in health that can lead to multiple trips to the hospital and other settings—trips that are extremely costly and disruptive to their lives, and that are often preventable.
The combination of technological innovation and human talent is embedded in our CMO’s structure. Each plan member is assigned a care manager from the CMO who checks in regularly to make sure the member is taking medications appropriately, getting to doctors’ appointments, and receiving any other services they need. The member also has access to remote monitoring technology devices in the home so the care manager can automatically track vital signs. If we spot a problem such as rising blood pressure or increased weight gain, we’ll check in right away and, if needed, quickly send in a nurse practitioner for a home visit.
When remote monitoring in one older New Yorker’s home recently signaled a sudden spike in blood pressure, the care manager contacted the member immediately. The care manager learned that the member had misplaced her blood pressure medication—and so had stopped taking it. In short order, the medication was replaced, a follow-up doctor’s visit was scheduled, and the member was on the path to better health.
For another CMO member, telehealth technology showed an unexplained drop in blood oxygen levels—which could have resulted in a health crisis or a trip to the emergency room. The care manager was on the phone with the member right away, and, through careful questions and active listening, discovered that the member was self-medicating her asthma with cough syrup rather than using a rescue inhaler. The care manager promptly arranged a home visit from a CMO nurse practitioner to reeducate the member on how to use her inhaler, and the problem was solved.
Other innovative technologies to manage patients’ health include virtual video-visit consults that CMO clinicians can conduct through an app, allowing them to speak face-to-face via computer screen with patients and their doctors, as well as real-time alerts that sound if a CMO member shows up in an emergency room. The CMO also has technology that can tailor telephonic surveys to individual clients, helping them identify the need for extra social supports or medication refills. Meanwhile, our CMO’s clients can, at the press of a button, reach a care manager at any time.
When it comes to innovations in health care technology, what truly matters is how a new technology is able to extend the reach of oversight and care, all in the name of elevating overall health. Our CMO’s virtual visits are a good example of this. “There’s a lot of evidence showing that, in the absence of in-home face-to-face care, remote monitoring with virtual-visit capability helps to engage the patient,” says Rose Madden-Baer, VNSNY’s Senior Vice President for Population Health and Clinical Support Services. “And patient engagement is critically important to their overall health.”
Our organization, along with much of health care, makes sure we are guided by evidence as we strive to deliver the most effective care to the greatest number of people. Our CMO actively uses research and analytics capabilities to predict and mitigate risk around the vulnerabilities that its members face. That can include depression, transitions of care, and mortality within six months for those nearing the end of life. For individuals transitioning home from the hospital, for instance, we’ll look closely at data in determining how we prepare them for their first primary care physician appointment within seven to ten days.
Caring for vulnerable people in their home is a complex human endeavor, and it takes more than technology and data to get the job done. As with the rest of VNSNY, an interdisciplinary care team is at the heart of how the CMO provides both big-picture and day-to-day care. The team is really the rudder that steers all this innovation and data-based evidence to the benefit of the patient.
The diverse care team that our CMO puts in place to address each member’s physical and behavioral health issues, as well as their social determinants of health, includes nurse practitioners, care managers, pharmacists, dietitians, health and wellness coaches, social workers, and transitional care associates who make sure patients transition home smoothly from the hospital. “The CMO is a living, breathing example of how we work together in an integrative fashion across all of a person’s care needs,” says Rose.
In addition, as technology is increasingly introduced into the health care experience, it is vitally important—especially when caring for an older generation—to make sure that patient education keeps pace. The tablets that our CMO uses for remote monitoring—which record vitals such as blood pressure, blood glucose, respiratory rate, and temperature—also contain education modules to help members better understand their diagnosis, plan of care, risks and red flags, and steps to take should their condition change.
While our CMO represents VNSNY’s newest business line and is highly responsive to the times, it also exemplifies and extends a concept that we have long known and practiced: that the true value of health care lies in attending to whole-patient wellness.
Lillian Wald, our organization’s founder, was the nation’s first public health nurse, hiking up flights of stairs in Lower East Side tenements with her team of devoted nurses to tend to poor, largely immigrant patients suffering from tuberculosis, polio, measles, and other illnesses of the time. While it would never replace the bedside care she delivered, I don’t doubt that if she could have extended care between visits through the use of remote technologies, she would have taken advantage of every opportunity to help the individuals, families, and communities she served.
Lillian would also embrace, I’m quite sure, the data and analytics that help inform us today. In fact, she helped build some of the world’s earliest population health data systems, including a data collection process around the influenza epidemic that swept New York City in 1918. She and her team of nurses drove the public health response to that crisis, creating daily records and using that data to help coordinate the citywide response.
And, of course, she would happily recognize her direct descendants, the tireless and committed care teams—who still, on any given day, can be found climbing flights of stairs in downtown walk-ups, even as the exciting innovations and resources for augmenting that care continue to expand our ability to enrich the health of the vulnerable communities they serve.