Ascension at Home Wisconsin, a network of agencies that support patients’ transition from acute care facilities to their homes, is determined to provide the best care possible. The market for telemonitoring and home health services is growing quickly as hospitals seek to improve the patient experience and decrease readmission rates. However, meeting this growing demand means agencies like Ascension at Home must serve more patients despite an industry-wide talent shortage, beef up educational resources and proactively intervene before patients are readmitted to the hospital. In the past, patients either overwhelmed staff with questions and requests for unscheduled visits, or they didn’t communicate enough and let their health deteriorate between weekly nurse visits. To improve patient care, Ascension at Home needed a robust remote care solution.
Readmission rate for Ascension at Home telemonitoring patients is 8 percent, compared to 24 percent nationally.
“With telemonitoring, we can spot the negative trend in a couple days, rather than waiting until the next nurse visit.”
Nathan Agen, Ascension at Home’s director of clinical services
Providing Collaborative Care
This enables Ascension at Home to provide better care to more patients, without taxing the field staff. “Ascension has around 120 telemonitoring patients at any given time, and they’re spread across the state,” says Dr. Jeffrey Beeson, emergency medicine physician and senior vice president of Evolution Health. “They can’t possibly have nurses in all those locations around the clock. But MCC can do virtual patient visits to answer questions and address concerns. And using the data, we can help Ascension identify and prevent patient decompensation.”
For example, patients with congestive heart failure who gain two or more pounds per day might be retaining fluid. “With telemonitoring, we can spot the negative trend in a couple days, rather than waiting until the next nurse visit, when the patient has gained 15 pounds and can’t breathe.”
Ascension at Home has also enhanced its ongoing disease management education by matching up weekly nurse teaching modules with relevant content from Vivify’s video library. “Home health is that short-term gap to get patients stabilized in their own homes,” says Agen. “A big part of our job is education and encouraging the patient to be engaged in their disease process.”
Ascension at Home has grown its patient population by about 300 people over the past year and has opened up new lines of business.