November/December 2015

Remote Monitoring in Geriatric Care
By Julie Carr, RN
Today's Geriatric Medicine
Vol. 8 No. 6 P. 26

There is no denying that our population is getting older. In a 2014 report, the US Census Bureau projected that the population aged 65 and older will reach 83.7 million by 2050, nearly double the 2012 estimates. By comparison, the number of geriatric care specialists has failed to keep pace with the growth of the older adult community. The shortage of care professionals, specifically in assisted living facilities, has led to significantly increased workloads and has resulted in high turnover rates industrywide, a trend that threatens to negatively impact the overall quality of elder care.

The health and well-being of older adults can change in an instant, and the stagnant growth among assisted living professionals means fewer caregivers monitoring and caring for those in greatest need of care. Amid the health care industry's continuing focus on pay-for-performance measures and meaningful use, remote patient monitoring (RPM) systems have emerged as effective solutions to help improve care for the aging population.

Passive Monitoring
The concept is simple: Create a reliable tool that allows care managers to monitor older adults' health without compromising their freedom or privacy.

Early forms of in-home monitoring have long existed in geriatric care, most commonly for tracking patients' vital signs. While vitals monitoring has become increasingly popular in recent years, care improvements associated with the technology remain inconsistent for two reasons. Operationally, these systems require patients to actively participate in the daily measurement of blood pressure, pulse, weight, and other metrics, which often limits compliance. Furthermore, significant changes in vitals often indicate the need for immediate, and in some cases emergency, medical attention. As a result, traditional vitals monitoring often delivers negligible health benefits and an increased cost of care.

Thus, in order to generate significant improvements in patient care and the caregiver workflow, RPM must not only enable 100% compliance but also do what traditional vitals monitoring cannot—detect possible conditions in advance of visible symptoms.

Long before vitals decline, patients exhibit changes in their activities of daily living (ADLs) that can indicate the onset of possible medical problems. Effective RPM systems take a passive or "hands-off" approach to monitoring. They use remote sensors placed throughout a patient's home to monitor for significant changes in ADLs, including movement in the home, toileting sessions, kitchen activity, and bed "loading and unloading." Once sensors are in place, patients carry on with their normal routines while the system monitors all in-home activity. The absence of a need for direct patient interaction results in 100% compliance among participants, an imperative requirement in tracking ADLs.

After the initial setup, RPM systems establish a baseline for patient activity and then begin monitoring for variations in routines. The success of passive monitoring stems from its ability to collect data continuously, 24/7. Consistently healthy older adults show little variance in ADLs, while those with chronic or emerging conditions display fluctuations in their daily routines. Upon detecting a change in ADLs, RPM generates alerts for caregivers, notifying them of the need to initiate contact with a patient and potentially schedule an appointment with a primary care provider. Alert methods vary among systems, though two common approaches include notifications via an RPM portal or dashboard and e-mail.

The overall goal of RPM is to improve senior care and, by extension, long-term wellness. The challenge is that patients' health is expected to change with time, causing a potential lasting variance in the initial baseline metrics. To counter this problem, RPM systems update baseline data on a rolling-calendar basis and set new benchmarks for ADLs based on these changes, thereby ensuring the accuracy and efficacy of alerts.

The Power of Data
In its infancy, remote monitoring aimed to improve the health of patients with chronic conditions. The primary goal focused on reducing the complications associated with congestive heart failure (CHF), COPD, and diabetes. These conditions have a significant effect on patients' daily routines, emphasizing the need to monitor key ADLs such as in-home movement, sleep quality, toileting, and kitchen activity. For example, patients suffering from CHF often show a reduction in toileting during the day and an increase in toileting at night, as well as restless sleep. Alerts indicating a significant decrease in bed loading have become a hallmark sign of CHF, as patients often abandon their beds in favor of a recliner, where sitting upright allows them to breathe more easily. Upon receiving these alerts, caregivers conduct a follow-up visit to inquire about the ADL changes and, when appropriate, schedule an appointment with the patient's primary care provider. Once confirmed, patients receive the medications and treatment necessary to prevent hospitalization.

It's important to note that the responsibility of diagnosing patients lies solely with physicians, not RPM metrics and alerts. Instead, data provide caregivers with the insight needed to manage and improve the lives of older adults who are or may become sick.

As the technology continues to mature, it has become clear that ADL monitoring helps detect conditions beyond those originally intended. Alerts for increased toileting, for example, help detect urinary tract infections long before a patient complains of symptoms. Conversely, a decrease in toileting, combined with inactivity in the home, can indicate dehydration. RPM isn't limited to physical ailments; its reach extends to psychological conditions as well. Alerts for restless sleep and in-home activity during late or early hours often indicate the onset of depression, a condition that is difficult for many patients to discuss.

Whether the condition is physical or psychological, the data within these systems alone do not improve patient care. Like any tool, RPM's abilities depend on the professionals behind them.

A Tool for Care
The exponential growth of geriatrics populations continues to place undue stress on many caregivers who are already overworked. As a result, low job satisfaction and high turnover rates continue to plague the geriatric care profession and, subsequently, reduce the quality of life for many older adults. RPM has demonstrated the ability to curb this trend by helping professionals better manage older adult populations. At the click of a mouse, caregivers can view the ADL metrics of every patient in their charge.

While this may seem like an impersonal approach to a traditionally compassionate trade, in reality RPM can improve relationships between older adults and their caregivers. The details of how elders live and interact with their environments give staff members advance knowledge when conducting rounds, particularly in an overpopulated facility. When patients trigger ADL alerts, caregivers know the precise problem and can engage elders accordingly. Consider an individual who suffers from restless sleep. During normal rounds when a nurse asks how she slept, she may not complain or simply not remember the severity of the problem. When an ADL alert is triggered, a nurse knows exactly which problem needs to be addressed and can press the issue if a patient dismisses the concern.

The Future of Care — Preparing for Boomers
Remote monitoring use remains inconsistent throughout the industry as the regulatory environment becomes increasingly complex. The 2014 LeadingAge Ziegler 150, a report on 150 nonprofit assisted living communities, showed that 76.6% of the surveyed facilities had adopted electronic point-of-care or point-of-service documentation systems, while only 4.1% had adopted systems for RPM. While current priorities have made RPM a luxury for many, its value to providers and patients may soon make it a necessity.

In 2014, the Centers for Medicare & Medicaid Services (CMS) drafted a provision to cover remote monitoring for managing chronic care using the updated current procedural terminology, though reimbursements are limited to certain providers, conditions, and types of RPM. However, as adoption increases and providers demonstrate its value, CMS could begin to incentivize monitoring as a pay-for-performance measure—a move that would mutually benefit facilities' operations and financials as well as older adults' quality of life.

In its current state, RPM can significantly improve older adults' quality of life. As developers and providers continue to innovate and realize the possibilities of ADL metrics, they are providing baby boomers a glimpse of their care in the future. Current advances in cloud technology allow RPM to more easily extend beyond care facilities and into private residences, while improvements in health information technology interoperability can begin to link ADL data with electronic health records and decision-support technology.

However, the foundation of care, particularly in geriatrics, lies within patient interactions and the questions every caregiver asks, such as, How did you sleep? How's your appetite? Are you getting enough exercise?

RPM strengthens this foundation by leveraging the latest health information technology innovations to deliver more quality answers, thereby achieving older adults' and providers' desires to age in place and improve long-term health.

— Julie Carr, RN, is the director of clinical operations for Healthsense, Inc in Minneapolis.