By Liberty Fallon
“It is a good thing you came in to see me today, Mr. Jones, you have some fluid beginning to build up in your lungs. If you had waited a couple more days, I believe you would have ended up admitted to the hospital with acute congestive heart failure (CHF) exacerbation.” There have been a number of similar comments made by physicians who have patients being monitored remotely. In this case, the patient had become increasingly short of breath and after his weight triggered an alert to his community paramedic (CP) he was encouraged to call his physician. “I really didn’t want to bother my physician, after all I felt okay overall, but my Community Paramedic insisted I call. I am grateful that I did though, I was able to avoid spending another week in the hospital.”
There is something to be said about empowering patients by involving them in managing their health and providing education surrounding their given health issues. Remote patient monitoring (RPM) does just this.“ The confidence this program gives patients speaks for itself,” said Community Paramedic Cathie, “I have heard it from many of my clients. They feel safer knowing that someone is keeping an eye on them and it provides peace of mind to their family.”
By providing patients with equipment that they can use in the comfort of their home, yet still be connected to a health-care provider offers a level of confidence in the patient’s ability to self-manage their chronic disease. There is a program currently that enlists the expertise of community paramedics to provide patient education and RPM. This initiative across Ontario is referred to as Community Paramedicine Remote Patient Monitoring or CPRPM.
Patients living with congestive heart failure or chronic obstructive pulmonary disease (COPD) are often regarded as the ‘frequent fliers’ of the healthcare system. Paramedic services in collaboration with community partners identify eligible patients who are at high risk of independence loss due to the challenges of self-managing their chronic disease. Once identified, the community paramedic engages the patient and asks if they would like to participate.
Once enrolled, community paramedics visit each patient in their home and the patient is provided a set of bluetooth enabled devices relating to their disease. Depending on the nature of the patient’s conditions a weigh scale, blood pressure cuff, pulse oximeter and/or glucometer are provided. In addition to the equipment and education provided to each patient by the community paramedic, a customized care plan and alert thresholds are established and uploaded to that patient’s profile.
The patient is asked to take their readings each day, which are automatically transmitted to the community paramedic.If a patient falls outside of their predetermined set of alert thresholds, an alert is sent to the community paramedic to review.“People oddly enough struggle with how simple it is to use, they expect it to be more complicated than it is.After they do it a couple times they realize how easy it is,” said Community Paramedic Steve.
Community paramedics look for trending data and based on their objective findings combined with the patient’s symptoms they are able to decide what the best course of action is. In some cases, community paramedics may choose to schedule a home visit to further evaluate the patient or consult with the patient’s primary care physician or specialist. Sometimes a referral to another agency for home oxygen therapy or supplemental support such as a personal support worker to assist the patient is generated by the community paramedic. In any case, each contact the community paramedic makes with the patient is an opportunity to celebrate strategies that are proving effective as well as teach patients and caregivers about their biometric values, symptom management and strategies to improve their chronic disease self-management. “Well, Mrs. Smith your weight was up today but you feel okay. Can you tell me what you had to eat last night? I see … did you know corned beef is full of sodium?” Unfortunately, patients are not aware of all of the dos and don’ts with regard to their disease as many primary care providers do not have the time to share all of this information.
Thus, communication amongst health-care providers is key to the success of a Remote patient monitoring program and educating patients as a collaborative team. Remote patient monitoring provides an effective platform to foster or enhance partnerships across interdisciplinary health-care providers. In one case, a patient with a longstanding history of diabetes had blood glucose values exceeding 16 mmol/l on average. After a couple weeks of monitoring the community paramedic was able to substantiate a blood glucose trend and unite the physician and diabetic educator. The patient’s medications were titrated and he met with the diabetic educator. This combined effort resulted in his blood glucose values being decreased to single digits. Without Remote Patient Monitoring and inter-professional communication, it is unlikely this would have been resolved so efficiently.
Not only do patients feel more comfortable and safe in their homes, their family members do as well.“The long weekend was approaching and I went away with my kids.When I called my sister (who has COPD) to see how she was faring, I noticed she sounded winded.She said she was okay although I thought differently.I decided to leave it and we hung up”.The same patient was trending negatively in terms of SpO2 readings and the community paramedic took notice and called her.After speaking with the patient it was decided that the physician’s office should be notified.The physician reviewed her data and brought her in to the office to initiate treatment to prevent any further exacerbation and avoid a hospital admission.“When I came back from vacation and heard what had happened, I immediately called and left a message for the community paramedic to let her know how grateful we are”. These sentiments have been echoed time after time.
As with everything, there are challenges that surround Remote patient monitoring.The main challenge has been the consistent use of the technology by the patient, which in turn can lead to false alerts.There is a learning curve for patients after being introduced to the equipment. After a week or so patients generally become comfortable and figure out the best time and way to take their readings.Also, the alert thresholds set do not fit everyone.There are always outliers that require threshold adjustments. To adjust these parameters the community paramedic consults the patient’s physician, which is simply another opportunity to discuss the patient’s health status, progress and how to best improve their quality of life.
Although getting used to the equipment takes some practice, a significant benefit to Remote patient monitoring is that patients are not required to self-report, which has been a well-known issue amongst physicians. Self-reporting leaves room for patient transcription error, omission of high or low readings they do not want the physician to know about or not bringing the log to the appointments. With Remote patient monitoring clinical reports can be faxed to the physician, completely eliminating this issue.
We have had a few patients discharge from our program because they felt confident enough in knowing how to monitor their vitals and gauge their symptoms. Kudos to Remote patient monitoring and the care provided by community paramedics for empowering these patients. “I bought myself a blood pressure cuff and a pulse oximeter to take my readings, I know now what ‘good’ numbers are and I know that even if I have a ‘good’ number but feel short of breath that I should call my physician. Before this program I used to just call 911 if I got short of breath. Now I know the difference between when I should call 911 and when I should call my physician.”
As a result of the marriage of technology and the clinical acumen of community paramedics, we have experienced a dramatic reduction in 911 calls from this ‘frequent flier’ population. The benefits to the patient include reductions in adverse events from their chronic disease, reduction in the urgent use of paramedic services, reductions in emergency department and hospital admissions and an improved quality of life. Additional benefits of Remote patient monitoring and community paramedicine to the health care system include a reduced demand for long-term care and empowering older adults to remain independent and living in their own home with the support of loved ones and caregivers.
The financial offset to governments, insurance companies and the patients are enormous. We are in the process of evaluating the full scope of the financial impact to the paramedic and health Systems. While there are many arguments for supporting Remote patient monitoring and community paramedicine, I am convinced that by assisting someone to manage their own health with Remote patient monitoring we can increase their confidence and ability to self-care exponentially. Only good can come of that.
About The Author
Liberty Fallon as a Bachelors of Human Kinetics from the University of Windsor. After finishing her degree, she completed an American College of Sports Medicine Internship at a hospital in the United States which resulted in a full time position as an Exercise Physiologist in a Cardiac Rehabilitation and Exercise Physiology Laboratory. After having children, she left the hospital setting and became Clinical Manager of a privately owned and operated Cardiology Clinic which concentrated on transforming health care service delivery through innovative technology. Her passion for preventative medicine and technology is responsible for her career path leading her to Community Paramedicine and Remote Patient Monitoring.