A year-long home health monitoring and care coordination pilot in Hawaii has already seen marked results in reducing hospital admissions and patient emergency room visits.
The Hawaii Island Care Coordination Services on Wednesday announced the results of its pilot, which enrolled 78 high-cost, high-risk patients across the island of Hawaii. These patients all had complex care needs due to chronic diseases, such as diabetes, high cholesterol and were frequently admitted to the ER. The patients received the help of a care coordinator registered nurse and a health coach for a year. Forty-two of the 78 patients also received in-home health monitoring technology for that time.
The RN worked with each patient to create a service plan to improve his or her health, pilot officials said. They provided ongoing education about their complex conditions, helped patients get access to specialists, and helped keep track of prescriptions and appointments.
Officials say the health coach provided support to make lifestyle changes, and the home health monitoring allowed the patient to take biometric readings at home such as blood pressure, blood sugar and weight; submit the data electronically to the RN; track their own progress; log food intake, exercise and activities; and communicate with the RN via video calls.
Data showed a significant impact during the pilot’s 12-month timeframe, including:
● 36 percent improvement in HbA1c blood sugar
● 37 percent improvement in triglycerides
● 29 percent reduction in inpatient hospital admissions
● 25 percent reduction in emergency room visits
Officials do note, however, that due to the small sample size and short intervention period, the reductions in ER visits and hospital readmission numbers – despite being striking – were not conclusive.
"These results show that care coordination is highly effective, even in a short amount of time," said Susan B. Hunt, project director and CEO for Hawaii Island Beacon Community, which supported HICCS, in a Sept. 18 news release.
"It was inspiring to watch people’s lives change," added Dew-Anne Langcaon, co-founder of HICCS, in a news release. "People who were homebound overwhelmed and in declining health are now hopeful and excited to live life again. They gained confidence in knowing how to manage their health together with their primary care physician, and by the end of the study, most felt empowered to take control of their own plan for wellness."
This complex care coordination pilot with HICCS was one of HIBC’s nine initiatives to improve health care on Hawai‘i Island: care coordination, care transitions, patient engagement, practice redesign, health information technology, health information exchange, payment reform, wellness, and data collection and analysis. In addition to the HICCS care coordination pilot, additional care coordination pilots were conducted at Bay Clinic, Hāmākua Health Center, and West Hawaii Community Health Center.with health insurance through HMSA.