Telemonitoring and the Appropriate Level of Care
Carol Pearce, RN

Following some initial pilot work, Alacare Home Health and Hospice began our organization-wide implementation of telemonitoring approximately four months ago. Patients admitted to this program typically have congestive heart failure necessitating frequent hospitalizations, trips to the ER, and physician-office visits.

The equipment used in this program solicits both objective and subjective information.
During the planning phase of the program, many of us anticipated that we would see some of these telemonitoring patients transition to Hospice. How or why this would occur was not clear to us at that time, but our experience over these last few months has proven that the transition to Hospice is real and not just a theoretical occurrence.

The hows and whys of this transition are varied and are expanding our knowledge of the transfer process from home health to hospice. The variations are patient-specific, but tend to cluster around a recurring theme-the accumulation of daily objective and subjective data that underscore the severity and chronic nature of their disease. The telemonitoring reports provide evidence and become a daily reminder not only that the patient will require repeated, aggressive interventions (likely including hospitalizations) for symptom and vital-sign management, but also that overall health status is progressively declining.

The patient and family also begin to realize the implications of the reports, and in some instances this realization assists them in working through the denial often associated with chronic illnesses. At this point, a referral to Alacare's Palliative Care or Hospice program can be initiated. The palliative care program offers skilled intervention and comfort measures that address the special needs of chronically and terminally ill patients. The hospice program addresses end-of-life issues holistically and begins the important work of improving the quality of remaining life with comfort and dignity. It is at this point we are still continually evaluating and learning how daily monitoring can provide support for the hospice patient and their families. Opportunities exist for the daily readings to optimize pain control through the use of symptom based questions. Additionally readings can provide predictive clinical information that will allow both family and nurse to make timely preparation for end of life. Readings may also assist in triage for nursing access in the rural areas served by Alacare particularly in planning care after hours.

What are the implications of this information for Alacare's telemonitoring program specifically, and the use of home telemonitoring in general? Perhaps that all of us involved in this new frontier of care need to remember the World Health Organization's definition of health as "the state of complete physical, mental and social well-being and not merely the absence of disease and infirmity." Certainly many patients placed on home telemonitoring may never again know the absence of disease, but they can be cared for by providers who consider their patients' holistic needs and who are prepared to address end-of-life issues as soon as the situation warrants. Referral processes that speak to the appropriate level of care for patients, internally if possible or through close working relationships with end-of-life care providers in the community, can help with these transitions.