We have pilots underway at several hospitals to help them manage the care transition of patients post-discharge with the objective of reducing readmissions. So far, these pilots have focused on informing the patient daily of their care plan activities, having a clinician monitor their biometric device and self-reported data, and intervening when necessary before the patient’s condition deteriorates to the point that rehospitalization is required.
Not yet included in these pilots, our platform includes the capability of having multiple clinicians participate in the patient’s care team to coordinate care plan activities, collaborate in monitoring the patient’s progress and deciding on appropriate interventions when indicated.
Also not yet included in these pilots, the patient can also invite family members to participate, so they can monitor the progress of the patient. Our belief is that the involvement of family members will motivate the patient to be more engaged and compliant with their care plan, with the family members providing a support network to help the patient through the period of care. An added benefit is that for patients that live remotely from family members, they will benefit from the contact and engagement by their family members – especially important for elderly patients. As an example, a child monitoring their parent could see if the patient has not taken their meds, or has suddenly lost a significant amount of weight, and could call their parent and check what is going on.
Our first pilot of these capabilities are with Patient Al, an elderly person with several comorbidities, including diabetes and cancer. There are three physicians that are members of Patient Al’s Care Team, and five Family Members are monitoring his progress, all through the iGetBetter system. Data from biometric devices and self-reported data include weight, blood pressure, heart rate, blood glucose level, blood oxygen saturation, exercise adherence, medication adherence, appetite level, sleep quality, anxiety/depression level and pain level.
In the first three weeks, the members of the Care Team monitoring him have addressed a couple of situations successfully that might not have been noticed without the iGetBetter system, and his Family Members have checked in with him several times when they noticed some of his data not being optimal. The result is that Patient Al is better engaged and focused on his own care, with an improved outcome, and feels his family is really connected with him and supporting him through this process.
The outcome of this first pilot is so positive, we have started a pilot with another patient with three physicians participating on his Care Team, and one Family Member.
We think we are on the right track to comprehensive care management and coordination that improves patient outcomes and avoids unnecessary readmissions. How much do we believe in our approach?
Patient Al is my Dad.
Win Burke, President & CEO