Using Health360 to Reduce Readmissions and Keep Patients Healthy at Home

Tribridge is helping Barnes Healthcare Services (Barnes), one of the largest privately-owned post-acute care providers in the country, to leverage an innovative approach to monitor patients for post-discharge to curb readmissions and drive adherence and wellness in managing chronic conditions.

After a successful pilot, the provider has turned to Tribridge Health360 to scale the Healthy at Home project, which equips patients with tablets and appropriate tracking technology for home monitoring including blood pressure cuff, scale, pulse oximeter and other monitoring devices.

Barnes is leveraging the Health360 platform to:

  • Collect and analyze patient data gathered from IoT devices and surveys
  • Evaluate patient readmission risk
  • Proactively monitor patient data to quickly identify potential condition exacerbations
  • Deliver self-care and other educational materials

By identifying patients in danger of readmission or relapse, Barnes staff can intervene to provide the specialized help they need in their homes without returning to the hospital.

Connectivity with IoT devices

To effectively and efficiently manage care across geographically dispersed patients, Barnes relies heavily on devices “internet of things” (IoT) . From blood pressure cuffs and pulse oximeters to weight scales, the Healthy at Home team can closely monitor each patient for critical changes that may require intervention, even when they are remote.

Each day, the patient logs into the portal and answers personalized questions based on their condition. Based on the answers to those questions and the quantitative data from the IoT devices, Health360 aggregates the data, analyzes it and tabulates symptom scores that calculate the risks for readmissions or a worsening of the patient’s condition.

Evaluation scores that indicate a high potential for a negative health issue are immediately sent to clinical staff for personal follow-up. Readings that are slightly out of range may trigger the portal to deliver patient education. That education may include text, images or short videos.

A patient with CHF (Congestive Heart Failure), for example, may be asked questions about last night’s sleep, any swelling in the limbs or headaches. The answer to the swelling question, coupled with the patient’s weight today weight versus their historical weight, could indicate that an intervention is needed. Tribridge developed the branching logic behind the health questions for the Health360 platform.

Overall, the scores help clinicians identify patients who are at risk and require immediate medical response, those who remain borderline and those who are responding well to their individualized treatment plan and likely will not need monitoring past the 30 or 60-day mark.

Based on success with Healthy at Home, Barnes is now using Health360 for chronic care management and data generation for nonclinical purposes, including producing data on success rates for interventions and referrals that can help secure new partnerships with providers and employers.

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