Sherry Showalter, a licensed clinical social worker with Inova Home Health in Alexandria, calls Miriam Cowles, a Fairfax resident who has congestive heart failure, to see if she is ready for her visit. Cowles, 85, tells Showalter to call her back, she is still eating her breakfast. The fact that the commute from Showalter’s office would be more than 30 minutes is irrelevant. Showalter waits at least 10 minutes,
calls back and the visit begins.
Showalter is able to check Cowles' blood pressure, listen to her heartbeat, ask about her injured ribs caused by a recent fall and generally just chat with her patient. After a few minutes, Cowles lets Showalter know she is in no mood for idle chitchat.
"I'm getting ready to get feisty," Cowles said from the comfort of her living room.
Cowles is one of 29 patients currently enrolled in a pilot program, Elder Community Care, which uses a home telemonitoring system allowing Showalter to "visit" with everyone on a weekly basis using a unit that consists of a video monitor, speaker phone, stethoscope and blood pressure cuff. The program allows patients who have been diagnosed with congestive heart failure (CHF) to have regular home assessments and maintain as much independence as possible.
THE UNITS RECORD the patient’s vital signs and charts them over the course of time. The units also allow Showalter to keep track of the person's medications and any weight losses or gains. The monitoring ensures they are following doctor's orders and helps reduce the need for
"Elders with heart failure, when they are discharged from home health care, are frequent users of the emergency room," Showalter said. "We came up with telemedicine. We're able to check their vitals once or twice a week and provide real intensive community support."
The pilot, funded through a grant from the Virginia Health Care Foundation and money raised at an Inova gala, has had as many as 35 patients at any given time. Showalter estimates it could handle 75 patients, however, the program only has 25 home monitors available. Besides, the weekly televisits, the program involves actual home visits by volunteers, Showalter, registered nurses and physical therapists, as needed. And so far, it has proven successful at keeping people out of the emergency room.
"Ninety percent of congestive heart failure patients return to the emergency room and are admitted. For Inova, 85 percent have return emergency room visits," said Beth Donald, Inova Health System media relations specialist. "Four percent of the people in this program have returned to the emergency room and hospital."
Showalter said one visit to the emergency room, which for a CHF patient typically results in a five- to seven-day hospital stay, can cost up to $5,000 compared to the estimated $300 per month cost of the program.
Thanks to the $50,000 grant and an additional $100,000 from the gala, there is no charge to the patients. Once a patient enters the program, he or she stays until they die, opt out or stabilize and don't need the home care anymore. After the pilot is over, it is possible there will be a need to have some sort of fee.
"I'm hoping once I can show that in the long run the program saves money, people will be willing to put money into it," said Showalter, the program's director. She said Inova is seeking additional grants and lobbying legislators for more funding.
WHEN THE PROJECT was first proposed, Showalter was one of its biggest skeptics. She was not convinced the program would offer the opportunity for herself and the patient to form a relationship and that it would be impersonal. Now she and even her patients, three of which are 100 years old, have been won over. "I think it's very beneficial, if they keep doing it like they should," Cowles said. "I don't miss any of the visits. And anyone who has to go to the doctors knows that. I was going every week."
The televisits, while reducing the need for emergency care, do not replace the patient’s need for regular doctor’s check-ups. However, the units are sensitive enough to allow Showalter or a nurse to detect heart murmurs or other changes that may signal a person needs immediate medical attention. Just recently, Showalter was televisiting with a patient when the monitoring indicated the patient was going into heart failure.
Showalter immediately instructed the patient's husband to take her to the hospital, while she called the emergency room with the patient's vital information. Unfortunately, for some reason the patient refused to go as advised and days later had a massive heart attack. Since the program's
inception last March, Showalter said her first five patients are still with the program, two patients have died and in the case of her first client, the program has helped avoid a crisis situation six times.
Overall, the patients seem to enjoy the televisits and have gotten use to the technology.
"They actually get ready for these visits," said Peggy Taylor, the Inova Home Health regional director.
Showalter had one patient, that for his first visit wore a button shirt, tie and sweater. Now he wears only boxer shorts with the occasional T-shirt. Another time, for a first visit, a patient had a ball gown draped over her. One of her 100-year-old patients giggled when he first saw
himself on the home video monitor, Showalter said.
"It's funny seeing how comfortable they get," Showalter said. "A lot of times they are so sick you see them in their robes. But there are some ladies who can't stand it if their hair is messed up. When you're sick, self image can be important."