Mr. Jack Jones: 18 Months and Counting Without a Hospitalization for Heart Failure

June 30, 2016
Dawn Milstead, BSN, MBA / Vice President, Clinical Innovation, Geneia


At Geneia, technology has a heart. For our physicians, nurses, technologists, analytics experts, and business professionals, that means we understand the heart of healthcare transformation is people. We know our solutions must be helping people like ValJody and Curt who are working to improve healthcare as well as the many patients struggling with chronic conditions.

Throughout this year, we’ve been writing about the people we serve. Today I want to tell you about Mr. Jack Jones and the @Home nurse who works closely with him.

To refresh your memory, Geneia recently announced the results of our successful year-long remote patient monitoring pilot program. In short, the heart failure patients in our @Home remote monitoring pilot fared much better than the control group:

  • Their risk score stabilized, which is indicative of a slowing of disease progression for participants.
  • They spent far less time in the hospital.
  • Their quality of life improved as did their satisfaction with their healthcare experience.

Perhaps you know someone with heart failure. The American Heart Association estimates there were 5.1 million people living with heart failure in 2012 and that number is expected to exceed eight million by 2030.

Heart failure is a common condition within the Medicare population.

According to a 2015 Milliman research report, 11 percent of the more than 53 million Medicare beneficiaries have heart failure.

Living with heart failure is not easy. Patients often experience shortness of breath, fatigue and weakness. Swelling in the legs, ankles and feet is common as are a frequent cough and a rapid or irregular heartbeat. Many need to be on oxygen. Frequent trips to the emergency department and hospitalizations are the norm. Without a doubt, it’s a life-changing diagnosis.

Mr. Jack Jones* is one of the heart failure patients who participated in Geneia’s @Home remote patient monitoring program. Like the other participants, he spent more time in the emergency department and hospital before joining the program, indicating that his condition was uncontrolled. Our predictive analytics suggested that he would be the kind of patient most likely to participate in and benefit from the program – and he was.

Mr. Jones is a 75 year-old male with heart failure and a history of chronic obstructive pulmonary disease (COPD), diabetes, and hypertension. When he entered the program in early 2015, he was on continuous oxygen and his blood sugar and blood pressure were not well-controlled. Being on continuous oxygen kept him home-bound and put him at increased risk for falls due to the extension tubing he had to use to get around his house.

The Geneia @Home program is different than other remote monitoring solutions. Many simply mail patients the technology and connect them with a call center. In contrast, our program has a face-to-face component.

At the outset, the patient’s assigned nurse visits the home to explain the equipment, perform a safety evaluation, and complete a comprehensive needs assessment. The home visit also allows the nurse and patient to develop a trusted working relationship with open communication. The nurse can tailor the program to help the patient achieve their personal goals and their highest level of function.

That’s what happened with Mr. Jones and his @Home nurse, Linda. She established a good rapport with him and developed an education plan individualized to his needs. She worked with him to increase his knowledge of proper diet, deep breathing exercises, and importance of adhering to his physician’s treatment plan.

Each day, Linda reviewed his remote monitoring measurements – blood pressure, pulse oxygen, respiration, weight, blood glucose, heart rate and activity level - to determine trends. If a trend was noted or a measurement was missed, Linda called Mr. Jones to perform an assessment, identify interventions and engage his physician when appropriate.

In the 18 months since Mr. Jones has been in the program, many exciting things have happened:

  • He is no longer required to wear oxygen continuously.
  • His blood pressure has normalized and he is now only on one blood pressure medication.
  • He has been committed to checking his blood sugar every day and, because it has been much more controlled, his insulin has been decreased.
  • He has not had any hospital admissions or emergency department visits for heart failure.

The changes to his social life have been tremendous as well. Rather than being home-bound and fearful, he got on a plane and went to the family wedding. He now enjoys going out with friends and is no longer a homebody.

*The story presented here is used with permission. The name, likeness and certain identifying details have been changed to protect the privacy of the patient.


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