Chronic Care Management Tool Becomes Important Patient Resource

Imagine stepping on the scale, and, before you know it, a nurse from National Jewish Health is calling to check on you. Your numbers — sent automatically through a home monitoring device — suggest your body may be retaining fluid, an early sign of worsening heart failure. Now your care team is on the phone with you, helping you adjust your medication and prevent a possible hospital visit.

That’s the real-time responsiveness of National Jewish Health Chronic Care Management, an innovative tool designed to keep patients with complex, long-term conditions connected to their care teams. Using a suite of home monitoring devices, participants record vital information such as oxygen levels, heart rate, blood pressure and weight. Those numbers feed directly to a team of nurses and care coordinators who monitor trends, identify potential problems early and reach out to patients before symptoms become serious.

Erika Kaye, executive director of Ambulatory Practice at National Jewish Health, has seen firsthand how powerful that connection can be. “They love having access to the toys,” she said with a laugh, referring to the blood pressure cuffs, pulse oximeters and smart scales patients use at home. “Let’s say someone has congestive heart failure, and they have an increase in their weight overnight. We’re going to see the weight increase in the dashboard, call them, and let them know how to manage it. It’s a great feeling.”

For Kaye and her team, that feeling comes from dozens of daily interventions. “The patients have been super happy,” she said. “For instance, there was someone last night. They checked their pulse oximeter, their oxygen level, and they were at 84%. And we called within three minutes. When the patient answered, she said, ‘I knew you guys would be calling.’”

Team members will monitor information and make contact with patients from 8 a.m. to 5 p.m., seven days a week all year. When new information comes in overnight, staff will contact patients promptly the next day.

Behind these swift responses is a sophisticated dashboard that displays data from every enrolled patient. Each color-coded alert that comes in through the system prompts the team of nurses to review recent readings, note patterns and make calls that can prevent complications before they escalate.

The model is flexible across multiple conditions. However, the tool is specifically designed for patients with two or more chronic conditions. “We started monitoring pulmonology, cardiac issues, and pulmonary hypertension when we started last year. Since then, we’ve expanded to a range of chronic conditions, including autoimmune and rheumatological diseases. We’re about to kick off sarcoidosis, and we’re building support for gastrointestinal diseases as well, including ulcerative colitis, Crohn’s disease and liver diseases.”

The number of patients using the tool has also grown considerably over the year. “We have hundreds of patients using the tool now,” said Kaye. “We’re now at the point where we can call about 100 patients a day who need a follow-up.” The increase, Kaye noted, shows not only how many patients are enrolling, but also how efficiently the team is using the system to deliver care.

One thing that stands out to Kaye about the Chronic Care Management tool is how much patients value the human touch that the technology enables. “It’s pretty incredible for these patients when we call them when something’s wrong, versus them waking up and feeling like garbage and thinking, ‘Oh, I feel badly. Should I call my doctor or not?’”

The balance of high-tech tools and human attention is at the heart of the program’s success. “The patients seem just delighted that someone else is paying attention to their health, even when they’re not,” Kaye said. For patients with chronic conditions, that kind of care is more than convenience; it’s peace of mind.