Reduce 30-day readmissions for cirrhosis and post-transplant patients by remotely monitoring weight, mental function, medication adherence and temperature

Vandana Khungar,MD,MSc
Clinical Lead
Matt Van Der Tuyn, MA
Innovation Lead
Stephanie Brown, BS
Implementation Lead

The Challenge

Cirrhosis affects 600,000 US adults. Less than half of those waiting for a liver transplant nationally will actually receive one. 2-3 people die a day waiting for a liver transplant. 462 days is average wait time in US. It is therefore critical to ensure that people who receive a transplant adhere to post-discharge protocols closely. The national re-admission rate is 35%.

Patients with cirrhosis and those who have undergone a liver transplant are very ill and it takes a lot of effort to keep them out of the hospital. Many patients with cirrhosis are so ill that their estimated 3 month mortality is greater than 50%. At Penn Medicine, 29% of cirrhosis patients and 32% of patients who have a liver transplant are readmitted within 30 days of discharge. Together, the readmissions for these populations lead to more than $21 million in costs each year.

Telehealth has not yet been attempted in this population but looking to CHF as a model population we can model our work off another disease state that has successfully employed this technology.

The Approach / Study Overview

The initial pilot tested a remote monitoring approach in which a 90 day telehealth monitoring by highly skilled RNs process was utilized. Bluetooth scales, BP monitors and pulse oximeters were given to patients along with a 4G tablet. Patients with cirrhosis and those who had undergone a liver transplant were eligible but due to home nursing criteria, there was limited eligibility. The study was successful and was able to show readmission reduction from 28% (the average) to 13%. However, the cost to implement this was too high - both in terms of technology and personnel and therefore not scalable

Way to Health was then utilized as the solution to automate the above process. An automated SMS based solution was designed and tested to engage patients post discharge and monitor their weight, temperature and medication adherence. The platform allowed the clinical team to build in algorithms to flag patients with maximum risk, thereby improving the staff’s efficiency.

Way to Health use

The Way to Health Platform was used to support the LiveBetter Program in the following ways:

  • Two way texting: SMS for medication reminders and also to receive BP and other data
  • Rules Engine: Implementation of a clinician designed algorithm to detect abnormalities for follow-up
  • Alerts: To providers or other care providers in case of violations

Using the Way To Health services:

  • 90% of messages were managed by the Way to Health platform alone and did not require follow-up
  • Messages that did require attention were first triaged by a patient liaison and then escalated to an RN as needed
  • Finally, less than 4% of messages were escalated further and required MD / PA involvement
  • Cost of treatment (devices etc.) was reduced from $1050 to less than $50 per patient
  • Most importantly, the refined intervention resulted in a 43% reduction in 30-day readmissions among the pilot population. At scale, these results are projected to lead to a $6.8 million reduction in costs related to cirrhosis 30-day readmission costs, and a $2.2 million reduction in costs for 30-day liver transplant readmissions annually.

Results / Outcomes

Based on the following results, the team aims to test this intervention further in a year-long pragmatic trial before making this the standard of care at Penn Medicine.

  • Reduced 7 day readmissions by 43%
  • Reduced preventable readmits by 75%
  • Reduced staff utilization while still maintaining level of care
  • Reduced per patient device costs from $1000+ to less than $50