Chronic condition management using remote monitoring and telehomecare

Individuals afflicted with multiple chronic conditions should be managed in real life settings and real time, while simultaneously reducing use of costly acute care services. New models of care delivery will enable patient participation in life-long care management programs and activities that target “wellness” while minimizing, delaying, or preventing clinical deterioration that requires hospitalization and/or visits to emergency care facilities. Successful care models will likely require new organizational and financial approaches that re-purpose health professional roles, responsibilities, and relationships. Remote monitoring and telehomecare technologies that employ advanced data management and analytic algorithms as well as dashboard displays of clinician- and services-relevant health information will support clinician decision-making at the point and time of care. Optimally, health professional financial incentives will be re-structured to support and sustain outcomes-driven long term chronic care that rewards efficiency and effectiveness. We present a work-in-progress model, RightHealthTM, including pilot project outcomes.