Case Studies

Using In-Home Telemonitoring to Reduce Rehospitalization

The Problem

According to the American Heart Association, heart failure affects about 5.7 million Americans, with 670,000 new cases reported each year. Patients with heart failure typically require frequent hospital admissions, making it one of the most costly cardiovascular ill-nesses. Readmission rates are in the double digits for heart failure patients at many hospitals. BHHC focused on reducing hospital readmissions, lowering health care costs and improving compliance with treatment and quality of life for its heart failure patients.

The Solution

In 2004 BHHC began a program that combines in-home telemonitoring and patient education to care for heart failure patients. BHHC puts telemonitors in the homes of heart failure patients, and patients check their own blood pressure, oxygen saturation, and heart rate, and monitor their weight. The telemonitors, which are about the size of a clock radio, connect to a phone so patients can transmit their vital signs, along with answers to questions about breathing difficulty, ankle swelling, difficulty sleeping, and other health issues. BHHC nurses are trained to monitor the results daily and check in with patients if readings fall outside certain parameters. Unfavorable trends are sent to a physician, who follows up with the patient by phone or in person. Patient education is an important part of the BHHC program. Nurses schedule five to seven home visits within a two-week period for physical assessments and to review instructions and address patient concerns. These visits are scheduled around physician appointments. After each home visit, patients have homework assignments to complete, which involve them in their own care and disease management. Nurses use the teach-back method to assess patients' understanding of what they should be doing and what they need to know. Expected outcomes for the home visits include patients being able to verbalize understanding of instructions, disease management, medication usage, and early warning signs of heart failure.

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