Hospitals in pursuit of excellence

Remedy for Readmissions

Restructuring care has reduced readmissions at St. Mary?s Duluth (MN) Clinic Heart and Vascular Center, part of Essentia Health. Serving northern Minnesota and northern Wisconsin, SMDC has restructured outpatient care for congestive heart failure patients to combine chronic care and disease management principles and provide home telemonitoring. This program coordinates care for more than 1,400 CHF patients, targeting those at greatest risk, including elderly patients and patients with severe conditions. After hospitalization, patients return for regular follow-up visits, and nurses call patients between visits to check in. For high-risk patients, an in-home telemonitoring system tracks weight and monitors other symptoms. As a result, patients? appropriate use of medications has increased from 50 percent? 60 percent before the program to 95 percent? 98 percent afterward. The six-month readmission rate has decreased to 3 percent ? 4 percent, down from 20 percent? 25 percent, with readmission rates for patients monitored at home averaging less than 2 percent. For more information about SMDC?s program, contact Linda Wick, manager, heart failure program, at linda.wick@essentiahealth.org.