At Partners HealthCare, home monitoring and education for patients with heart failure are part of the standard of care. Those who are at risk for hospitalization or recently discharged from the hospital are enrolled in the program. Once enrolled, the tele-monitoring team at Partners HealthCare at Home works with each patient, providing timely support, education and care coordination.
For over five years, the heart failure monitoring program has been effective in keeping patients healthy at home, and out of the hospital. For these patients, we have seen significant decrease in 90 day re-hospitalizations as well as improvements in mortality.
Each morning, patients take their blood pressure, pulse, oxygen levels and weight. In addition, patients answer symptom questions on a small touch-screen computer, and transmit the data to Partners HealthCare at Home. A nurse reviews the data and, when readings are outside established parameters, appropriate intervention is taken. This includes a call to the patient to check on their condition and, when necessary, coordination with the patient's physicians.
Daily monitoring, “just in time” teaching, and weekly, structured education sessions help patients become keenly aware of their daily behaviors and the impact such things as nutrition, medication, and exercise have on their condition. Patients learn specific interventions that make a difference.
This results in behavior changes and the development of new self-management skills. When patients are out of established clinical parameters, collaboration with providers often results in prompt intervention, thus avoiding unplanned hospital admissions. Patients surveyed say the program increased their confidence and improved their understanding of heart failure and helped them avoid hospitalizations.
If you are a Partners clinician and would like to refer a patient to this program, please contact Partners HealthCare at Home at: firstname.lastname@example.org or 1-800-307-4898.