Targeting Heart Failure Readmissions
with Telehealth Monitoring

To further investigate gaps in care, Central Maine Medical Center expanded a team already focused on outcomes improvement for 30-day readmissions to include providers, nurses, home care and hospice. The resulting intervention incorporated home health visits supplemented with telehealth, explains Susan Horton, DNP, APRN, CHFN, executive director of Central Maine Heart and Vascular Institute. This innovative work also led to other home-based interventions that were not always restricted to individuals identified by Medicare as homebound.

Guide to Home Visits for the Medically Complex"About that time our home care and hospice group approached us. They had the opportunity to write a grant for telehealth monitors. They wanted to know whether Central Maine would support that application so that they could then target these telehealth monitors for our heart failure population," Horton explains in the Guide to Home Visits for the Medically Complex. For more information on this resource, please visit:

"We supported that grant, and they got it. However, that decision caused us to determine that we needed to be more strategic in our partnership with home care and hospice. From that, we developed a job description and hired a full time equivalent: 20 hours on the medical center payroll, and 20 hours on the home care and hospice payroll," she added. "Thatís where the home visit program really took off. We were able to say that whether Patient A meets Medicare criteria for homebound or not, home care would go into the patientís home as a guest of Central Maine Medical Center. We explained to each patient at the time of discharge that we wanted to evaluate their home situation to make sure they were safe."

Horton said this was important because they were looking at all-cause readmissions. If a heart failure patient living in an unsafe situation trips and falls and gets readmitted with a head injury, thatís still going to be a black mark for heart failure readmission. Itís all-cause readmission. "We felt that we needed to assess what was going on in the home. Who was there for the patient? What were they doing in terms of support? Could they take their medication? Did they have a scale? Could they read the scale?," she said. "And we would offer telehealth."

To order your copy of Guide to Home Visits for the Medically Complex today, please visit:

You may also be interested in these care transition resources: