Summary
Background
The reduction of all-cause hospital readmission among heart failure (HF) patients
is a national priority. Telehealth is one strategy employed to impact this sought-after
patient outcome. Prior research indicates varied results on all-cause hospital readmission
highlighting the need to understand telehealth processes and optimal strategies in
improving patient outcomes.
Objectives
The purpose of this paper is to describe how one Medicare-certified home health agency
launched and maintains a telehealth program intended to reduce all-cause 30-day hospital
readmissions among HF patients receiving skilled home health and report its impact
on patient outcomes.
Methods
Using the Transitional Care Model as a guide, the telehealth program employs a 4G
wireless tablet-based system that collects patient vital signs (weight, heart rate,
blood pressure and blood oxygenation) via wireless peripherals, and is preloaded with
subjective questions related to HF and symptoms and instructional videos.
Results
Year one all-cause 30-day readmission rate was 19.3%. Fiscal year 2015 ended with
an all-cause 30-day readmission rate of 5.2%, a reduction by 14 percentage points
(a 73% relative reduction) in three years. Telehealth is now an integral part of the
University of Pennsylvania Health System’s readmission reduction program.
Conclusions
Telehealth was associated with a reduction in all-cause 30-day readmission for one
mid-sized Medicare-certified home health agency. A description of the program is presented
as well as lessons learned that have significantly contributed to this program’s success.
Future expansion of the program is planned. Telehealth is a promising approach to
caring for a chronically ill population while improving a patient’s ability for self-care.
Keywords
Telehealth - hospital readmission - hospitalization - heart failure - home health
