Cardiac Care Program with Link to Care Transitions Program

 Care Coordination 
 CMS Demonstration 

VNA Health System in Shamokin, Pennsylvania.
Agency Description
VNA Health System has multiple locations throughout central Pennsylvania, including home care, hospice, private duty, adult care, etc.  
Population Impacted
The area includes 18 counties throughout central Pennsylvania and the population targeted is 65 and older with chronic heart conditions that are recently post-operational.
Project Description
The Quality Management Department conducted reviews and research for more than two years on chronic care conditions, reasons for rehospitalizations, knowledge deficit for particular populations, medication management, necessary education, and the use of telehealth monitoring in the home setting. This research was then combined with an already established cardiac education program, able to hit all the necessary areas for complete cardiac patient care. 
The next step was to determine that poor care transitions results in more frequent early rehospitalizations based on the research and cardiac patients. The Quality Management Department then investigated the proper visit frequency for patients with and without telehealth monitoring to benefit from the program. This was done by reviewing the number of frontloading visits, phone calls to follow up in-between visits, and determining when to place the telehealth unit in the home. VNA Health System used national, individual hospital, and state statistics to look at age, demographics, education level, and income to determine the population that would benefit from a link of these patients with the care transitions program. 
Twenty percent of all Medicare patients are readmitted within 30 days. Half of those patients never had a follow-up appointment with their doctor or surgeon. Congestive heart failure (CHF) is one of the top diagnoses in which patients are readmitted frequently, because of a lack of follow-up care and lack of knowledge regarding proper diet for associated illnesses. Lack of knowledge in simple daily weights and how to follow-up with results was found to be missed with patient education very frequently. Medication changes are one of the top three reasons for hospitalization. Research found that the nurse discharging the patient from the hospital had an average of just 21 minutes to perform discharge education. The discharge information was fully comprehended by patients only 25 percent of the time. 
Psychosocial factors increase the risk for early rehospitalizations. Possible use of IV diuretic therapy in the home may decrease the need for ER visits and hospital readmissions. Home telehealth monitoring has shown to be able to determine early signs and symptoms of heart failure, giving the home nurse the ability to contact the physician for medication changes to prevent an ER visit or hospital readmission. In certain areas researched, lack of education and depressed areas with lack of funding may lead to an inability to understand medication regimen and/or purchase medications. Research in certain areas finds lack of caregiver involvement leads to less cooperation from the patient. Without oversight by family member or caregiver, patients do not comply with medication regimen and/or diet regimen, leading to early rehospitalizations.
VNA Health System has proven cost containment by decreasing nursing visits per episode of care related to daily telehealth monitoring. Further, there has been success with patient compliance and appreciation of monitoring. VNA Health System is able to determine other areas of concern, i.e. atrial fibrillation with a patient, blood pressure problems, oxygenation issues, etc. While the telehealth system for monitoring has worked without issues, the equipment used has several problem areas.
Outcome Measures
This program has reduced early hospital readmissions and ER visits, taking into consideration the CHF diagnosis and age population. Not only has this helped with chronic conditions, but also with other telehealth monitoring issues (i.e. BP and/or oxygenation problems) leading to a decrease in readmissions and/or ER visits.
Barriers to Implementation
The main barriers include issues with the telehealth system's accessibility in homes without a phone line or with people that bundle their phone, television, and internet. Outsourcing of telehealth monitoring has also been a barrier because of companies that only perform for several months and because many patients only have cell phones as their main telephone line, causing issues with installing telehealth systems. VNA Health System has added in-house monitoring for more personal control and to acquire the statistics needed to determine the benefits for the targeted populations. Cost control is an issue because insurance companies do not reimburse for telehealth monitoring.