1. Collaboration of Care through Home Telehealth for HF
Evidence Based Outcomes
Veteran self-management skills supported
Veteran satisfaction exceeds goals
Collaboration supports HF management
Hospital readmission rates decrease
Collaboration between
PACT, Home Telehealth,
and Specialty Providers
(Cardiology / HF clinics)
supports management
Veteran Engagement -
Assessment + “S.M.A.R.T.” Goal Setting
RN Monitoring
Problem Identification
Interdisciplinary collaboration
Early Intervention
Communication –
Partnership : Veteran, Telehealth RN + Care Team
Veteran
Improved self management + outcomes
Disease Management Protocol (DMP) Topics
What is heart failure?
Symptom recognition / knowing when + who to call Preventing problems
Managing HF symptoms
Proper use of medications
Monitoring fluid intake
Working with your health care team
Daily weights
Managing Blood Pressure
Diet
Tobacco and alcohol use
Benefits of physical activity
Safety with exercise
Health promotion and vaccines
Preparing for emergencies
Living a healthy lifestyle
Advance directives
Poster Presenter:
Debora Deverel, MSN, RN
Home Telehealth
VA Palo Alto Health Care System
VISN 21
June, 2016

2. References:
Antonicelli, R., Mazzanti, I., Abbatecola, A., Parati, G., (2010). Impact of Home Patient Telemonitoring on Use of beta blockers in Congestive Heart Failure. Drugs Aging , , 2010.
Baker, L., Macaulay, D., Sorg, R., Diener, M., Johnson, S., & Birnbaum, H. (2013). Effects of Care Management and Telehealth: A Longitudinal Analysis Using Medicare Data. Journal of American Geriatrics Society, 61, doi: /jgs.12407
Darkins, A., Kendall, S., Edmonson, E., Young, M., & Stressel, P. (2015). Reduced Cost and Mortality Using Home Telehealth to promote Self-Management of Complex Chronic Conditions: A retrospective Matched cohort Study of 4,999 Veteran Patients. Telemedicine and E-Health, (January). doi: /tmj
Noel, H., Vogel, D., Cornwall, D., & Levin, F. (n.d.). Home telehealth reduces healthcare costs. Telemedicine, 10(2),
Smith, A. C. (2013). Effect of Telemonitoring on Re-Admission in Patients with Congestive Heart Failure. Medsurg Nursing, 22(1), January/February,