1. Home Health Remote Patient Monitoring For Heart Failure
Background
Heart disease is the leading cause of death in the US
Statistics: 5 million with CHF – 300,000 deaths
Changes to CMS reimbursement
1 in 4 Medicare patients with CHF is readmitted within 30 days of a hospital discharge.
Effectively managing the needs of this rapidly growing population requires modification of current health care delivery models.
Leading cause of death: about 611,000 deaths & costs of >$100 billion / year
Approximately 5 million people in the US have CHF, and it contributes to 300,000 deaths annually.
Effective October 1, 2012, CMS began reducing hospital payments for CHF (readmissions within 30 days of discharge)

2. Home Health Remote Patient Monitoring For Heart Failure
Project Goals
To improve the quality of patient care
Promote self-management
Prevent unnecessary hospital visits
Improve the overall health of this population

3. Home Health Remote Patient Monitoring For Heart Failure
Provide remote patient monitoring of Home Health’s CHF patients.
Selected participants are monitored daily in their home by a designated Home Health nurse.
Scale, Blood Pressure Cuff, Health Check Monitor supports daily monitoring of patient’s vital signs, weight and symptoms

5. How are patients identified for the remote monitoring intervention?
Clinical Criteria:
Heart Failure
Expected length of service 4-6 weeks or more
Exclusion Criteria:
Unwilling or unable to operate remote monitoring equipment
Patient or Caregiver not able to understand and complete health check routine
Residence is not conducive/safe/pest infestation
Patient weighs >450 lbs
Residence does not have electricity
Patient requires hemodialysis

6. Roles User Type Responsibilities Patient
Monitor their blood pressure, weight and other symptoms from their home for improved clinical outcomes, avoidance of unnecessary visits to the ED, and increased patient satisfaction.
Home Health Nurse
Monitor the patient daily and determine the most appropriate care for the patient.
Vendor
Provide the home monitoring devices to the patient, and work with Home Health and Telehealth throughout the contract to assist with equipment needs or contract changes.
Management (Home Health and Telehealth)
Manage the project objectives, ensure that patients’ needs are met, and determine whether to expand the program after project completion.

7. Preparing for Home Health Discharge
Field Staff Support of Transition to patient self-monitoring:
Plan for transition two weeks prior to HH Discharge
Compare and document remote monitoring scale weight versus in-home scale reading
Review education materials again
Notify Remote Monitoring Nurse
Return equipment to office
Patient calls Remote Monitoring Nurse daily until discharge to give daily weight

8. Metrics 15.9% 88% 100% 65% 89% Totals for Program
Measurement
Metric/Target
Measurement Date
Tool
Reports
Decrease in CHF and 30-day hospital readmissions – baseline of 168 patients
10% prevented patient readmissions. Baseline of 25%
Q2 2017
Omnivisor
15.9%
High staff and provider satisfaction with timeliness and clinical benefit received from the services
85% likelihood to recommend
Select Survey
88%
High patient satisfaction
85% positive
Survey tool
100%
Utilization of the Cardiocom units
90% utilization
Cardiocom
65%
Patient Adherence to following their prescribed measurements: weight and BP.
80% adherence
89%
Totals for Program
Number of Unique Patients (Oct '15-Current)
163
Patients admitted within 30 Days of discharge 26
% of Patients Readmitted
16.0%
% National Average (1 in 4)
25%
% of reduction
9.0%
Total Reductions Saved
14.7
Average Cost of readmission within 30 days
$18,000
Estimated Savings
$264,000
Challenges—staffing; since part of large system, many wanting to slice/dice the data, and we have to be careful of data integrity, e.g. patients being counted who never received home health, or who were hospitalized for a planned event

9. Home Health Remote CHF Patient Monitoring
Conclusion and Next Steps
Data is still being evaluated on efficacy of program
If our results are confirmed, we’ll develop this program for other diagnoses, e.g. COPD
We will also need to determine whether there is benefit to expanding this to other services outside of Home Health