Community Health Network considers it a failure of the system if a patient with chronic illness has to go to the hospital. Deborah Lyons, Community Health Network's disease management executive director, describes how the integration of telehealth into care of heart failure patients is helping to keep hospital readmission rates down for this population.
It’s all part of Community’s network strategy. That’s really a failure of the system if a patient has to go to the hospital—at least for those with chronic diseases. Our strategy has been to keep patients out of the hospital regardless of disease type. We want to keep patients out of the hospital.
As part of an integrated strategy, we’ve used our experts in home care to do high-risk home visits rather than creating a siloed entity to do this. Home care was doing telehealth for their homebound patients in home care, and we didn’t want to recreate this functionality. We chose to work with our home care telehealth experts and expand this to the non-homebound population.
This network strategy helps us to better manage the health of patients by looking at what expertise exists and then expanding it to meet the population needs.
When we first started developing the strategy, we also started with heart failure originally because we have a lot of heart failure patients and an issue with readmissions.
When we looked at the heart failure patients, we found that first, about 43 percent of our patients that were readmitted were patients that were discharged home to self-care, meaning they didn’t qualify for traditional home care. They weren’t going into a facility. These were people that were going home alone. And this group was driving 43 percent of our readmissions.
When we looked at what was occurring in our own network, we also found that our home care agency was doing telehealth with their home care patients and had a national best readmission rate. We asked ourselves how we could replicate this for our non-homebound patients. There are experts there that are getting great results. Now we want to apply this to our non-homebound population. And that’s where we decided to do this with IVR, the automated telephonic system that calls the patients at home.
Excerpted from: New Horizons in Healthcare Home Visits