“Transitions in the location of care can create risks for patients,” says Philip Madvig, MD, Associate Executive Director of The Permanente Medical Group in Oakland, California. Patients being discharged home from the hospital “risk losing inpatient improvements when they return to the outpatient setting,” he says.

 

At two of its locations, Kaiser has piloted a program to smooth that transition for congestive heart failure patients, using both human and technological support. “Transition nurses identify heart failure patients in the hospital, and get directly involved in providing intensive education before they are discharged,” says Madvig. These nurses stay in touch with patients at home for several weeks after discharge, helping them get follow-up appointments or referring them to disease management programs.

 

In addition, some patients are trained at home on the use of a device that measures their weight, blood pressure, heart rate and even blood glucose if necessary. “The patient uses the device every day, and data is transmitted by modem to nurse case managers,” says Madvig. Based on protocols, or in consultation with a physician when necessary, the nurse might advise patients to change their medication within a set range, or make diet changes.

 

This home telemonitoring not only helps prevent deterioration, but also gives patients a more sophisticated understanding of how to manage their health. As a result, most patients only need the device for three or four months.

 

The dual approach seems to be working. Madvig says the two medical centers have decreased their hospitalization and readmission rates for heart failure patients to about a third of Kaiser’s average system-wide rate.