Page 7 Case Studies in Telehealth Adoption Partners Health Care Connecting Heart Failure Patients to Through Monitoring

PArTners heAlThcAre: connecTing heArT FAilure PATienTs To Providers Through remoTe moniToring
valuable when they were newly diagnosed or trying
to regain control of their diabetes. Electronic com-
munication between providers and patients outside of
scheduled office visits was perceived as important in
improving diabetes management.
THE CONNECTED CARDIAC CARE
PROGRAM
CCCP is developing new ways to help patients at risk
for hospitalization to manage their heart disease, by
integrating technology into remote patient care and
supporting self-monitoring. Contract changes to the
Medicare payment structure for the home care indus-
try—in which Medicare provided a prospective pay-
ment rate for up to 60 days of service—presented an
impetus to create CCCP. Partners HealthCare at Home
(PCAH), one of the region’s largest home care provid- This impact leads to changes in behavior and the devel-
ers, partnered with the Center for Connected Health to
develop CCCP, and provides all of the telemonitoring
nurses and clinical support for the program. PCAH,
which is recognized as a top-performing agency by the
Centers for Medicare and Medicaid Services, offers
medical, therapeutic, and supportive home-based ser-
vices for patients who are recovering from a hospital-
ization, managing chronic illness, or those who need
assistance to remain in their own homes.
CCCP’s core components are care coordina-
tion, education, and development of self-management
skills through telemonitoring. Patients use equip-
ment—a home monitoring device with peripherals
to collect weight, blood pressure, and heart rate mea- patients from across the Partners HealthCare system on
surements, and a touch-screen computer to answer
questions about symptoms—on a daily basis for four
months. Telemonitoring nurses monitor these vitals,
respond to out-of-parameter alerts, and guide patients
through structured biweekly heart failure educa-
tion (Exhibit 6). This concentrated effort is effec-
tive in meeting the primary goal of reducing hospital
readmissions.
PCAH was initially interested in using tele-
health under the new Medicare reimbursement model
to leverage staff across more patients. Heart failure
was targeted as a priority condition because of the
7
high costs involved in caring for heart failure patients
and the potential savings from preventing unnecessary
admissions to hospitals. The support of Partners’ senior
leadership was critical to the program’s expansion. In
particular, the leadership’s interest in connected health
solutions as a way to augment care delivery system-
wide and its commitment of funds to support the devel-
opment of the program have been critical to scaling
CCCP across Partners’ network.
CCCP allows patients to monitor their physi-
ological health on a daily basis and provides a virtual
link to their health care team from their home. Daily
monitoring, “just-in-time” teaching—based on the
immediacy of interventions in response to monitored
patient data—and weekly structured education sessions
help patients become aware of their daily behaviors.
opment of new self-management skills. The CCCP
team provides the technology, support, and training. It
also installs equipment in patients’ homes and shows
them how to use it. PCAH and other clinical partners
provide the expertise for successfully designing and
implementing the technology for use in care practices.
There is no cost to patients to enroll or for use
of the equipment. The program is open to all patients
with a Partners’ affiliated primary care physician or
cardiologist. Patients are referred by hospital case
managers, nurse practitioners, primary care physicians,
cardiologists, and other clinicians. Since the inception
of CCCP in 2006, the program has included eligible
an opt-out basis.
Evaluations of CCCP have been limited to
before and after evaluations rather than randomized
controlled trials. Such assessments have shown a posi-
tive, sizable effect in reducing readmissions, which
increased the comfort level among Partners senior
leadership with the intervention. There has also been
ongoing iterative research using small groups of people
to assess the intervention and identify the need for
modifications. CCH has also been working with PCH to
test effective adoption and the role of financial incen-
tive mechanisms to facilitate spread. CCH’s in-house