Page 8 Case Studies in Telehealth Adoption Partners Health Care Connecting Heart Failure Patients to Through Monitoring

8 The commonweAlTh Fund

analysis estimates that the program has generated total the workflow to enable providers to more effectively
cost savings of more than $10 million since 2006 for assess patient status and provide just-in-time care and
the more than 1,200 enrolled patients (Exhibit 7). education, and using personal health data to help edu-
cate and motivate patients to make necessary lifestyle
LESSONS LEARNED IN TAKING CCCP changes. Even though it has not always been met with
FROM PILOT TO SCALE immediate success, the organization has persevered
Partners’ experience with connected health technolo- to introduce telehealth-enabled care management
gies and with successfully implementing telehealth- solutions, to generate evidence of impact, and to use
enabled programs across the provider network high- that evidence to advocate for broader deployment
lights the significant potential value of transforming across the provider network. This experience imparts
care delivery, improving care outcomes, and lowering important lessons for the successful planning, imple-
costs. Social processes are as important in ensuring mentation and deployment of telehealth-enabled care
program success as are the technical factors. Key social management programs at scale and for identifying
factors include leadership support and the champion- future opportunities for continued program advances in
ing of technology, the integration of patient data into patient care management.

Exhibit 6. Key Features of the Connected Cardiac Care Program

ü Four-month home telemonitoring of congestive heart failure patients by a telemonitoring nurse

ü Intervention by telemonitoring nurse based on physician orders
ü Interactive patient education and lifestyle management

ü Reports posted in electronic health record with email alerts to physicians and nurse practitioners
ü No cost to the patient

ü Open to patients with a Partners’ afiliated primary care physician or cardiologist

Who is eligible? Who is not eligible?
• Patients age 18 and older with a diagnosis of heart failure • Patients currently receiving skilled home care services***

• Patients considered to be at high risk for hospitalization • Patients with end-stage renal disease on dialysis

• Patients who have a Partners’ afiliated primary care physician • Patients with organ transplant
or cardiologist • Patients in hospice

• Patients covered by Medicare, Medicaid, or certain patients in
the safety net* • Patients with an active cancer diagnosis

• Patients able to speak and read English** • Patients who reside in nursing homes
• Patients mentally competent and willing** • Patients who do not have a stable environment to conduct
the monitoring
• Patients with a traditional phone line
• Patients with any physical disability that precludes use of
telemonitoring equipment

* Limited funding available for some patients with commercial insurance.
** Or those with a primary caregiver willing to assume responsibility for telemonitoring.
*** Exception: Partners' Health at Home skilled Medicaid and commercial patients.
Source: Partners HealthCare System, Connected Cardiac Care Program, http://www.connected-health.org/media/224132/cccp summary 6 2 11.doc.