Individuals with chronic diseases often face many trips to the hospital each year. These readmissions to the hospital are challenging for both the patients and our healthcare system, and many are preventable.
Celtic Healthcare decided to take on the daunting task of readmissions for their chronically ill patients by establishing a Virtual Care Program in partnership with Carlisle Regional Medical Center in Carlisle, Pennsylvania. The program’s goal is to ensure no interruption in patient care, which can go a long way toward reducing unnecessary readmissions. In the program’s two years, Celtic Healthcare has been able to reduce readmissions for individuals with heart failure from 14 percent to just under 5 percent.
How It Works
Celtic Healthcare’s Virtual Care Program has two components that work together. One revolves primarily around coaching; the other is telehealth care.
A Virtual Care Coach, who works closely with Case Managers, identifies patients most appropriate for participation in the program. The coach gets the necessary medical records and paperwork aligned before the patient is discharged from the hospital to ensure there is no gap in care due to incomplete information.
Involving a Virtual Care Coach, who is typically a Registered Nurse or Medical Social Worker, provides extensive care coordination, including assurance that prescriptions have been sent directly to the patient’s pharmacy. Adding this accelerated layer of support is critical, because many times home care or follow-up physician appointments do not occur for several days after discharge. Research has found that the highest rate of re-hospitalization occurs within seven to 10 days after discharge from the hospital.
The Virtual Care Coach often recommends telehealth technology. If this step makes sense, our Home Health Nurse sets up the telehealth program and teaches the patient how to take his own vital signs (weight, blood pressure and oxygen level) at the same time each day. The patient then reports through an automated telephone system. A specially trained nurse reviews the data on a daily basis. If something is not right, the nurse contacts the patient and, if necessary, the doctor. The nurse also schedules weekly phone education sessions with the patient to ensure that the patient understands lifestyle changes needed to be successful in managing his own disease.
Why It Works
People with chronic diseases who require complex care frequently receive care in multiple settings. Healthcare professionals in these settings often work independently from one another, which can lead to lack of information about the care for the patient. When this occurs, patient care and safety is compromised. This can lead to rehospitalization.
Patients Experience Empowerment at Home
Celtic Healthcare’s program is designed to ensure both coordination and continuity of care. It is all about improving patients’ confidence in their ability to care for themselves and learn when and why to alert their doctor or nurses if something doesn’t seem right. Ultimately, getting patients to understand their vital signs and symptoms and what they mean will help prevent unnecessary readmissions.
Celtic Healthcare’s goal is to keep patients at home, where they want to be. The program gives patients the opportunity to succeed at home, where they are comfortable. We know there still are going to be times when a patient needs to return to the hospital, but the program is helping prevent a significant number of preventable readmissions. Reducing heart failure readmissions to less than 5 percent speaks for itself. We know our program is working.
Better patient understanding leads to better quality of life and, ultimately, less of an impact on the healthcare system. Patient welfare is our priority. At Celtic Healthcare, we have created a program that is contributing to reducing preventable hospital readmissions and creating a better quality of life for our patients.
by Dr. Tonya Miller, PT, DPT, Eastern Regional Vice President for Celtic Healthcare.
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