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Winthrop’s Telehealth Monitoring Program: Making the Home the Preferred Place of Care

It’s 10 a.m. in the Levittown home of Charlie Dispenzieri. A small medical monitoring device sounds, greeting Mr. Dispenzieri and reminding him that it’s time to take his vitals.


(Pictured left) Patricia Carman, RN, Heart Failure Nurse Coordinator at Winthrop’s Certified Home Health Agency (CHHA), assists Mr. Dispenzieri with taking his vital signs and transmitting them to CHHA Telemonitoring Coordinator Lorraine Greene, RN, (pictured above), for thorough clinical review and evaluation. If the data triggers an alert, Ms. Greene immediately follows up with the patient to inquire about their symptoms.
Every day, the 87-year-old steps on a scale and measures his blood pressure and oxygen with simple devices that attach to the monitoring system, and answers a series of brief questions about how he’s feeling. With the simple touch of a button, he transmits the information through his telephone land-line to a computerized monitoring system for clinical review and evaluation by a nurse in Winthrop- University Hospital’s Certified Home Health Agency (CHHA).

Mr. Dispenzieri suffers from congestive heart failure and for almost two years, he has been a participant in the Agency’s home telemonitoring program – a remote monitoring program that enables patients to take an active role in their care under the daily supervision of a skilled team of clinicians. This specialized program was designed to help patients follow their post-hospital treatment plans through personalized, physician-prescribed therapies, education and support provided at home.

“Telemonitoring has greatly reduced the readmission rate of our patients,” said Anne Calvo, RN, BSN, MPS, Administrator, Winthrop’s Certified Home Health Agency.

Before beginning the telemonitoring program in 2008, frequent hospital admissions were a regular occurrence for Mr. Dispenzieri. But that all changed after Patricia Carman, RN, Heart Failure Nurse Coordinator at Winthrop’s CHHA, conducted a comprehensive assessment of his condition and created a detailed plan of care in consultation with his primary care physician Jack Geffken, DO, of Bethpage Primary Medical Care. Ms. Carman and Dr. Geffken agreed – Mr. Dispenzieri was an ideal candidate for telemonitoring services. Since then, Mr. Dispenzieri has had great success with the program, for which he and his wife, Grace are grateful.

“My husband hasn’t been admitted to the hospital in over a year and a half!” said Mrs. Dispenzieri.

Education

Preventing incidents and conditions that can lead to rehospitilization is one of the Agency’s goals. To that effect, the staff educates patients about self care, disease prevention, nutrition and medication management in order to slow disease progression and avoid unnecessary hospitalization.

“By providing patients with consistent care and educational tools that are current and based on best practices, we teach them how to better manage their conditions so they can stay out of the hospital,” said Ms. Calvo.

For heart failure patients, an informational brochure and DVD with tips for managing heart failure recently compiled by a committee of clinical experts from the Long Island Health Network (LIHN) are just some of the instrumental educational tools that are provided to patients.

“Patients enjoy the educational component of our program because it helps them better understand their condition; it increases compliance and empowers patients to take an active role in their care,” said Ms. Carman, who served as the Winthrop representative on the LIHN committee, and has played an instrumental role in Mr. Dispenzieri’s care and education.

Telemonitoring

Patients in the program are visited periodically by a homecare field nurse. During visitations, the nurse performs a comprehensive physical assessment; teaches the patient how to use the telemonitoring equipment; and educates them about the important roles of medication and lifestyle management.

“The telemonitoring program also helps provide comfort to family members, who can rest assured that their loved one’s care is continuously being monitored,” said Debra Tracy, MS, RN, Mr. Dispenzieri’s long-time homecare field nurse.

Patients take their vital signs each day; the information is sorted within a color-coded computerized system which alerts the nurse if any information is missing, incomplete and when there is a need for immediate intervention. If a patient’s vital signs flag an alert in the system, the nurse immediately follows up with the patient to inquire about their symptoms.

“Sometimes, a simple retest is all that’s needed to address the concern. Other times, patients require care in which case we immediately arrange for a home visitation by the patient’s nurse and follow up with the patient’s physician,” said Lorraine Greene, RN, Telemonitoring Coordinator for Winthrop’s CHHA. Ms. Greene is one of the nurses responsible for performing detailed evaluations of the vitals for the 67 patients currently utilizing telemonitoring services.

“We know our patients well because we deal with them every day. Sometimes they even know it’s us calling to check on them when the phone rings because they learn to recognize any variation in their health status, and know that we will address it immediately,” she added.

A Collaborative Approach

The strong collaboration between Winthrop’s CHHA nurses and patients’ physicians is a vital component of the telemonitoring program. The team works together to rapidly address the needs of patients before they result in complications.

Recently, the telemonitoring program proved its effectiveness, once again. Upon noticing an increase in Mr. Dispenzieri’s heart rate, weight and blood pressure, Joanne McLean, RN, Telemonitoring Coordinator for Winthrop’s CHHA, called Mr. Dispenzieri and arranged for a home visitation by his nurse, Ms. Tracy.

Ms. Tracy immediately went into the home to perform a full physical assessment, and discovered an accumulation of fluid in Mr. Dispenzieri’s lungs. She contacted members of his primary care team, who quickly made adjustments to his diuretics. Just two days later, Mr. Dispenzieri’s weight was down and his doctor is grateful that the Agency’s team intervened before any complications arose.

Winthrop’s Certified Home Health Agency: Among the Best in the U.S.

For the third consecutive year, Winthrop’s Certified Home Health Agency (CHHA) has been recognized among the HomeCare Elite – a compilation of the most successful Medicare-certified home health care providers in the United States.
“Without a doubt, Winthrop’s Home Health Agency team and the telemonitoring program have helped prevent Mr. Dispenzieri’s rehospitalization,” said Dr. Geffken. “The constant communication and reports that the Agency provides keep us informed and help us examine trends in his vital signs and make adjustments to medications when necessary in order to avoid hospitalization.”

Today, as Mr. Dispenzieri continues to utilize the program, his wife takes comfort in knowing that her husband’s care is in good hands.

“With Winthrop’s telemonitoring program, there’s always reassurance that someone is watching over you,” she said.

Although the majority of the referrals for telemonitoring services come from patients hospitalized at Winthrop, patients may also self-refer, be referred by their physician, a family member, neighbor or community organization, or even another hospital.

For more information about Winthrop’s Certified Home Health Agency or telemonitoring services, call 1-866-WINTHROP.
Vol. 20, No. 1
Winter/Spring 2010

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