Beginning in October, under the Patient Protection and Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) will impose penalties on hospitals with high readmissions for patients with congestive heart failure, myocardial infarction and pneumonia. The penalties, which will recover CMS provider payments, are motivating hospitals across the country to find ways to lower their readmission rates.

A number of techniques have been developed or improved as healthcare providers figure out how to not just treat the sick but also how to keep people healthy. Can it be done through electronic medical records, integrated care or better discharge routines? There are several ways to better track and maintain a patient’s health.

Recognizing how challenging the transition from acute care to home can be, Mercy Home Health, a member of Mercy Health System of Southeastern Pennsylvania, has found one way to improve the healing process at home while reducing hospital readmissions — its Telehealth program.

Every morning, Telehealth patients step onto a scale, strap on a blood pressure cuff and clip on a fingertip pulse oximetry device, which monitors heart rate, oxygen saturation and weight. The information captured on the device is wirelessly sent to a small monitor connected to the patient’s landline phone. Within a few minutes, a Mercy Telehealth coordinator receives the patient’s vital signs and analyzes the results. The daily snapshot provides an important picture of a patient’s behaviors and trends, allowing the coordinators to intervene if necessary.

“Mercy Home Health nurses are connected to you all the time. You get up and get weighed, take your blood pressure and pulse; it all goes right to their office,” says Patricia Prelle, a 75-year-old Telehealth patient with diabetes and congestive heart failure. “If your blood pressure is a little high, there's someone on the phone to find out why."

The partnership and collaboration between Mercy and the patient’s physician is equally as important. When a patient starts the telehealth program, the physician establishes normal parameters for weight, blood pressure and blood oxygen level. If, for example, a coordinator is alerted that a patient’s blood pressure is significantly above or below the parameters set by their physician, the home health nurse is alerted. The nurse contacts the physician and together they identify the root cause and a course of action, which often circumvent the need for an ER visit or hospital readmission.

“Because we see our patient’s vital signs daily, they tend to follow their physician’s discharge instructions more closely,” says David Dolt, a telehealth coordinator for Mercy Home Health.  “As a secondary benefit, telehealth instills comfort in patients and lessens their worries, including when to call the doctor or when to return to the hospital.”

On average, Mercy Home Health patients use the telehealth monitoring equipment for 50 to 60 days. During the time they are enrolled in the program, patients play an active role in their healthcare management, learning more about their disease and the appropriate parameters in which they should fall. Mercy has found that after experiencing the telehealth program, patients have adopted sustainable lifestyle improvements. They have increased knowledge, confidence and feel more comfortable self-managing their health.

But beyond empowering patients to take a more active role in their healthcare management, Mercy’s Telehealth program has yielded notable results. Every patient referred to Mercy Home Health with a cardiovascular, respiratory or chronic illness is offered the Telehealth program. All the patient needs is a telephone line and the ability to self-administer the home monitoring equipment (with or without the aid of a caregiver).

In the four years since the inception of telehealth, Mercy’s patients have achieved lower readmission rates. Specifically, in 2011, Mercy Home Health’s Telehealth patient’s readmission rate within 30 days of discharge from a hospital was 11 percent. According to OCS HomeCare research, the average readmission rate for home care agencies across the nation is 26.9 percent overall.

“The telehealth program works because it provides person-centered, coordinated care management across the continuum,” says Ruth Martynowicz, vice president of operations for Mercy Home Health. “The patient is an active participant in their own care, nurses are in the home visiting the patient regularly, the telehealth coordinators are monitoring their vital signs daily, and the physician is in contact with both the patient and Mercy Home Health. This is exemplary of the person-centered care model at its best.”

Taryn Duckett is the director of marketing and communications at Mercy Home Health. Mercy Home Health is part of the Mercy Health System of Southeastern Pennsylvania. She can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it. or 215-339-4520.

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