Abstract
Telehealth in home care has proven to decrease rehospitalization rates across the country. This article describes one home care agency's journey and strategies that have reduced the rehospitalization rate of patients with heart failure. Early identification of high-risk patients, implementation of a dedicated staff person to facilitate referrals and monitor the program, intensive staff education, and clinical collaboration has resulted in measurable outcomes. This northeastern U.S. home care provider, that is, the Rockingham Visiting Nurse and Hospice Association, has demonstrated reduced hospitalizations for heart failure patients by 17%.
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