HRS Analytics

Using HRS’ innovative solutions, Liberty HomeCare’s team was able to reduce readmissions for patients with CHF, Hypertension, and COPD. They leveraged communication tools including text messaging, phone calls, and video conferencing. Clinicians monitored patient vitals, symptoms, and medication adherence 24/7 and promptly responded to patient needs and changes in health status. Communicating with every patient following a high-risk alert enabled the telehealth team to assess, educate, and prevent not only hospitalizations, but future exacerbations.

Frederick Health's CCM telehealth program targeted high-risk patients with an increased risk of hospitalization, including COPD, CHF, diabetes, AFib and hypertension, among others. The solution allowed the CCM clinical team to monitor patient vitals and medication adherence, provide disease-specific education to patients, and improve patient-clinical communication. The telehealth team now performs daily and weekly check-in calls, virtual visits to resolve medication discrepancies, and home visits depending on the patients’ health status. The program has allowed them to prioritize high-risk patients, improving their quality of life while saving them millions in costs.

In April 2020, 3HC expanded its telehealth program, offering a mobile app solution to its patients. Initially targeting heart failure patients already equipped with monitoring devices such as blood pressure cuffs, the mobile telehealth platform is now offered to 3HC patients across numerous high-risk patient populations, including heart attack, AFib, cardiac surgery, and joint replacement surgery. With multiple platforms available to patients, 3HC can offer each patient an individualized care solution. This has resulted in reduced readmissions and increased utilization, patient engagement, and patient satisfaction.

In 2019, Avera@Home launched a pilot telehealth and remote patient monitoring (RPM) cardiac program. In coordination with the Avera Heart Hospital, Avera@Home’s pilot program targeted high-risk cardiac patients to enhance outpatient care, mitigate patient anxiety, and reduce hospital readmissions and ED visits. Within six months, Avera@Home’s pilot program achieved a 3.6% overall 30-day hospital readmission rate and recorded a 95% patient satisfaction rate.

HRS, Hackensack University Medical Center, and Holy Name Hospital launched a multidisciplinary study to evaluate the impact of an advanced practice, nurse-directed patient education approach to heart failure treatment while integrating an interactive 4G android tablet. Patients utilizing the tablet had an 8% readmission rate compared with a 28% readmission rate for patients who did not receive a tablet. This enabled both Jackensack and Holy Name to reduce their Medicare penalty by preventing 5 excess readmissions. The average New Jersey hospital is losing approximately $25,000 for these types of readmissions.