The Heart Institute’s Telehome Monitoring Program (THM) is a nurse-run, intensive, post-discharge home health program designed to improve patient outcomes and reduce hospital readmissions. It is part of the Telehealth Programs run by the Cardiac Telehealth department.
The largest acute home monitoring program of its kind in Canada, it has reduced hospital readmission of heart failure patients by 54%, saving up to $20,000 in health care costs for every patient diverted from an emergency room visit or hospital stay. Most patients enrolled in the telehome monitoring program have advanced heart failure, though some patients with pulmonary artery hypertension or who have undergone complex surgery may also participate.
Patients determined to be in need of the extensive daily follow-up are referred to the program before discharge from the Heart Institute. All patients receive several pieces of home monitoring equipment and training in how to use them before they are discharged:
- a scale
- an automated blood pressure cuff
- a pocket ECG (optional)
- a home monitor that transmits vital signs and other pertinent data to a central station manned by expert cardiac nurses at the Heart Institute
Once home, patients use the equipment as taught once a day to transmit their vital signs and weight by regular phone line or cellular connection. A nurse at the Heart Institute reviews the data daily, contacts the patients as needed for further assessment, and alerts a Heart Institute physician if safe levels in any of the parameters are breached. Patients’ diets and medications can be adjusted as needed.
Patients’ primary physicians and families are kept informed of the monitoring results and of any required changes in medications. Patients stay in the Telehome Monitoring Program from one to four months after discharge, depending on the severity of their disease. Some patients who require longer follow-up are transitioned to an automated calling or interactive voice response system, with calls from the system every two weeks.
With support from the Champlain LHIN, the Heart Institute has deployed monitoring equipment to most of the community hospitals. This allows identification of patients and training to be done locally, with follow-up by the THM nursing staff in collaboration with community physicians.