Improvement Stories:
Keeping Heart Disease Patients Healthy and Out of the Hospital
Heart failure is the main reason that people over the age of 65 are admitted to hospitals. And, more than half of the readmissions for heart failure are preventable. “Identify and Connect” is a system-wide program at Partners HealthCare that aims to identify the 2,600 heart failure patients we discharge each year and connect them with specialized heart failure outpatient care. Our goal is to improve the quality of their lives and reduce repeat visits to the hospital. We have discharged over 300 patients in the system to a home telemonitoring program that helps the patient and the health care team stay in close touch regarding important signs and symptoms of heart failure. North Shore Medical Center helped create one of the first heart failure programs like this in the United States. Once they identify patients, NSMC staff members meet with them and they explain how to manage the disease with diet, exercise, weight control, and medications. The staff teaches patients to spot their symptoms before a crisis calls for a return to the hospital. Some patients receive follow-up care with a nurse practitioner in the Living Well with Heart Failure Clinic at NSMC’s Salem and Lynn campuses.