Sentara Home Care Employs Telehealth to Reduce Hospital Readmissions

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Sentara Home Care Services has achieved a 30-day all-cause readmission rate of 9.09% for their telehealth patients after partnering with Health Recovery Solutions in December 2018.

We believe in the ability of technology to bolster patient care and highly value patient engagement to promote patient independence.

Sentara Home Care Services has achieved a 30-day all-cause readmission rate of 9.09% for their telehealth patients over seven months; 39% lower than the average hospital readmission rate among Medicare patients in Virginia. In December 2018, Sentara Home Care partnered with Health Recovery Solutions, bringing advanced telehealth and remote monitoring to their high-acuity patients.

Patients enrolled in the telehealth program primarily suffer from CHF, COPD, and other chronic conditions. Sentara telehealth patients show an average acuity of 3.62 according to SHP, placing their risk for readmission 25% higher than Sentara’s non-telehealth patients. Sentara's telehealth program has maintained an average patient satisfaction score of over 90% from January through June of this year.

Sentara attributes the telehealth program's success to the care continuum set up by the clinical team. The telehealth clinical team leverages the use of a centralized care model and careful clinical documentation to ensure communication across providers and quality care for all patients.

Patients are enrolled in Sentara's telehealth program following a direct physician referral or home health nurse assessment. Once enrolled, patients receive a 4G tablet, pre-loaded with HRS' software, and a suite of Bluetooth devices to record their vital signs, including weight, blood pressure, and heart rate. Via the tablet, patients also have access to educational videos and quizzes, daily symptom surveys, and medication reminders. Patient data, from biometric readings to survey and quiz answers, are forwarded in real-time from the patient's tablet to the clinicians' dashboard at Sentara's central office.

Sentara's centralized care model places a dedicated team of nurses at the core of the care team. The primary responsibility of the nursing team is to monitor the vital signs and health status of patients on the telehealth program. The telehealth nurses collaborate directly with nurses and physicians when an intervention is required to mitigate a patient's symptoms or prevent an ED visit or hospitalization.

When a patient's vitals fall out of normal range, the central telehealth team contacts the patient immediately to retest the patient's vital signs and document any additional symptoms. An intervention is deemed necessary if the patient's vital sign abnormalities persist, prompting the central telehealth team to contact the patient's nurse, as well as send a trending report to the patient's physician.

The tablet and telehealth software provided by HRS enable continuous communication between patient, clinician, and caregiver through voice calling, three-way video conferencing, and text messaging platforms. In recent months, Sentara's telehealth team has significantly increased the use of text messaging to improve patient engagement, resulting in monthly patient satisfaction scores over 90%.

“We have experienced an increase in patient engagement when patients utilize all features of the system, i.e. those patients reviewing their disease-specific educational sessions tend to be more engaged in their care, said Kim Bradley, Nurse Executive and Director of Clinical Services at Sentara Home Care. “We believe in the ability of technology to bolster patient care and highly value patient engagement to promote patient independence.”

“Sentara’s Telehealth Team is capitalizing on the full capabilities of a telehealth and remote monitoring platform through their detailed clinical documentation, use of text messaging, and implementation of a centralized telehealth model, resulting in fewer hospital readmissions and healthier patients,” added Nolan Santosa, Director of Client Success at HRS.

About Sentara Home Care Services
Sentara Home Care Services is the leading provider of home health and hospice services in Virginia and Northeastern North Carolina. The organization provides a full spectrum of home care services to meet the individual needs of patients and works closely with physicians to coordinate the multiple therapies and services each patient may require – from skilled nursing care and rehabilitative services to infusion therapy and hospice care. Sentara Home Care Services is part of Norfolk, Va.-based Sentara Healthcare. To learn more about Sentara Home Care Services, visit or call 1-888-461-5649.

About Health Recovery Solutions
Health Recovery Solutions (HRS) supplies leading health systems with the most advanced remote monitoring platform and technology-enabled management services focused on changing patient behavior to reduce readmissions and improve clinical outcomes. HRS' disease-specific telehealth solutions are customized with educational videos, care plans, and medication reminders while also integrated with Bluetooth peripherals to engage patients. For clinicians, HRS' software allows for the management of high-risk patients and provides seamless communication with them through video chat, wound imaging, and text messaging. For family members and caregivers, HRS' software gives them the ability to be fully involved in their family member's care and well-being. To learn more about Health Recovery Solutions, visit or call 347-699-6477.

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Tess Meehan
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