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Community VNA Case Study

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Overview

Community VNA Engages Patients, Coordinates with Physicians using Telehealth

Community VNA is a community-based, healthcare agency serving southern Massachusetts. Community VNA provides skilled nursing care, social services, and rehabilitative therapies to individuals in their homes, and is committed to improving patient outcomes and access to care services.

Challenge

In Massachusetts, over four million people have at least one chronic condition and nearly two million suffer from two or more chronic conditions. Chronic diseases place a heavy burden on patients and their families, both emotionally and financially. Community VNA launched a telehealth and remote patient monitoring (RPM) program in 2005 to provide additional support to high-acuity, chronic care patients. Through telehealth, Community VNA addresses the following challenges to chronic care management:

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Clinician Collaboration: Coordinating between primary care physicians (PCPs), specialty physicians, and other providers.

Pill Bottle

Medication Compliance: Educating patients on their condition and medication regimen, ensuring patients are compliant.

Hospital + Health Systems

Emergency Department (ED) Visits and Hospitalizations: Identifying exacerbations to prevent ED visits and hospital readmissions.

Countryside House

Barriers to Healthcare Access: Addressing the social determinants of health (SDoH) that impact patients’ overall health and quality of life.

Solution

Care coordination and patient communication are pivotal components to chronic care management and a successful telehealth program. To enhance coordination across providers and ensure patient engagement, Community VNA operates its telehealth and RPM program through a centralized model.

In a centralized model, Community VNA leverages dedicated installers to educate patients on the platform, field nurses to provide in-home care services, and a nurse monitor to triage patients, perform virtual visits, and communicate with physicians.

Community VNA’s Centralized Telehealth Model Improves Patient Outcomes by:

  • Prioritizing Patient Engagement: Dedicated installers are responsible for introducing patients to the telehealth platform, ensuring patients are comfortable with the technology and understand the benefits to their health.

  • Building Patient Trust: Daily calls, performed by the nurse monitor, answer any questions patients have, and establish trust between patients and their care team.

  • Strengthening Care Continuity: Patient reports, highlighting biometrics trends and medication compliance, are reviewed and shared with referring physicians to make timely and appropriate changes to patient care.

  • Preventing Hospitalizations: Risk alerts and virtual visits are used to monitor and triage patients, allowing Community VNA to intervene and prevent adverse outcomes. 

The ability to not only see patients’ vital signs but to see them in real-time and perform a virtual visit with them is amazing and has added tremendous value to our services. We’re able to keep patients home, where they want to be while providing comfort to patients and families, and protecting our staff at Community VNA.

- Sandy Legg-Forgiel
Community VNA

Daily Patient Adherence Rate

Average Patient Satisfaction Rate

30-Day Hospital Readmission Rate

Results

To evaluate the success of the telehealth and RPM program, Community VNA assesses several key metrics, including patient adherence, patient satisfaction, and hospital readmissions across patient populations.

From January through June 2021, Community VNA recorded an average 7% 30-day hospital readmission rate for its telehealth enrollees. Specifically, among telehealth patients diagnosed with COPD and CHF, Community VNA averaged hospital readmission rates of 0% and 2.2%, respectively.

Community VNA largely attributes their reduction in hospital readmissions to the daily engagement of their patients with the telehealth program, boasting a 93.7% daily patient adherence rate. Due to the additional support and education provided to patients via telehealth, Community VNA also averaged monthly patient satisfaction rates over 95%.