Care Management

Preventing Readmissions with a Personal Touch

October 23, 2018 2:04 pm

Transitional Cardiac Care (TCC) is an in-home and online cardiac education and monitoring service designed to work with congestive heart failure (CHF) patients to prevent unnecessary hospital readmissions and improve patient quality of life outside the hospital setting. What makes this program unique is its partnership with at-risk patients during the fragile time after discharge. Through monitoring, education, and counseling, the program can simultaneously meet the needs of chronic care patients while freeing acute care clinicians to concentrate on those who require more immediate interventions.

A multifaceted program

When a patient is discharged following a CHF diagnosis, TCC closely follows the individual for 30 days, using proprietary software that syncs with Bluetooth-enabled medical equipment. Through the technology, TCC continuously captures a variety of patient vital signs, including weight, blood pressure, pulse, and pulse oximetry. The readings are automatically sent to an online platform, where there are registered cardiac nurses monitoring them daily.

Should a nurse spot a concerning trend in the patient’s vitals, the organization communicates with the patient via email or text. “We touch base with the individual to get further information about what’s going on,” says Terra Goodrich, founder and CEO of Transitional Cardiac Care. “Sometimes, after we provide education and counseling, the situation resolves itself. Other times, we reach out to the patient’s physician, so he or she can adjust medications or tweak therapies.”

As part of the service, TCC also offers a complete on-demand education portal where patients and families can obtain lifestyle and symptom management tools to guide them in handling their diagnosis on a day-to-day basis. The educational offerings take the form of three-minute videos that use plain language to describe various conditions, medications, and health and wellness information. “Since the videos are relatively brief, patients don’t get distracted or overwhelmed,” says Goodrich. “By combining vital sign monitoring with robust education, we are helping CHF patients make healthier choices and avoid return trips to the acute care setting.”

Stemming from real-world experience

Goodrich created TCC based on a need she saw in treating cardiac patients in the acute setting. “The health systems in which I worked were committed to preventing readmissions, but there was no definitive plan on how to effectively do that,” says Goodrich. “I started asking patients what they thought they would need to successfully live outside the hospital and manage their disease on their own. Their feedback was they wanted someone who would keep an eye on them to make sure they weren’t declining and then educate them on the proper choices in a positive and empowering manner. Many patients with this condition feel lost and overwhelmed and are concerned they will never be well enough to make memories with their loved ones. The worry is that they will always be in and out of the hospital, and that’s not a great way to live. We developed our program to help these patients regain their independence and remain healthy enough to do the things they want and love to do.”

TCC also is sensitive to the healthcare provider perspective. “In addition to the readmission penalties and the rising costs of care, it is disheartening for doctors to keep seeing the same patients over and over with the same problems,” says Goodrich. “We act as an extension of the healthcare organization, helping patients manage their conditions without acute intervention. This ensures that individuals only return to the hospital when they truly need it, allowing physicians to spend more time with those at greatest risk.”

Offering different options increases reach

TCC currently has three avenues for accessing its program:

  • Private play clients. When TCC contracts with an individual patient, a registered cardiac nurse visits the individual within four days of discharge. “Statistics show that most readmissions happen within seven days, and if a patient can’t get in to see a doctor during this time—which is a frequent problem—then the likelihood of readmission goes up.” The nurse establishes a baseline for the vitals and gets the patient set up with the monitoring equipment. He or she then serves as an extra set of eyes for the doctor, intervening if necessary.
  • Licensing with a healthcare facility. TCC also partners with home health organizations, skilled nursing facilities, and hospitals. “We provide licensing or a white-label service,” says Goodrich. “Depending on the circumstance, the organization may have us do everything, or it may have its own nurses perform the in-home visits and we oversee the monitoring. If we spot something amiss, like a blood pressure spike or other worrisome vital sign, we can reach out to the nursing team and suggest they contact the patient or schedule a visit.”
  • Certifying nurses. TCC also certifies other area nurses in the program. This gives clinicians who are operating their own telehealth and post-acute care companies access to a comprehensive monitoring and education program built on best practice.

TCC works with a variety of healthcare entities through these models, expanding their proactive efforts to address CHF and prevent readmissions.

Achieving solid clinical and financial outcomes

TCC’s program has had a significant impact on its patients and the organizations that treat them. “We recently conducted a study with 60 of our patients,” says Goodrich. “There was an average decrease in readmissions of 46 percent, which translated into more than $350,000 in hospital costs.” For those patients readmitted, the average length of stay declined from 5 to 7 days to around 3.5 to 4 days.

Patients also indicated they were highly satisfied with the program. “Every patient we surveyed shared that they came away with a better grasp of their diagnosis and how to manage it,” says Goodrich. “They also tended to be more compliant because they understood that the treatment plan was still in force after they left the hospital and not something they could just forget about.”

The company also has received a positive response from physicians—especially cardiologists. “Any qualified physician can be given privileges into the program,” says Goodrich. “When we reach out to a patient’s physician, he or she knows to log into the program, look at the data, and make decisions about whether to change up medications, treatments, and so on. Since many of these physicians are overtaxed with trying to keep up with their patient loads, our service lets them focus on people who need interventions without having to spend precious time continuously monitoring everyone.”

Looking to the future

Right now, TCC’s offerings center around CHF patients, however the company is interested in expanding to address all readmissions benchmarks, including myocardial infarction, diabetes, chronic obstructive pulmonary disease (COPD), and so on. Going further, the organization hopes at some point that physicians will put individuals who are at risk for these conditions—such as pre-hypertensive or pre-diabetic patients—on the program. This way people can learn how to manage their diet, exercise, and stress level to prevent the onset of these conditions.

The ultimate goal of TCC’s program is to get in front of readmissions and intervene before the patient needs to go to the hospital. “The idea is to not only avoid readmission penalties, but also reduce the costs associated with an emergency room visit and readmission,” says Goodrich. “From a patient perspective, it’s all about helping them realize a better quality of life outside the hospital.”

For more information about Transitional Cardiac Care, go to


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