Connected Cardiac Care
Connected Cardiac Care is a home tele-monitoring and education program for patients with Heart Failure (HF) who are at risk for hospitalization. Patients are referred by hospital case managers, nurse practitioners, PCPs, cardiologists and other clinicians. Once enrolled, the tele-monitoring team at Partners
HealthCare At Home works with each patient providing daily support, education, and care coordination.
For over 5 years, Connected Cardiac Care has been effective in keeping patients healthy at home, and out of the hospital. We have seen a 48% decrease in re-hospitalizations by these patients after enrollment in the program. The program continues to expand across the Partners HealthCare system.
What do patients do?
Each morning , using provided technology, patients take their blood pressure, pulse, oxygen levels, and weight. They then answer symptom questions on the touch-screen computer, and send the data to Partners HealthCare At Home. A nurse reviews the data and appropriate intervention is taken when readings are outside established parameters. This includes a call to the patient and, when necessary, coordination with the patients’ physicians.
Why does it work?
Connected Cardiac Care is conducted at home in the patient’s own environment. Daily monitoring, “just in time” teaching, and weekly structured education sessions, help patients become keenly aware of their daily behaviors and the impact this has on their condition. Patients learn specific interventions that make a difference. This results in behavior changes and the development of new self-management skills. When patients are out of parameters, collaboration with clinicians and MDs often results in prompt intervention and avoiding unplanned admissions. Patients surveyed say the program increased their confidence and improved their understanding of HF and helped them avoid hospitalizations.
For more information:
If you are a Partners-affiliated physician or clinician, you can refer your heart failure patients to the program by contacting our Nurse Coordinator, Regina Nieves, at cccp@partners.org or 617-347-9600.
Patient Information
CCCP Physician Orders document
CCCP Referral document
CCCP Summary document
Below photos courtesy of Partners HealthCare At Home