Nurse-Driven Remote Monitoring Programs for Heart Failure (HF) Management

Objective: To develop nurse-led remote monitoring programs for HF management to improve quality of life and reduce hospital readmissions.
Background: The nurse-driven remote HF program was developed to refocus the APP's work burden, allowing them to focus on billable encounters. Leveraging a dedicated RN to assess and manage the HF patients keeps team members working at the top of their licenses and allows for consistent, safe patient care.
Methods: A multidisciplinary heart failure team was developed to include an MD and APP, as well as a new HF RN position created for remote HF monitoring. Together, the team streamlined processes and developed tools to ensure a standard workflow was followed. Remote monitoring has enabled us to further support and improve quality of life for our advanced HF patients by allowing us to remotely monitor their fluid status on a daily basis. By doing so we are able to closely follow trends and promptly respond with assessment and interventions. Interventions may include medication adjustments, lab orders, same-day provider visits, and reinforced education. Often, temporary diuretic adjustments combined with reinforced education are enough to prevent hospital readmission.
Results: HF patients feel more empowered in their care and are more likely to reach out in early stages of decompensation, which results in earlier interventions and reduces need for emergency department visits. The RN builds a strong relationship with the patients and works with patient and family to develop an individualized treatment plan. Patients express "feelings of being watched over" and comfort in knowing who to reach out to for questions. In early stages of program development, it was identified that patients benefited from targeted HF education specific to symptom monitoring and management, medication compliance, diet, and additional beneficial resources available through our healthcare system. Because of this, we developed a virtual HF education class tailored to address these specific needs.
Conclusions: Since implementing the nurse-driven HF remote monitoring program, we have expanded the program to include two additional devices that are remotely monitored. As ambulatory care continues to evolve and the pressure to reduce hospital readmissions increases, healthcare organizations will find that remote monitoring in the outpatient setting enables us to provide quality, timely care while reducing the need for emergency services and preventing hospital readmissions.