Saint Elizabeth’s Medical Center’s Advanced Heart Failure Disease Management Program aims to improve follow-up care and reduce readmissions for patients after a heart failure hospitalization.
The program provides patients with a minimum of two check-in appointments via telemedicine, three and seven days after discharge:
Day 3 – Phone call
- Reinforce discharge instructions/education
- Ensure patients are complaint with medications
- Assure local follow-up has been arranged
- Connect patients to visiting nurse services if necessary
Day 7 – Telehealth visit (or in person if preferred by patient/family)
- Check status of symptoms
- Review lab results when appropriate
- Make medication adjustments when indicated
- Reinforce local follow-up appointments when appropriate
- Assess need for further monitoring via telehealth prior to patient’s follow-up with primary cardiologist or PCP
Heart failure experts from SEMC’s Advanced Heart Failure Center work collaboratively with each patient’s primary cardiologist to adjust treatments when needed. This unique model of care ensures patients stay connected to their local primary cardiologists while receiving personalized, one-on-one virtual care from a SEMC heart failure specialist.
About the Advanced Heart Failure Center
St. Elizabeth’s Advanced Heart Failure Program is recognized as a leader in the New England region. Its multidisciplinary team of experts diagnose and treat cardiomyopathies/heart failure, as well as other complex conditions involving the heart.