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September 3, 2013

Follow-up care without a visit to a doctor’s office

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Central Virginia residents recently released from University of Virginia Medical Center will receive extra help managing chronic illnesses – but they won’t need to visit a doctor’s office to receive assistance.

UVA Continuum Home Health is teaming with Broad Axe Care Coordination LLC to establish a care coordination center (C3) in Charlottesville. Patients recently discharged from UVA with heart failure, pneumonia, COPD or after suffering a heart attack can receive 60 days of home monitoring. The goal: Prevent patients from being readmitted to the hospital .

The service is available beginning Sept. 3 and will be provided at no additional cost to recently hospitalized UVA patients from Albemarle, Culpeper, Greene, Madison, Orange, Louisa, Fluvanna, Buckingham, Nelson, Augusta, and Rockingham counties as well as Charlottesville, Waynesboro, Staunton and Harrisonburg.

How the C3 works

A staff member from the C3 will visit patients at home to install monitoring equipment, such as a blood pressure cuff and scale, and teach patients how to transmit information to the monitoring center. “The C3 staff will place the equipment where the patient would like to have it in their home and make sure they’re comfortable using it,” said Maggie Short, RN, MSN, NEA-BC, administrator for UVA Continuum Home Health.

Nurse care coordinators at the C3 will review the vital signs information transmitted by each patient as well as the answers to symptom-related survey questions. The regular flow of information will help nurses quickly identify at-risk patients and enable a speedy intervention to prevent a hospital readmission and protect a patient’s health if the data shows any concerning trends or the patient stops transmitting data. But the center will do more than just track vital signs, Short said: “We also want to help educate patients through this process.”

The nurses will also help patients keep track of their medications, comply with discharge instructions, schedule follow-up appointments and ensure all of the patient’s healthcare needs are being met.

“The level of institutional support we have received from UVA Health System has been extraordinary,” said Broad Axe CEO Kirby Farrell. “It has enabled Broad Axe to develop a complete Remote Care Management Service that begins with detailed data analytics, integrates with UVA’s inpatient and outpatient clinical services and then reports in a meaningful way back to the Health System.”

Planned expansion to Southwest and Southside Virginia

In the first year, UVA hopes to enroll more than 1,000 patients in the C3 program, Short says. Working with the UVA Center for Telehealth , there are also plans to expand the program to patients in Southwest and Southside Virginia with the help of grant funding from the Virginia Tobacco Indemnification and Community Revitalization Commission and the office of UVA President Teresa A. Sullivan. Satellite care coordination centers in both regions are scheduled to open in December 2013.


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