Appl Clin Inform 2016; 07(02): 238-247
DOI: 10.4338/ACI-2015-11-SOA-0157
State of the Art / Best Practice Paper - H3IT Special Topic
Schattauer GmbH

Using Telehealth to Reduce All-Cause 30-Day Hospital Readmissions among Heart Failure Patients Receiving Skilled Home Health Services

Melissa O’Connor
1   Penn Care at Home, University of Pennsylvania Health System
2   Villanova University, College of Nursing
Usavadee Asdornwised
3   Mahidol University, Bangkok, Thailand
Mary Louise Dempsey
4   PENN E-LERT® Telemedicine Program, University of Pennsylvania Health System
Ann Huffenberger
4   PENN E-LERT® Telemedicine Program, University of Pennsylvania Health System
Sandra Jost
1   Penn Care at Home, University of Pennsylvania Health System
Danielle Flynn
1   Penn Care at Home, University of Pennsylvania Health System
Anne Norris
5   Infectious Diseases Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine
› Author Affiliations
The authors would like to acknowledge and thank the University of Pennsylvania Health System for their support of this program.
Further Information

Publication History

received: 20 November 2015

accepted: 02 February 2016

Publication Date:
16 December 2017 (online)



The reduction of all-cause hospital readmission among heart failure (HF) patients is a national priority. Telehealth is one strategy employed to impact this sought-after patient outcome. Prior research indicates varied results on all-cause hospital readmission highlighting the need to understand telehealth processes and optimal strategies in improving patient outcomes.


The purpose of this paper is to describe how one Medicare-certified home health agency launched and maintains a telehealth program intended to reduce all-cause 30-day hospital readmissions among HF patients receiving skilled home health and report its impact on patient outcomes.


Using the Transitional Care Model as a guide, the telehealth program employs a 4G wireless tablet-based system that collects patient vital signs (weight, heart rate, blood pressure and blood oxygenation) via wireless peripherals, and is preloaded with subjective questions related to HF and symptoms and instructional videos.


Year one all-cause 30-day readmission rate was 19.3%. Fiscal year 2015 ended with an all-cause 30-day readmission rate of 5.2%, a reduction by 14 percentage points (a 73% relative reduction) in three years. Telehealth is now an integral part of the University of Pennsylvania Health System’s readmission reduction program.


Telehealth was associated with a reduction in all-cause 30-day readmission for one mid-sized Medicare-certified home health agency. A description of the program is presented as well as lessons learned that have significantly contributed to this program’s success. Future expansion of the program is planned. Telehealth is a promising approach to caring for a chronically ill population while improving a patient’s ability for self-care.

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