Avera Health
- Project Title: Avera@Home Connected Care
- Grant Period: FY2021 Rural Health Care Services Outreach Program (Outreach Track), 2021-2025
- Program Representative Interviewed: Rhonda Wiering, Vice President of Clinical Growth and Innovation
- Location: South Dakota
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Program Overview: The Avera@Home Connected Care program is a care transitions program
supporting patients with congestive heart failure after hospital discharge using remote patient monitoring
(RPM) in rural South Dakota. The CHF Connected Care program connects patients with nurses, a cardiac
specialist, and a pharmacist through a cellular-data-enabled tablet for text messaging and video calls. The
tablet allows for a personalized patient care plan and interface between the clinic's electronic medical
records. The program provides medical equipment including a scale and blood pressure cuff for patients to
self-monitor, assess, and report daily vital signs. Providers also use the video visits to assess the
equipment's functionality and the patient's ability to use the equipment and offer guidance where needed.
Keys to Avera's success in managing congestive heart failure through RPM include early efforts by nurses to build relationships with patients, increasing familiarity with conducting video calls with providers, and garnering support from and developing awareness of the program among company executives. Although originally planned to be a 90-day post-discharge program, Avera has continued to offer RPM services to patients as long as they need. For example, one patient, who experienced multiple hospitalizations before the program, participated in the program for seven months. Healthcare provider buy-in and referrals from local clinics, primary care doctors, and hospitals have been critical to Avera's success. They are planning to expand RPM services from congestive heart failure to include COPD through the addition of a respiratory therapist, as many patients have both conditions co-occurring which factors into their personalized care plan.
Avera has sought opportunities to strengthen their program through partnerships with existing organizations. They have also identified needs and provided specialty training for staff on congestive heart failure and COPD management and cultural competence. Ultimately, Avera@Home aims for their Connected Care program to help patients independently manage their chronic conditions, with the goal of staying out of the hospital and improving their health.