The care coordination center, called C3, was created through a partnership between UVA Continuum Home Health and Broad Axe Care Coordination, a remote care management company. Under the program, a C3 staff member will install monitoring equipment, such as a blood pressure cuff and scale, at the home of recently discharged UVA patients who had a heart attack or who suffer from heart failure, pneumonia or chronic obstructive pulmonary disease.
The staff member will teach patients how to transmit information from the equipment to the monitoring center, where nurse care coordinators will track patients’ vital signs and their answers to survey questions about their symptoms for 60 days. The goal is for nurses to quickly identify and intervene for patients at risk for readmission based on this clinical information. Nurses will also educate patients and help them manage their medications, schedule follow-up appointments and follow other discharge instructions, according to the news release.
UVA aims to enroll more than 1,000 patients in the C3 program in the first year, and it plans to work with the UVA Center for Telehealth to establish satellite care coordination centers in southwest and south Virginia in December.
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