Telehealth Program for CHF Patients Helps Mercy Home Health Cut Re-Hospitalization Rate to 5.26%

Mercy Home Health — the Medicare-certified home health arm of the Trinity Health Mid-Atlantic health system — has grown by 45% over the past five years. That strong growth has come despite an increasingly complex home health patient population nationwide and added financial pressure from Medicare.

Using telemedicine to drastically curb hospital readmissions has been one key to that success.

“I think a lot of our growth is based on the quality of care we provide,” Dan Drake, president of continuing care for Trinity Health Mid-Atlantic, told Home Health Care News. “We have a lot of referral sources who look at our innovative telehealth monitoring system and [disease-specific programs]. We have a lot of sources who come to us with specific needs, where we create a program that is tailored to that need.”


Based outside of Philadelphia, Mercy Home Health delivered roughly 557,000 patient visits in 2018. Just a handful of years earlier, that total hovered around 383,000.

While Mercy Home Health is part of the Trinity Health Mid-Atlantic system, the home health organization has been around for more than 100 years, according to Ruth Martynowicz, Mercy’s vice president of operations. Mercy’s team provides skilled home health care and wound care services, plus medication management, palliative care and a range of therapy services.

“We also provide mom-baby visits for new mothers and their [infants],” Martynowicz said.


Trinity Health Mid-Atlantic was formed in October 2018 when St. Mary Medical Center, Saint Francis Healthcare, Nazareth Hospital and two Mercy Catholic Medical Center campuses joined together.

One of Mercy’s most successful telemedicine-related programs is focused on patients with congestive heart failure (CHF), a common condition within the broader Medicare population.

About 6.5 million adults have heart failure, according to U.S. Centers for Disease Control and Prevention (CDC) statistics. Including the cost of health care services, medicines to treat heart failure and missed days of work, heart failure cost the U.S. an estimated $30.7 billion in 2012.

To make sure they stay out of the hospital, Mercy Home Health began connecting its homebound CHF patients with home health nurses who install telehealth monitoring equipment inside patients’ homes. After the equipment is installed, Mercy clinicians train patients to submit daily vital-sign measurements such as weight, blood pressure and blood oxygen levels.

If those vital signs seem abnormal, the telemedicine equipment then notifies a Mercy Home Health nurse, who begins a diuretics protocol. When it comes to CHF, sudden weight gain attributed to fluid increases can be particularly alarming.

“We’ve been working very hard to find ways to prevent unnecessary readmissions, and congestive heart failure is one of the diagnoses that is a frequent flyer to the hospital,” Martynowicz said.

In addition to medication, Mercy Home Health’s protocol leverages IV diuretic therapy.

“We have found that to be highly successful, and it’s coordinated with cardiologists for these patients,” Martynowicz said. “[For] patients who have repeatedly seen hospital stays, we’ve been able to keep them out for months at a time using this program.”

Results-wise, the program achieved readmission rates of 5.26% in fiscal year 2019 for CHF patients. Mercy’s overall Medicare readmission rate is 13%, in comparison.

The readmission rate for Mercy’s combined telehealth efforts — all programs using telehealth, not just the CHF one — is 2.84%.

Apart from its telemedicine efforts, Mercy Home Health has also worked to develop a robust referral process and a strong community liaison program that’s built around having a presence in area skilled nursing facilities (SNFs) and assisted living facilities.

All those steps mean Mercy Home Health will likely take another leap forward in 2020, Drake said.

“I think home health care as an industry is growing, even with the Patient-Driven Groupings Model (PDGM),” he said. “We’re going to continue focusing on growth, on supporting you best-in-class care delivery care models. We strongly feel that growth is in the picture moving forward.”

As for PDGM and its impact on therapy utilization, Mercy is not making any drastic changes, Martynowicz said.

“Our strategy is to make sure patients get the care that they need and that,” she noted. “We are going to monitor the utilization of those services. And we’re also looking at maintenance [therapy[ as an avenue for some patients who have chronic disease.”

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