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Home telemonitoring program for heart failure patients to expand
October 23, 2019

This article is for:

  • Cardiologists
  • Primary care providers
  • Discharge planners at acute care hospitals, rehabilitation hospitals, and skilled nursing facilities

We’re expanding our home telemonitoring program for eligible Medicare Advantage members with congestive heart failure diagnoses. As of November 1, 2019, the home health care providers listed below will join the program and can accept referrals.

Home Health Foundation (member of Wellforce), which includes:

  • Circle Home (home health care)
  • Hallmark Health Visiting Nurse Association
  • Home Health VNA

See below for a full list of all home health care providers participating in this pilot program.

What is home telemonitoring?

Telemonitoring gives the member’s physician important information about their daily vital signs. It also can be used as a tool to educate the member on good nutrition, symptom management, and self-care for their condition.

This program helps members self-manage their condition and may keep them out of the hospital or reduce readmission rates.

Who is eligible?

Healthy meals program
We also offer a healthy meals program to Medicare Advantage members with CHF that provides medically tailored, nutritional meals. Read more.

Medicare Advantage members may be eligible to receive this service through their home health care benefit. They do not need to be homebound to participate. In addition, the member must:

  • Have a congestive heart failure (CHF) diagnosis.
  • Benefit from having their vital signs monitored (blood pressure, pulse pressure, pulse oxygen, weight).

There’s no additional cost to the member if they meet the program criteria.

How does it work?

Once we identify a member (or receive a referral from the member’s provider), Blue Cross Blue Shield of Massachusetts works with the home health care provider.

The home health care provider will contact the member’s primary care provider to get an order for the services and the acceptable ranges for monitored vital signs.

Then, the home health care provider goes to the member’s home to complete an initial assessment. During their in-home visit, the registered nurse will assess whether the member is physically and cognitively appropriate for telemonitoring and provide any educational needs they may have. The registered nurse can also assess other unmet needs, such as meals and transportation, and suggest resources.

If the member meets assessment criteria, the nurse will install the equipment and show the member how to use it.

Telemonitoring typically lasts six to eight weeks. When the member is discharged, the primary care provider is notified with a detailed discharge summary. If applicable, Blue Cross case managers will continue to follow the member by phone with periodic check-ins.

Home health care contacts for referrals

Participating providers Contact for referrals
BAYADA Home Health Care
  • Phone: 1-508-778-8100
  • Fax: 1-508-778-5022
  • bayada.com
VNA Care—VNA Care Network & VNA of Boston
  • Phone: 1-800-728-1862
  • Fax: 1-774-778-1007
  • vnacare.org
Home Health Foundation, a member of Wellforce, including:
  • Circle Home
  • Hallmark Health Visiting Nurse Association
  • Home Health VNA
These providers have a single contact for referrals
Brockton VNA
brocktonvna.org
Visiting Nurse Associations of New England, Inc. (VNANE)
  • Phone: 1-774-404-2205
  • Fax: 1-508-480-0055
  • Email (must be encrypted): bcbs@vnane.org

Visiting Nurse Associations of New England, Inc. will contact us about your referral.

Community Nurse Home Care, Inc.
communitynurse.com
Community Visiting Nurse Agency, Inc.
communityvna.com
GVNA HealthCare
gvnahealthcare.org
Natick Walpole Visiting Nurse Association, Inc.
nwvna.org
Norwell Visiting Nurse Association, Inc.
nvna.org
Porchlight VNA/Home Care
porchlighthomecare.org
Visiting Nurse Community Health, Inc.
thevisitingnurses.com 
VNA of Southern Worcester Co., Inc.
vnaswc.org

Questions?

For questions about Blue Cross Blue Shield of Massachusetts’ program, call Tarcia Davis, RN, BSN, CCM, program manager in our case management department, at 1-617-246-4269.

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