This grant-initiated program, administered through the Congestive
Heart Failure Team (CHF) and Brockton Hospital School of Nursing, provides in-home coordinated care for high-risk patients. Utilizing telehealth technology, the team tracks and monitors patient vitals, including blood pressure, weight, and other key indicators, with results monitored by a CHF Registered Nurse. Also, a Managed Care Pharmacist connects with the patient or caregiver and conducts a thorough medication review with the goal of maximizing compliance post-discharge or between primary care visits. All told, Homeward Bound helps reduce hospital readmissions and Emergency Department visits for our highest risk populations.