The Homeward Bound program was developed for patients diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). The program provides each patient with the resources and education needed to manage their disease process successfully. The program aims to reduce Emergency Department visits and lower the hospital readmission rate for patients in these high-risk categories. Within the Homeward Bound program, the Brockton Hospital School of Nursing assists patients with COPD, and the Congestive Heart Failure Team assists patients with CHF.
To achieve the goal of reducing readmission rates, patients enrolled in the Homeward Bound program are provided with weekly home visits or telehealth phone calls from a Registered Nurse or nursing students and faculty from the Brockton Hospital School of Nursing. Depending on their diagnosis of COPD or CHF, the Homeward Bound program provides patients with applicable telehealth monitoring devices, including an iPad, pulse oximeter, blood pressure cuff, or a scale. Using these Bluetooth devices, the Homeward Bound care team can track and monitor patient vitals remotely. The devices also allow each patient to answer a set of questions about their current status, any changes in symptoms, their daily limitations, among other important data points. These submissions provide the Registered Nurse with information about the patient's overall health status each day. By analyzing this data, the Registered Nurse is promptly alerted to any warning signs of a patient's potential deterioration and can help arrange early treatment and intervention.
The Homeward Bound care team provides each patient with personalized education to successfully manage COPD or CHF. The care team reviews and offers education related to the patient's medications and encourages them to adhere to their treatment plan. A weekly check-in from the care team provides emotional support while also allowing each patient to ask questions in the comfort of their own home.