Optimising the care pathway of heart failure with telemonitoring

Good practice:

Integration of telemonitoring services as part of the care pathway optimalisation for chronic patients

NORTHERN NETHERLANDS  / Effective Cardio:  72/115 3/3

The continuing ageing of the population is expected to increase the prevalence of heart failure in the Netherlands from 120,000 (˜ 1 % of the population) in 2008 to approximately 200,000 in the coming decade.

Guidelines of the European Society of Cardiology (ESC) recommend a multidisciplinary approach that coordinates care along the continuum of CHF—often implemented as in person follow-up visits. Recently, alternative approaches such as telehealth and remote monitoring via cardiac implanted electronic devices have been proposed. These assess physiological parameters related to CHF exacerbation more frequently. Therefore, enabling remote disease management.

Customer's need

The optimal approach to non-invasive remote monitoring is uncertain. An ESC guideline recommendation is not yet supported because the randomised controlled trials (RCTs) performed to date have given inconsistent results. Even though most available data suggest that telehealth is a promising strategy for improving disease management of CHF patients, more data are needed to determine the most advantageous approaches.

The solution

To assess the impact of telehealth-based disease management on unplanned admissions, disease severity and quality of life in CHF patients, cardiologists and nurse practitioners need to collaborate within the hospital outpatient heart failure unit. Furthermore, primary care, local home care agencies and nursing homes play a key role in the care protocol of CHF patients.

Keys to success

  • An effectively designed pathway, in which we use all the knowledge in different levels of care, will enable us to tackle most of the problems in an early stage.
  • The majority of patient-related actions should be handled by a specialist nurse (nurse practitioner) with a prescription and treatment authorisation. This way the response time is very short and the (medical) specialist is not burdened with extra problems.
  • Include primary care in the organisation of care for heart failure patients and give them a central role in the management of the disease. Allied professionals can and should have more responsibilities in the management of chronically ill patients (when thoroughly trained in the specific diseases like HF, Diabitis, COPD).

Good practice: Integration of telemonitoring services as part of the care pathway optimalisation for chronic patients.

Good practice description

For patients with chronic conditions it is important that treatment begins quickly. This makes it possible to keep the likelihood of exacerbations and serious events as low as possible. In order to improve quality of life for patients, the aim is to slow down the progression of the disease, to maximise the chances of survival, and alleviate symptoms.

"Technology should support self-care and management of patients in order to respond quickly to exacerbations, by treating and managing patients in the home setting as much as possible"

Good practice example

Effective Cardio demonstrates optimalisation of the care pathway for heart failure patients. To integrate technology into the optimised care pathway, and not as an add-on component, a set of four steps are recommended.

The program

Patients participating in the program include:

  • CHF NHYA class II-IV patients in stable condition discharged after an admission with the primary diagnosis of heart failure or outpatients after an episode of new or worsening heart failure – judged by the attending cardiologist to have clinical symptoms and NT-proBNP levels elevated above normal limits.

Staff had prescription and treatment authorisation. Which prevented delay in response-treatment times and putting burden on the workload of the cardiologist. The telemonitoring system was used to obtain and check patient vital sign measurements (blood pressure, pulse, weight) on a daily basis. All members of the cardiology department had access to the telemonitoring system. This allowed them to check vital sign measurements at every moment. Enabling them to react accordingly.

From the learnings in previous experiences with telehealth, Effective Cardio builds on the optimisation of a coordinated care pathway in four steps:

  • Formulate clear goals, create a sense of urgency, ensure commitment and leadership, deploy persons from the own organisation.
  • Design the processes in the care pathway: organise referral from primary to secondary care, organise the diagnostic process, set up a treatment plan inclusive of telemonitoring, organise information regarding titrating up, make a plan for follow-up.
  • Determine the conditions for implementation: optimize IT support, contemplate using a Medical Service Center.
  • Secure the newly designed measure outcomes: develop reports on the process and outcomes, benchmark process and outcome data.

All patients were followed up for a period of one year with additional visits as required in case of deterioration. Follow-up visits at the outpatient unit took place 3, 6 and 12 months (study end) after enrolment. The nurse practitioners and cardiologists participating in the study were the same as those involved in the patients’ everyday care before the study. During the study period, all patients continued to receive the standard care provided to patients at the CHF outpatient unit. Patients received primary care from their own general practitioner. The study shows very promising results in clinical outcomes and cost efficiency.

Contact information

Javascript needed

Wietse Veenstra, specialist nure


  • Veenstra W, Op den Buijs J, Pauws S, Westerterp M, Nagelsmit M. Clinical effects of an optimised care program with telehealth in heart failure patients in a community hospital in the Netherlands. Neth Heart J. 2015 Jun;23(6):334-40.

Program partners