Ambulatory Intensive, Multidisciplinary Telehealth for High-Risk Discharges: Program Development, Implementation, and Early Impact.

This novel model using telehealth to provide intensive, multidisciplinary care to high-risk patients has been successfully developed and deployed. Key areas for growth and exploration include developing an intervention that captures a greater percentage of discharged high-risk patients, including non-homebound patients, improving the electronic interface with home health care, and reducing costs while serving more patients. Data show that the intervention results in high patient satisfaction, improvements in self-reported health, and preliminary data showing reductions in readmission rates.