Helping Patients Manage Chronic Illness at Home

Pictured above is Geraldine Hubbard, a patient enrolled in MedStar’s My Health@Home Program

My Health@Home Program

When Geraldine Hubbard was diagnosed with chronic heart failure, her doctor prescribed milrinone, a common medication used to treat the condition. Most patients remain on the drug indefinitely.  

But she had a different plan for herself.  

“When they told me I would be on that medicine for the rest of my life, I knew I didn’t want that,” says Hubbard, 79, of Washington, D.C., With diligence and a commitment to taking her medication as prescribed, checking her vitals, and making changes to her diet, Hubbard defied the odds—and has been off the medication since July 2018.  

She achieved her goals with the help of the MedStar Health Home Care program, My Health@Home.  

The program aims to help patients with chronic conditions, such as heart failure, chronic obstructive pulmonary disease (COPD), coronary artery bypass graft, and diabetes, take control of their health—starting in their own homes.  

Some patients are referred to My Health@Home by their primary care physicians, but most enter the program after discharge from a hospital, rehabilitation center or nursing home, says Carrie Koenig, vice president of Patient Experience and Communication, MedStar Health Home Care.  

“After leaving the hospital, the last thing a patient wants is to have to go back,” she says. “They want to heal at home with their families, and that’s what this program makes possible.”  

For the first few weeks of the program, registered nurses and therapists visit patients at their home several times per week, and as patients learn to manage their own condition, visits become less frequent.  

During home visits, nurses help patients learn how to track and monitor their symptoms, take medications as ordered, maintain a heart-healthy diet and weight, watch the amount of fluid they consume, and make healthy life choices.  

Some patients are given a book to log and track their vital signs, while others receive a remote monitoring device, which transmits the information to the patient’s healthcare team. This gives providers a way to intervene quickly if patient’s vitals reach levels of concern.  

“We want to identify negative symptoms before they turn into medical emergencies,” Koenig says. Hubbard calls the program a “godsend.”  

“It has made all the difference,” she says. “I attribute so much of where I am today to my nurse’s positive way of thinking and the tools she gave me to succeed.”