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A Home Telehealth Heart Failure Management Program for Veterans Through Care Transitions

Baldonado, Analiza DNP(c), MSN/Ed, RN, CCRN; Rodriguez, Lori PhD, RN, CNE; Renfro, David MS, RN, NE-BC; Sheridan, Shirley Barrett DHA, RN; McElrath, Mary MSN, RN, CNS; Chardos, John MD

Dimensions of Critical Care Nursing: July/August 2013 - Volume 32 - Issue 4 - p 162–165
doi: 10.1097/DCC.0b013e318299f834

Heart failure (HF) is a new epidemic in the United States. Advanced HF is a fatal illness affecting our veterans and causing frequent hospital readmissions in both the Veterans Affairs hospital and throughout the nation’s healthcare system. The clinician’s obligation is to offer the best alternatives in the care of chronic illness. The Veterans Affairs healthcare system has a comprehensive approach to treating HF. The comprehensive implementation of home telehealth, clinical informatics, and disease management supports the care of patients with advanced HF.

A multidisciplinary team describes a comprehensive approach to implementation of a disease management for veterans through transitions in care, using home telehealth and clinical informatics.

Analiza Baldonado, DNP(c), MSN/Ed, RN, CCRN, is a transition coordinator implementing Project RED (RE-Engineered Discharge), Avoiding Readmissions Initiative, at Veterans Affairs, Palo Alto, California. She has 13 years of critical care experience and previous Quality Improvement Coordinator of Valley Health Plan. Ms Baldonado was selected as an Evidence Based Fellow at the University of California San Francisco Center for Nursing Excellence. She has published and presented in multiple settings including a poster presentation in Amsterdam at the International Forum on Quality and Safety in Healthcare in 2011. Currently, she is pursuing her doctoral studies at CSU Northern California Doctor of Nursing Practice Program (Joint DNP program of Fresno State University and San Jose State University).

Lori Rodriguez, PhD, RN, CNE, is an associate professor at The Valley Foundation School of Nursing at San Jose State University and codirector of the CSU Northern California DNP Program.

David Renfro, MS, RN, NE-BC, is the chief nurse for Hospital and Specialty Based Services at the Veterans Affairs in Palo Alto, California. Additionally, he is the clinical lead for Project RED, Avoiding Readmissions Initiative. He has 28 years’ experience in advancing roles within nursing, including critical care, ambulatory care, and, for the past 13 years, nursing administration. Mr Renfro is both a patient and nurse advocate and demonstrates that in his leadership in healthcare initiatives.

Shirley Barrett Sheridan, DHA, RN, is an independent contractor and currently the chief operating officer of Cypress Urgent Care Centers LLC on the Central Coast of California. She has more than 40 years of nursing experience predominantly in emergency department management with a focus on the financing and development of new service lines and expansion of facilities.

Mary McElrath, MSN, RN, CNS, Home Telehealth RN care coordinator, has 40 years of nursing experience in a variety of roles. She has been a staff nurse and clinical specialist in critical care, a nurse manager, nursing educator, and research coordinator. She has a special interest in project development specifically to benefit patients with cardiovascular disease. In Home Telehealth, her particular focus is the veteran with heart failure.

John Chardos, MD, is an assistant clinical professor of internal medicine at Stanford and works full time at the VA Palo Alto Healthcare System. After completing his internal medicine training at UCSD, he was chief medical resident. In 2004, he became the director of telemedicine for the VA San Diego Healthcare System. He supervised the implementation and development of several telemedicine programs including Home Telehealth, Telemental Health, and Teleretinal Imaging. He also was a champion for Quality Improvement and System Reengineering. In 2008, he joined the Palo Alto VAHCS as associate chief of staff for ambulatory care. He has been particularly interested in delivery of care for recently returned veterans and is the clinical champion for post combat care for his region of the VA. He has also been the lead for the implementation of Patient Centered Medical Home (called Patient Aligned Care Teams within the VA) for the Palo Alto VAHCS and involved nationally within the VA as well. More recently, he has been leading implementation of Chronic Pain Management at Palo Alto VAHCS.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

Address correspondence and reprint requests to: Analiza Baldonado, DNP(c), MSN/Ed, RN, CCRN, Veterans Affairs Palo Alto Bldg, 100 A2-104 3801, Miranda Ave Palo Alto, CA (

© 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins