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Association of Skilled Nursing Providers 
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San Clemente, CA
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Association of Skilled Nursing Providers

15 Via Picato, San Clemente, CA 92673.

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Support our academic study to reduce hospital readmissions through education and technology.

Through our partnership with North American Health Care, WearMD, and Dr. Aaron Weaver, we will explore the correlation between reduced hospital readmissions and the Elevate Program, which combines North American Health Care’s ACHIEVE education program and WearMD’s 24-hour physician monitoring.

Objective: To determine the feasibility and potential impact of a non-pharmacologic multidisciplinary intervention for reducing hospital readmissions in elderly patients with heart conditions.

Design: Clinical trial, with all patients assigned to the study intervention. Patient readmission population will be compared with average hospital readmission rate.

Setting: Various post-acute locations in Washington, Utah, Arizona, and California.

Patients and participants:  Patients admitted with documented congestive heart failure, cardiac arrest, acute myocardial infarction, or other cardiac diagnoses.

Hypothesis: We hypothesize that a comprehensive, multidisciplinary approach to reducing repetitive hospitalizations in elderly patients with cardiac diagnoses will lead to a reduction in readmissions and hospital days, particularly in patients at moderate risk for early rehospitalization. 

Interventions: Comprehensive multidisciplinary treatment strategy consisting of

  1. Case management patient assessment within the first 24 hours
  2. Intensive teaching by a geriatric cardiac nurse,
  3. Detailed review of medications by a geriatric cardiologist with specific recommendations designed to improve medication compliance and reduce side effects
  4. Early consultation with social services to facilitate discharge planning,
  5. Dietary teaching by SNF dietician,
  6. Wearable technology training by WearMD staff,
  7. 24-hour physician monitoring through WearMD, and
  8. Close follow-up after discharge by home care and the study team.

Measurements: All patients will be followed for 30 days after initial hospital discharge. The primary study endpoints are rehospitalization within the 30-day interval and the cumulative number of days hospitalized during follow-up.