Heart Failure Program
Keep heart failure patients stable at home, and out of the hospital
AMC Health pairs daily home readings with clinicians who act on them, catching fluid buildup and warning signs days before they become an admission.
6.7M
Americans live with heart failure
1.2M
primary HF hospitalizations a year
1 in 4
people will develop HF in their lifetime
44%
lower odds of 30-day readmission with AMC Health (Geisinger Health Plan)
THE PROBLEM
The riskiest days happen after discharge
Heart failure decompensates quietly. A few pounds of fluid, a missed dose, a skipped follow-up — and a patient is back in the ED within weeks.
For hospitals, HF readmissions count toward Medicare HRRP penalties of up to 3% of base payments. For health plans, HF is one of the most expensive chronic populations to manage.
The 30-day window
Discharge
(Day 0)
Days 15–30
HRRP measurement (Day 30)
AMC Health's clinicians are in daily contact from day one — when readmissions are most likely.
HOW IT WORKS
Daily data. Clinical action. Measurable results.
Your care teams see the same data in real time, and our clinicians work alongside each patient's existing providers.
01
Identify
AI risk stratification finds the members or patients most likely to be admitted.
03
Monitor
Daily weight, vitals and symptom check-ins flow to AMC Health's clinical team.
02
Equip
Scale, BP cuff and pulse oximeter arrive ready to use. [Confirm: no Wi-Fi or smartphone needed]
04
Intervene
Clinicians call, coordinate with the patient's doctor and escalate before a crisis.
What we monitor
The signals that predict decompensation, checked every day.
Daily weight trends
Early sign of fluid retention
Blood pressure & heart rate
Trends flagged against each patient's baseline
Oxygen saturation
Pulse oximetry readings
Symptom check-ins
Breathlessness, swelling, fatigue
Medication adherence
Missed doses caught the same day
Post-discharge follow-up
Visits kept, education delivered
Case study
Case study
Peer-reviewed study of 1,708 heart failure members, 2007–2012
BY AUDIENCE
Built for the organizations that carry heart failure risk
Helping healthcare organizations identify heart failure risk earlier, act with confidence, and deliver better patient care.
Lower medical trend in your highest-cost HF members
We find the members most likely to be admitted in your claims data and keep them stable at home. Outcomes-based pricing is available: you pay from validated savings.
Reduce avoidable inpatient spend
Improve Plan All-Cause Readmissions
Savings measured against an agreed control group
Protect HRRP performance and free up your care managers
Our clinicians cover the 30 days after discharge so your team can focus on the highest-acuity patients. Reimbursable under Medicare RPM and CCM codes.
Fewer HF readmissions and penalties
No added headcount
Data flows to your care team in real time
Cardiology-level follow-up, hours from the nearest specialist
Extend daily monitoring and clinical follow-up to patients across your service area, with no new staff required.
Keep patients close to home
New reimbursable revenue
Fits RHTP-funded initiatives
The platform behind VA Home Telehealth
Trusted at 140 VA medical centers, with the security and compliance federal programs require.
140 VA medical centers
HITRUST CSF r2 certified
FDA Class II devices
Since 2002
Caring for patients at home
97%
Patient satisfaction
140
VA medical centers
The only RPM vendor with Class II FDA clearance
HITRUST certified
FAQ
Questions executives ask
Get clear answers to the questions that matter most—from improving patient outcomes and reducing costs to integrating virtual care into your existing healthcare strategy.
How does remote patient monitoring reduce heart failure readmissions?
Daily weight and vitals reveal fluid buildup days before symptoms send a patient to the ED. Our clinicians act on those changes — a call, a medication review with the patient's doctor, a same-week visit — while there's still time to prevent an admission.
Who responds when a reading is out of range?
AMC Health's clinical team reviews alerts and contacts the patient, escalating to the care team or provider per agreed protocols.
Is heart failure RPM reimbursable?
For eligible Medicare patients, RPM and chronic care management services are billable.
What devices do patients use? Do they need internet or a smartphone?
Confirm device list and connectivity: scale, BP cuff, pulse oximeter; cellular vs Bluetooth.
How does the program work with a patient's cardiologist or PCP?
We share readings and clinical notes with the patient's existing providers and coordinate any change in care with them.
How are results measured and reported?
We agree on metrics and a comparison method before launch, then report admissions, readmissions, engagement and cost outcomes on a regular cadence.
FORM
Are you a patient?
Ask your health plan or doctor whether they offer AMC Health.