Integrated telehealth care combining with discharge planning provides better nurse-led intervention for family caregivers and better care of the family as a unit. Chronic disease is not only a personal event; it is a critical family event. Providing discharge planning to heart failure patients and their families might improve patient self-care and reduce readmission
rates. Telemedical monitoring in chronic heart failure might reduce total mortality as well as the number and duration of hospital admissions for worsening heart failure. More integrative transitional care model should be developed, including discharge planning, telemedical
monitoring and holistic nursing care.
Although the monthly cost of telehealth care is not too expensive, a discussion of reimbursement from health insurance companies should be included. The results of this study suggest nurse-led nursing care with advanced high technology systems could be used in more hospitals with government support. This role of telenursing specialist should be established by more studies in the future.
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