ConnectedHeartHealth - Heart Failure Readmission Intervention

A key strategy of the Affordable Care Act is the Accountable Care Organization, designed to
improve the quality of care, promote population health and reduce costs by making healthcare
providers more accountable for health outcomes. With the increasing pressure to
simultaneously improve care and reduce the overall cost of care, there is increasing need for
better care coordination, especially for patients that are high risk for readmissions and
poor health outcomes, to stay connected with their healthcare provider outside of the
healthcare setting. Connected Heart Health is the American Heart Association's ACO
(Accountable Care Organization) strategy for post-acute care. This includes evidence based
CarePlans for heart failure, cardiac rehabilitation, and coronary artery disease. These
CarePlans are brought to life with technology enabled by Ambio Health, which allows patients
and doctors to be connected anytime and anywhere, encouraging the adoption of self-management
skills, healthy living, and evidence based practice, resulting in fewer cardiovascular events
and readmissions, and lower costs.

Ambio Health is an end-to-end remote patient monitoring system which includes a weight scale,
blood pressure meter and blood glucose meter with wireless transmission of biometric readings
through a home gateway to a web-based care management application that provides population
health remote patient monitoring and engagement with automated delivery of the CarePlans.

Ambio Health will be introduced as a viable method for remote monitoring of heart failure
patients, with an emphasis on reducing readmission rates and promoting self-management
skills. This program is intended to implement the AHA's Connected Heart Health CarePlan and
educational content for patients in conjunction with a platform designed to upload biometric
data and provide care coordination as directed and implemented by discharging
physicians/institutions. The intent is to design and execute a Pilot with Sinai Hospital of
Baltimore.

Inclusion Criteria:

- Has a diagnosis of Heart Failure as measured by the New York Heart Association (NYHA)
functional classification and is currently in functional class II- IV status.

- Have been hospitalized for an episode of acute HF decompensation within the last 30
days.

- Have access to the internet.

- Are physically and mentally capable to complete the monitoring process or have a
caregiver capable of assisting in the use of the Ambio Health system.

- Willing and able to sign an informed consent form to participate in this evaluation
for a duration of 180 days.

Exclusion Criteria:

- Have a life expectancy of less than six months.

- Live in a nursing home other multi-member assisted living facility

- Intend to be away from their home for more than 2 weeks (14 days) total during the
monitoring period.

- Are unable to read English at a minimum 5th grade level