Case study

Remote care to support heart failure patients' self-management and reduce risk through early detection

Introduction

Heart Hospital and Buddy Healthcare co-developed a remote care service to support heart failure patients’ self-management and monitoring of patients’ symptoms and vital signs. 

This is achieved by using Buddy Healthcare’s care coordination platform. The remote care model is designed to identify early warning signs of deterioration, supporting triage and enabling alerting if there is a patient requiring clinical review or escalation.

Challenges

Heart failure is a leading cause of hospital admissions among older adults, and demand is rising as the population ages. Symptoms are often recognised too late, and they develop gradually, leading to costly emergency admission and the need for specialist care, such as intravenous diuretics or intensive care. 

Without proper remote monitoring, patients’ symptom progression is often identified too late, and healthcare costs remain high. This is why Heart Hospital co-developed a remote care service to monitor and support patients with heart failure at home. 

Objectives of the remote care

The objective of the remote care service for heart failure patients is to prevent new hospitalisations by identifying high-risk patients using a weight and symptom questionnaire and directing them to remote follow-up with a heart failure nurse, and, when necessary, intensifying their treatment.

  • With heart failure affecting growing numbers of patients, the remote care system enables Heart Hospital to manage larger patient populations without proportionally increasing clinical workload. Risk scoring and intelligent alerts help clinicians prioritise those who need attention most, preserving quality even as scale increases.

  • Earlier detection of clinical deterioration enables timely intervention and reduces avoidable hospital admissions and costly intensive care.

  • Remote care supports patient self-management by increasing engagement and understanding of their condition through symptom tracking and personalised guidance.

Our solution

Remote care and early detection

The Heart Hospital partnered with Buddy Healthcare and co-developed a remote care service to support patients with heart failure.

Using Buddy Healthcare’s care coordination platform, patients use the OmaSydän (*MyHeart”) mobile app to receive timely education and supportive self-management materials for use at home. Additionally, patients submit structured, heart failure–specific symptom questionnaires alongside daily weight recordings. Healthcare professionals use a care pathway management dashboard that automatically scores questionnaire responses, applies risk stratification, and flags high-risk patients for review by the heart failure team.

  • Monitoring aligns with the European Society of Cardiology (ESC) heart failure guidance and is designed to detect fluid overload and early decompensation:

  • Daily patient reporting: weight and changes in health status. If significant symptoms are reported (e.g., weight change, general wellbeing, dyspnoea, arrhythmia, oedema) based on the scoring, an alert is raised for review by a healthcare professional.

  • Threshold-based alerts: the most important monitored parameter is weight. An alert is generated if the weight increases by ≥2 kg within three days, or if the weight decreases by >4 kg over 14 days.

  • Automated scoring: alerts are triggered when predefined clinical thresholds are exceeded, prompting clinician review and, where appropriate, escalation of care.

Results

 

  • Among patients with a new diagnosis of heart failure (HFrEF), 30‑day readmission rates are low 6.3% of patients require rehospitalisation, which is clearly lower than the 30‑day readmission rates typically reported in the era of contemporary medical therapy (approximately 15–20%)

  • Investing in the heart failure care pathway ensures high-quality care from the moment of diagnosis

  • Guideline-recommended, evidence-based pharmacological therapy is implemented well
    Evidence-based medical therapy is in use at discharge in 71% of patients

  • Remote care service supports continuity of care in everyday life
    Evidence-based treatment is maintained and intensified consistently after discharge

  • Investing in early-phase management together with a remote care service is reflected in clinical outcomes
star icon star icon star icon star icon star icon

"These positive outcomes are enabled by the OmaSydän (MyHeart) remote care service: changes in patients’ conditions are detected early, medication can be optimised in a timely manner, and fluid restriction can be guided more effectively. In addition, close monitoring and remote care facilitate efficient up-titration of guideline-recommended medications. This often helps prevent clinical deterioration and avoid the need for emergency care. Reduced hospitalisations significantly improve patients’ quality of life and are also highly cost-effective."

Markku Eskola
Medical Director

Additional case studies

How a digitised perioperative pathway allowed Tampere University Hospital to manage 50% more ENT patients preoperatively

How a digitised perioperative pathway allowed Tampere University Hospital to manage 50% more ENT patients preoperatively

How Orton hospital reduced its orthopaedic patients' post-operative visits by 20%

How Orton hospital reduced its orthopaedic patients' post-operative visits by 20%

How the Kymenlaakso County Cardiology Unit saves 1 hr. with patients before cardioversion

How the Kymenlaakso County Cardiology Unit saves 1 hr. with patients before cardioversion

×