Horizon Health Network Helps Heart Failure Patients Self-Manage at Home While Reducing Calls and Hospital Visits with SeamlessMD
Horizon Health Network, which serves more than half a million people across New Brunswick, partnered with SeamlessMD to extend heart failure support beyond the clinic and help patients confidently manage their condition at home.
SeamlessMD
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Horizon Health Network, which serves more than half a million people across New Brunswick through 12 hospitals and more than 100 medical facilities, clinics and offices, partnered with SeamlessMD to extend heart failure support beyond the clinic and help patients confidently manage their condition at home.
Heart failure is a provincial priority for New Brunswick. Approximately 1,500 patients receive treatment through Horizon’s Heart Function Clinics, and many are long-term patients – including patients without a family physician – who need close, sustained follow-up. Faced with increasing demand for care but unable to simply add staff, Horizon looked for a way to support more patients while maintaining the patient experience its teams had already built.
With a bilingual SeamlessMD Digital Care Journey, 96% of heart failure patients would recommend SeamlessMD and 97% felt more confident at home, while 73% reported avoiding at least one call to the care team and 60% reported avoiding at least one hospital visit.
Key Results
- 73% avoided 1 or more calls to the care team
- 60% avoided 1 or more hospital visits
- 96% of patients would recommend SeamlessMD
- 97% felt more confident at home
- 89% felt less worried at home
- Delivered in English and French
Extending Heart Failure Support Beyond the Clinic
Horizon’s Heart Function Clinic teams already provided patients with ongoing education, monitoring and personalized support. As demand for heart failure care grew, Horizon saw an opportunity to extend that support beyond scheduled appointments.
Partnered with SeamlessMD since 2023, Horizon was already using the platform in clinical areas such as orthopedics and cardiac surgery, with strong results reducing length of stay, readmissions and ED visits. Building on that success, Horizon launched a bilingual heart failure program, working closely with Heart Function Clinic physicians, nurses, pharmacists and administrative leadership to customize protocols and content.
From their first clinic assessment through self-management at home, patients receive multimedia education, reminders, to-do lists and tasks through text message, email, mobile app and web, covering heart failure, low-sodium diet, fluid balance, activity and medications. The platform helps patients understand what their numbers mean, recognize early warning signs and know when to take action – and come to their care team with more informed, individualized questions.
Daily Zone Checks Turn Symptoms into Action
At the centre of the program is a daily Zone Check, where patients report symptoms and vital signs including weight, blood pressure, heart rate, swelling and shortness of breath. Each day’s responses are sorted into a green, yellow or red category, and patients receive an immediate recommendation on how to manage a low-risk issue or when to escalate to the clinic or hospital.
Care teams receive alerts and monitor dashboards to identify when a patient’s status changes, with alert routing configured separately for each clinic so teams see and act on their own patients. The program also digitally collects Patient-Reported Outcome Measures (PROMs), including PROMIS-10, PHQ-2, GAD-2 and PSS-4.
As Janine Doucet, Director of the New Brunswick Heart Centre at Horizon Health Network, explained:
With the implementation of Seamless MD, heart failure patients are no longer limited to documenting their weight, blood pressure, and symptoms on paper and reviewing them only at scheduled clinic appointments. Historically, clinically significant changes may not have been identified until a routine visit. Today's technology allows patients to transmit this information in real time, enabling the care team to identify concerning trends, intervene earlier, and adjust treatment plans when clinically appropriate. This proactive approach supports improved symptom management, helps prevent avoidable emergency department visits and hospitalizations, and enhances patient engagement in managing their condition. By providing timely access to patient data, clinicians can make more informed decisions and respond to changes in a patient's status before they progress to a more serious clinical event.
Catching At-Risk Patients Earlier in the Community
One Horizon patient’s experience shows what this looks like in practice. After a hospital stay, the patient began experiencing extreme dizziness and drowsiness at home – a common side effect of the medications he had been started on. He reported his symptoms on SeamlessMD, which placed him in the yellow category on the daily Zone Check and alerted his nursing team to act right away.
“I called the heart function clinic when I was in the yellow category,” he said. “The receptionist connected me with my nurse that was assigned to me… and she called back within 30 minutes. Within three hours, (the doctor) had adjusted my medications.”
Afterward, the patient reported that his blood pressure and heart rate had stabilized and his breathing had improved – one of many examples of how the program is helping patients stay healthier at home in the community.
Improving Patient Confidence and Satisfaction
Patients reported feeling more confident and less worried managing heart failure at home: 96% would recommend SeamlessMD, 97% said it helped them feel more confident at home, and 89% said it helped them feel less worried at home. SeamlessMD is also reducing the need for more costly healthcare services, with 73% of patients reporting that it prevented at least one call to the care team and 60% reporting that it prevented at least one visit to the hospital.
Because the program was delivered in English and French with content built to health literacy standards, 98% of patients found the information they needed easy to read and easy to find, 100% found the pictures, graphs and videos easy to see, and 96% said the visuals made the content clearer.
Patients described feeling followed and supported between appointments. As one Horizon patient shared, “The fact that I was being followed daily was very reassuring to me and I didn’t feel alone with this scary diagnosis.”
Jennifer Nouwens, Manager of the Cardiovascular Health & Wellness Program at Horizon Health Network, shared:
SeamlessMD has become part of how we deliver patient centered heart failure care. Their collaboration with our clinicians to incorporate feedback, adjust content and work alongside our teams to implement protocols, have helped to support patients with a new diagnosis of heart failure. The platform provides patients with accessible, practical tools that encourage self-management, and promote confidence in established treatment plans. Patients tell us they enjoy the daily check-ins and access to resources which help them to feel more informed and supported as they navigate their diagnosis.
Supporting More Patients Without Adding Staff
Staying connected to heart failure patients between appointments used to mean a nurse picking up the phone. Now patients describe feeling followed, watched over and not alone with a frightening diagnosis, and many report that their digital care journey spared them a call or a visit to the hospital. Horizon set out to support more patients without adding staff – and in the process, built closer contact with each one.
Read the full case study to learn how Horizon Health Network is using Digital Care Journeys to help heart failure patients self-manage at home, catch at-risk patients earlier and support more patients without adding staff.