Shifting heart failure care from hospital to home

Monday 19 January 2026

Over the past three years, seven Santeon hospitals have worked together extensively to make remote care possible through digital technologies. Recent international publications by UT PhD candidate Charell Jansen show how home monitoring for heart failure can be scaled up and embedded sustainably. Based on data from the seven Santeon hospitals, Jansen examined not only the technology behind digital care but also how such care can be organised on a large scale and sustainably embedded in existing care processes. The studies were published in the European Heart Journal – Digital Health and JACC: Advances.

What if patients only came to the hospital for truly necessary medical procedures and everything that could be done at home was actually done at home? "Heart failure leads to around 34,000 hospital admissions in the Netherlands every year," says Jansen. "With an ageing population, that pressure is only increasing. If care that does not require hospital treatment can be delivered at home, we can make the system more future-proof."

From hospital to home

For her publications, she investigated how seven Santeon hospitals implemented an app for home monitoring of heart failure in their cardiology departments, integrated into existing clinical protocols. Representatives from the seven Santeon hospitals formed a so-called heart failure core team, which reported to a medical board. The implementation was done step by step, and processes were continuously improved.

Heart failure patients participating in the programme measure their weight, blood pressure and heart rate at home and enter this information into the app. This data is sent to a team of nurses who monitor the values. When values fall outside normal ranges, they consult with nursing specialists and, if indicated, with cardiologists, and treatment can be adjusted immediately. Often, without the patient having to go to the hospital.

"Essentially, you are shifting part of the care from the hospital to the home," says Jansen. "This fits in with today's reality: a growing group of patients, an increasing demand for care and limited capacity in hospitals."

A single approach across seven hospitals

An important feature of the programme is that consensus has been reached and all seven Santeon hospitals work with a single uniform protocol for home monitoring in cases of heart failure. Among other things, this protocol describes which parameters patients measure, which threshold values apply and how healthcare professionals should respond in the event of deviations.

In her first publication, Jansen describes how this protocol came about. "What interested me was not only what is measured, but above all how this working method was developed jointly," she explains. "Cardiologists and nursing specialists from all hospitals set this up by clinicians directly involved in patient care. This ensures support and consistency in care." She emphasises that this joint approach is crucial for success on a larger scale. Even outside the Santeon network and possibly even outside the Netherlands.

How does this work in practice?

The second publication focuses on the first 17 months after the introduction of the protocol. During that period, 2,916 patients participated in home monitoring for heart failure. The analysis shows that participants are on average slightly younger than non-participants (67 and 71 years old on average, respectively). It also shows that men participate more often than women.

"We were surprised by this difference," says Jansen. The next step is to better understand where these differences come from, so that we can make the use of home monitoring accessible to everyone."

Faster contact, more control for patients

In addition to the figures, Jansen also hears about the benefits of home monitoring in practice. "Patients are often enthusiastic. They have faster contact with healthcare providers, for example via the chat function in the app, and do not have to wait on the phone or for an outpatient appointment." However, these results will be studied further in the future.

For healthcare providers, the work process is also changing. Home monitoring is increasingly becoming an integral part of outpatient care and may play an important role in the vulnerable phase immediately after hospitalisation, when patients with heart failure go home and are monitored more closely.

Continuous learning and improvement

The two publications are a starting point, Jansen emphasises. In the coming period, further research will be conducted into what home monitoring means for hospital admissions, quality of life for patients and workload in healthcare. The research will also look at how participation can be further increased, particularly among groups that currently participate less often.

"The research shows that implementing developments takes time and attention, but that this can lead to great results," says Jansen. "It's about collaboration, trust and smart process design. That is where meaningful innovation happens."

More information

Charell Jansen is a PhD candidate in the Biomedical Signals and Systems (BSS) research group (Faculty of EEMCS / TechMed Centre). She has published her work in two articles in the scientific journals European Heart Journal – Digital Health and JACC: Advances. Her (co-)supervisors are Dr Mark Schuuring and Prof. Miriam Vollenbroek-Hutten. (both BSS; Faculty of EEMCS) and Prof. Job van der Palen (CODE; Faculty of BMS).

The article was written in collaboration with Geert van Hout, Mark Schuuring and Luuk Otterspoor. The medical board and the heart failure core team were also involved in the development and implementation of the protocol.