This is an Awardee of the Government Best Practice Recognition Awards


TeleCARE Nursing


Philippine Heart Center

Best practice Focus Area(s)

Customer and citizen focus

Year Implemented



The Telephone Call-Assisted Reinforcement of Client Education (or TeleCARE) is a telehealth service provided by the PHC. It aims to reinforce education, encourage physician follow-up, and prevent readmission. Under Linda G. Buhat, RN, Ed.D, an ad hoc committee was formed in 2016 to learn about telehealth and propose its implementation. This is rooted in telehealth, the use of “telecommunications and virtual technology to deliver health care outside of traditional health-care facilities.” The PHC delivers the service by making outgoing calls to discharged patients through mobile phones and landlines. Piloting was done in 2017 and implemented by May 2018.

Background and Problem

The TeleCARE service aims to provide the continuity of care to the PHC clientele after hospital discharge by providing them with the highest quality health education through telephone calls. The program is a product of meticulous needs assessment and planning that identified the lack of continuity of care for discharged patients from the hospital. Patients are often left unassisted and unsupervised at home which could lead to various complications including death.

Solution and Impact

The creation of this service was brought about by the fact that upon discharge, PHC patients are left on their own devices. They are expected to perform self-care, medicate themselves, dress their wound, all without the guidance of a healthcare professional. This could lead to a gap in the continuity of care. TeleCARE was created to fill this gap. Through this service, the following assumptions were made: Patients will increase their compliance to take home medications, adhere to their scheduled check-up, and decrease the readmission rate.

All patients discharged from the service wards are contacted by the TeleCARE nurse after 24 to 72 hours. This is the First Call Encounter wherein all home instructions are reviewed with the patient/primary caregiver and reiteration of the scheduled doctor’s appointment is done. This is followed by the Second Call Encounter one day after the scheduled appointment to check for compliance and concerns. In 2016, four nurses were assigned to study telehealth and conceptualize a program that can be applied by the institution. The proposal was approved and immediate piloting was done the following year. By May 2018, the program was implemented and covered all discharged patients from the service wards.

After a total of 3 months of implementation, the program was evaluated for the following lead measures: adherence with the discharge instructions, readmission rate, attendance to follow-up, and patient satisfaction. Only 75% of PHC clients were expected to adhere to their discharge instructions, attend their follow-up schedule, avoid readmissions, and verbalize satisfaction; however, the results showed that more than 90% of those who received the TeleCARE service successfully complied to their discharge instructions, 93.98% dutifully went to their doctor’s appointment and only 7.64% of the clients reported being readmitted.


The TeleCARE program was given the Patient Care Initiative of the Year Award by the Healthcare Asia Awards held on May 23, 2018, at the Conrad Centennial Singapore. As this service is currently being rendered to patients discharged from the institution’s charity wards, plans to expand it to cover all patients is underway. A new TeleCARE office has been constructed to anticipate the arrival of more TeleCARE nurses and equipment to deliver this novel service to all PHC clients.