Harnessing remote patient monitoring technology to improve transitions of care

BACKGROUND: Virginia Commonwealth University developed a Transitional Remote Patient Monitoring (tRPM) program in April 2020 with the goal of leveraging remote patient monitoring technology alongside enhanced care coordination support to improve transitions of care METHODS: Patients deemed to be at high risk of readmission are referred to the tRPM program and provided a cellular-enabled tablet along with a Bluetooth-enabled pulse oximeter, blood pressure cuff and thermometer prior to discharge Vital signs are monitored over a 16-day period post-discharge by nursing staff based in VCU's Continuum Integration Center (CIC) CIC nurses are in close communication with tRPM patients and receive real time alerts if vital signs fall outside of individualized parameters Patients typically participate in virtual transitional care visits with a tRPM provider and are also invited to participate in a virtual Advance Care Planning session CIC staff also provide care coordination and social work support Thirtyday hospital readmission rates and length of stay for tRPM graduates were examined and compared to a group of patients with similar diagnoses and LACE scores Telephone surveys were conducted to gauge patient satisfaction RESULTS: From April to December 2020, 357 patients were enrolled in VCU's tRPM program Approximately one third of these patients were COVID positive Patients enrolled in tRPM over this period had an average LACE score of 11 5 and average age of 58 8 The top three diagnosis-related groups (DRGs) for patients enrolled in tRPM were sepsis, congestive heart failure and respiratory infections Patients assigned to these top three DRGs who were enrolled in tRPM had a 24 6% reduction in 30-day readmissions and a 12 9% reduction in hospital length of stay when compared to patients assigned to these DRGs with similar LACE scores 97 5% of surveyed tRPM participants reported they were satisfied with the telemedicine device and its use during their evaluation CONCLUSIONS: VCU's tRPM program has demonstrated that telehealth and remote patient monitoring technology can be harnessed in conjunction with enhanced care coordination support to improve transitions of care, reduce length of stay and hospital readmissions