Transitioning from hospital to home is a vulnerable time for patients, sometimes resulting in readmission after discharge. Specifically, patients with chronic conditions and their families often have difficulty managing care between discharge and a follow-up visit with their physician. In 2018, Columbia Memorial Hospital began an initiative to use tele-monitoring technology to help patients and reduce avoidable readmissions.
The initiative focused on tele-monitoring of patients at risk for readmission. Staff provided the at-risk patients with a tele-monitoring toolkit consisting of a scale, blood pressure cuff, pulse oximeter and smartphone. This allows patients to monitor their daily vital signs and send them electronically to their case manager. Self-monitoring and daily communication with the case management team allows for early intervention for problems that may otherwise cause the patient unnecessary emergency room visits or readmissions. The simplicity of the program increases the likelihood of patient participation.
In 2018, the tele-monitoring program inclusion criteria were expanded and the number of patients served increased 50% from the prior year. Patients who participated in the tele-monitoring program saw a 46% decrease in readmissions compared to the prior six-month period before joining. The case management team has found tele-monitoring to be an effective use of technology for engaging patients and their caregivers in chronic disease self-management and an efficient means of communication.
For more information, contact Rhonda Makoske, patient safety officer, at (518) 653-7149 or firstname.lastname@example.org.