At-home monitoring cuts hospital admissions by nearly 60%, study finds

© Oksana Klymenko - stock.adobe.com

A remote patient monitoring (RPM) program developed by Michigan Medicine reduced hospitalizations by 59% in high-risk patients, according to a new peer-reviewed study published in Telemedicine and e-Health. The findings, drawn from more than 1,100 patient encounters, suggest that regular at-home monitoring of vital signs — with timely clinical support — can significantly reduce preventable readmissions for patients with conditions like congestive heart failure, uncontrolled hypertension and COVID-19.

The study evaluated Michigan Medicine’s “Patient Monitoring at Home” initiative, a large-scale RPM program launched in April 2020 and still active today. Participants used a tablet connected to Bluetooth-enabled devices to track temperature, blood pressure, blood oxygen levels and weight. That data was sent in real time to a clinical team who reviewed it daily and could intervene as needed.

Researchers analyzed outcomes for 1,139 patient enrollments between November 2020 and August 2022. The average number of hospital admissions fell from 1.38 in the six months prior to RPM enrollment to 0.57 in the six months after — a 59% reduction.
Even when excluding cases of COVID-19, the study found a 49% drop in admissions.

“These are promising results for hospitalization prevention, which is very exciting because the risk of hospitalization is so high in the geriatric patient population, especially those with certain conditions,” said Sara Margosian, MD, the study’s lead author and a clinical instructor in geriatrics in the U-M Health Department of Internal Medicine.

The duration of participation varied widely — from one week to over a year — but the median enrollment period was 38 days. Notably, shorter durations of monitoring were associated with better outcomes, suggesting that early intervention might help stabilize patients more quickly.

The RPM program is managed by a team of registered nurses, nurse practitioners, and physicians who monitor patient dashboards seven days a week. If a patient’s readings or symptom surveys raise concern, nurses can escalate the case to a clinician for follow-up via phone or telehealth video visit. Patients also have access to on-demand support through the provided tablet, which uses cellular connectivity and does not require home internet.

Ghazwan Toma, MD, co-author and medical director of the Patient Monitoring at Home program, said one of the keys to success was integrating the monitoring workflow into U-M Health’s broader post-acute care system. The program collaborates with in-home services like Michigan Visiting Nurses and the U-M HouseCalls team, ensuring continuity of care post-discharge from the hospital.

“While remote patient monitoring has been expanding across the country for five years, there is no consistent guideline for how to operate such a program, including optimum patient selection, and decision-making for escalation,” said Toma, who is also a clinical assistant professor in the department of family medicine. “We hope our findings can inform best practices across the board.”

Patients were typically enrolled if they scored 10 or higher on the “LACE index,” which predicts the likelihood of hospital readmission. Roughly three-quarters of participants were referred directly after a hospital stay, while others joined following outpatient visits or short-term nursing home care.

Initially established during the early months of the COVID-19 pandemic, the program capitalized on the new flexibilities in Medicare and insurer billing rules for telehealth. It has since grown to include a broader range of conditions, including liver disease, cancer, sepsis, diabetes and chronic lung disorders.

In terms of financial sustainability, the authors reported that the RPM program more than paid for itself — generating an estimated $12 million in savings from avoided hospitalizations.

The study’s authors emphasized that additional research is needed to refine patient selection criteria and define the ideal duration and intensity of monitoring. They also expressed hope that their findings could support the creation of national standards for RPM and encourage long-term reimbursement policies beyond the current extension through fall 2025.

“This program targets the people at highest risk for rehospitalization, and the ability to have an intervention that works is really exciting,” Margosian said.