CA Health System Launches RPM Program to Reduce Hospital Readmissions

With the goal of improving care for high-risk patients with chronic obstructive pulmonary disease (COPD), the Comprehensive COPD Clinic at UC Davis Health created a remote patient monitoring (RPM) program to treat these patients.

According to the Centers for Disease Control and Prevention, 16 million Americans are battling COPD; however, there are likely a high number of undiagnosed cases.

Encompassing diseases that cause airflow blockage and breathing problems, such as emphysema and chronic bronchitis, COPD is a group of diseases that typically result in a high rate of hospital readmissions.

To enhance treatment for this condition among patients living in the Sacramento area, the Comprehensive COPD Clinic at UC Davis Health added RPM to its offerings. Enrolling up to 12 patients at a time, the program provides participants with a pulse oximeter, an electronic device that measures heart rate and oxygen saturation in red blood cells.

“COPD is a disease that comes in many forms, so treatment needs to be tailored to individual patients and their burden of disease,” said Brooks Kuhn, MD, assistant professor of medicine and co-director of the Comprehensive COPD Clinic, in a press release. “The core mission of the program is to empower our high-risk patients with health technology tools to help remove barriers to care, emphasize preventive care, and improve self-management, which are critical to improving clinical outcomes and patient quality of life.”

Respiratory therapists collect and monitor data from the devices daily through a dashboard in the patient's EHR. Patients are also asked daily whether their symptoms are better, worse, or the same as the day before.

UC Davis Health information technology team members developed rules to filter data on the dashboard and set up alarms to indicate when a patient's symptoms are worsening.

“The goal for our respiratory therapists is to work with patients to identify early signs and symptoms of their COPD exacerbation to avoid unnecessary health care utilization,” said Krystal Craddock, clinical operations manager for respiratory care, in the press release. “Each patient has an action plan, and our respiratory therapists lead them through their personalized plan to control their symptoms and get them over that exacerbation hump to prevent the need for readmission to the hospital.”

According to the press release, this is the first remote patient monitoring program in the Sacramento region for high-risk COPD patients.

“There are so many patients in our community that could benefit from a program like this and improve their clinical outcomes,” said Kuhn. “I appreciate the hard work of our amazing interdisciplinary team members, who have been crucial in getting the remote patient monitoring program operational. It allows us to personalize the care we provide our patients to their specific needs.”

Similarly, Watertown Regional Medical Center (WRMC) created an RPM program in September to treat various conditions such as hypertension and heart failure. Like COPD, these two conditions are common in the US and have a significant association with death.

The RPM program, however, uses various cellular-enabled devices such as blood pressure monitors and weight scales to allow patients to track health metrics and report information to care teams remotely. Although the program will initially treat only hypertension and heart failure patients, WRMC noted its intentions to eventually expand the program to treat more conditions such as diabetes and COPD.