JMIR Publications

ABSTRACT

Background:

Patients with respiratory or cardiovascular diseases often experience higher rates of hospital readmission due to compromised heart-lung function and significant clinical symptoms.

Objective:

Effective measures such as discharge planning, case management, home telemonitoring follow-up, and patient education can significantly mitigate hospital readmissions.

Methods:

This study educates high-risk patients or their primary caregivers on using communication measurement tools and recording/uploading data. Patients are familiarized with these tools before discharge and continue their usage for four weeks post-discharge. A project manager monitors daily uploaded health data, while a weekly video appointment with the program coordinator captures patients' heart and breathing sounds, tracks health status changes, and gathers relevant data. Care guidance and medical advice are provided based on symptoms and physiological signals.

Results:

Among 35 eligible patients, 92.6% were male, and 46.3% were aged 41-60, while 46.2% were 60 or older. The study revealed that home digital monitoring significantly reduced hospitalizations, emergency department visits, and total hospital days at three and six months post-intervention. (Before vs. after 3 months: average hospitalizations, 0.45 vs. 0.19, p = 0.03; average ER visits, 0.48 vs. 0.06, p < 0.001; average hospital days, 6.61 vs. 1.94, p = 0.08. Before vs. after 6 months: average hospitalizations, 0.55 vs. 0.23, p = 0.01; average ER visits, 0.55 vs. 0.23, p = 0.02; average hospital days, 7.48 vs. 6.03, p = 0.73).

Conclusions:

Implementing a home monitoring model for high-risk patients' symptoms, cardio-pulmonary physiological signals, and parameters post-discharge yields reduced short-term hospital readmissions and emergency department visits, contributing to the overall objective of minimizing hospital stays. Clinical Trial: N/A