Remote Patient Monitoring 101 for LTPAC

What is Remote Patient Monitoring?

In the wake of the pandemic, telehealth quickly became an integral part of care delivery by increasing access to care. This proved to be just as effective as in-person care for many diagnoses, especially with supportive legislation providing waivers and reimbursement changes.

Under the telehealth umbrella, the use of remote patient monitoring (RPM) technology has shown tremendous value in managing the care of patients who reside outside the hospital. This article provides a general overview and entry level description of RPM—an RPM 101 for the long-term and post-acute care (LTPAC) community.

In its simplest form, RPM involves the use of electronic monitoring devices to record objective data (heart rate, blood pressure, etc.) and subjective data (symptoms, daily surveys, etc.) for a patient typically at home or in a long-term care facility, and they are reviewed by a provider or clinical team at another location. These devices rely on the internet to communicate information to clinical portals or through direct interfaces to a provider’s electronic health record (EHR). The information and associated alerts are typically monitored and managed by a clinical triage team.

RPM use is usually offered in several spheres of care to provide a more comprehensive care management monitoring program for patients who reside outside of an acute care setting. The spheres covered in this article include:  

• Transitional RPM or tRPM: 0-30 days post discharge until stabilization
• Chronic care RPM: Used in both pre- and post-acute care management
• Hospital at home: Daily acute monitoring 3-5 days, followed by either recuperative home hospital care or tRPM up to 30 days

Examples of RPM

RPM involves the reporting, collection, transmission and evaluation of patient health data through electronic devices, such as: ¹

• Wearables: Watches, strap monitors, glucose monitors
• Mobile devices: Weight scale, O2/heart rate pulse oximeter, BP, glucometer, atrial fibrillation (a-fib), EKG
• Smartphone apps: Patient reported outcomes
• Internet-enabled computers

The most common conditions that benefit from RPM include persons with chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes (DM), hypertension (HTN) and chronic kidney disease (CKD).² 

Across those four conditions, the objective health data set that is most commonly captured are vital signs: body weight, heart rate (HR), blood pressure (BP), temperature, oxygen level (O2) and respiratory rate (RR). Additional variables commonly measured were oxygen saturation and blood glucose. Subjective data most captured includes pain level, symptoms (via daily questionnaire) and physical activity.

Within the wearables category, one common device example is the use of an Apple Watch to detect irregular heart patterns atrial fibrillation (Afib), etc., and perform an electrocardiogram in 30 seconds that can easily be transmitted to physicians.

Different Types of RPM

There are three different recognized types of RPM deployed for different patient populations with specified diagnoses and chronic care conditions that aim to help patients avoid unnecessary emergency visits and readmissions to the hospital.

Transitional RPM (tRPM) is used to monitor high-risk patients, immediately upon discharge from an inpatient stay. It is typically used for 30 days post-discharge. An RPM kit can include a tablet to facilitate video virtual visits, a Bluetooth blood pressure cuff, Bluetooth pulse oximeter, Bluetooth scale and thermometer. The kit is often provided prior to discharge or immediately following discharge to ensure timeliness of initiating RPM the next day. The benefits of such tRPM programs can decrease the average length of hospital stay and reduce the likelihood of a patient returning to the hospital within 30 days. This is an important value based insurance design and quality measure. If a patient does need to return for inpatient care, the close monitoring of the patient provides for pro-active escalation, which benefits the patient by getting more intensive care in a more timely manner.   

Chronic Care RPM is used as a preventative method to monitor patients who have high-risk chronic conditions to reduce the risk of hospitalizations, or as part of a longer-term transition post-hospital discharge. For high-risk patients living at home or in a long-term care (LTC) facility, providers may elect to continue chronic care monitoring long-term to help manage symptoms and reduce the incident of re-hospitalization. For high-risk hospital discharged patients, they are often educated about the advantages of being monitored at home remotely by a nurse prior to leaving the traditional brick-and-mortar facility.  Post-acute chronic care RPM is typically monitored for up to 90 days, with frequent check-ins by a nurse to provide coaching and encouragement to ensure engagement and sustainability.

Hospital-at-Home Programs are used to manage acute care patients who are typically transferred directly from the emergency department—or from an initial inpatient stay—to their own home for hospital-level care. Only select diagnosis are appropriate for this type of monitoring and patients are screened for the appropriateness of this level of care based on their condition and home environment. This model has grown significantly in the wake of the pandemic. RPM is the backbone of the technology that makes hospital-at-home possible. In these programs, patients are typically monitored for three to five days and are classified under RPM as an inpatient, in their home. They are then discharged from inpatient RPM to a transitional RPM program for up to 30 days to ensure their wellness and success with a goal of avoiding unnecessary ED visits or readmissions.⁶

In this category of RPM, more advanced hospital level devices are used to provide real-time monitoring with the care team back at the hospital. For example, smart intravenous (IV) pumps and vital sign devices are tightly integrated with active alerts that are monitored by a hospital level triage team. Clinical staff visit the patient in their home to deliver care.

The hospital-at-home care model has been in place for more than 20 years across the world, most notably in Australia, with success in quality outcomes, patient satisfaction and lower cost of care than traditional brick-and-mortar hospital inpatient stays.

In addition to these three more common types of RPM, a new form of RPM is emerging in the LTPAC sphere that is focused on proactive care and predictive diagnosis of chronic health conditions. Although this type of RPM does not have an official term, it is often referred to it as remote resident monitoring (RRM).

RRM refers to the technology used to monitor and create baseline data on the environmental settings of a resident’s home, social interactions and general activities of daily living (ADLs). Residents typically reside in an independent setting and use RRM as a part of their home care, home health services or services offered by a life planning community. Generally, there are three categories of monitoring technology that currently constitute this use case.

• Home monitoring: Environmental monitoring of heating, ventilation and air conditioning (HVAC), lighting usage and movement radars to create a baseline of the resident’s usual habits in these areas.
• Social interactions: the use of LTC social engagement software connected to devices like Alexa that enable residents to remain active and connected to their community, friends and family. This software can also create a baseline of resident activity data as well.
• General ADL monitoring:⁷ the use of technology such as wearables (bio monitoring watches, pendants, etc.) to track ADL data and create a baseline of the resident’s activity pattern.

Data collected from RRM technology can create a baseline of information over time. Changes in a resident’s baseline in one or more of these monitored areas are reported automatically to caregivers who can quickly investigate the deviations in the resident’s movement or behavior. Proactively investigating these changes can aid in an early diagnosis of a chronic condition, such as Alzheimer’s,⁸ or an early prevention of an impending fall,⁹ or physical injury that could drastically and suddenly diminish a resident’s quality of life.

These types of proactive RRM technologies are gradually being adopted and tested by healthcare providers with the goal of becoming an essential part of enabling residents to fulfill the goal of a longer and higher quality of life.

Benefits of RPM

In an LTPAC setting, patients often go months without seeing their providers. RPM allows for earlier detection of health complications and identify patients who need to seek medical attention prior to in-person appointments. The primary benefit of RPM is the ability for clinicians to identify escalating symptoms and provide medical intervention earlier than they normally would without monitoring. The result of better controlled symptoms leads to higher quality of care, higher patient engagement, higher patient and caregiver satisfaction, less incidents of hospitalizations, and lower total medical expenses.³ Moreover, RPM helps supplement clinical staffing and create workflow efficiencies for staff, especially during the current nursing staffing challenges.

In one study, the use of pulse oximetry monitors to monitor oxygen levels resulted in reduced costs and improved outcomes, resulting in 87% fewer hospitalizations and 77% fewer deaths among patients with access to remote pulse oximetry monitoring.⁴ Another study also indicated increased physical stamina as well as greater overall patient satisfaction and emotional well-being.⁵

CMS Reimbursement

In 2019, Centers for Medicare & Medicaid Services (CMS) established RPM Current Procedural Terminology (CPT) billing codes, which provides the opportunity to make RPM a net neutral, if not a revenue opportunity. Additional insight into these CPT codes and related reimbursement are available from two of the national telehealth resource centers: Mid-Atlantic Telehealth Resource Center and the Center for Connected Health Policy.

Summary

As these examples convey, RPM can bring value to a patient’s care through technology, providing a preventive tool to monitor, sustain and even improve their health. RPM is becoming more of a mainstay of a patient’s continuity of care, allowing for earlier discharge from the hospital, and better odds of the patient healing at home and avoiding being readmitted to the hospital setting.

References

1. NEJM Catalyst. (2018). What is telehealth? The New England Journal of Medicine. Retrieved from https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0268
2. American Telemedicine Association. (n.d.). Resources. Retrieved from https://www.americantelemed.org/resource/
3. Kariuki , F. (2022, November 3). The top 13 benefits of Remote Patient Monitoring. HRS. Retrieved from https://www.healthrecoverysolutions.com/blog/the-top-13-benefits-of-remote-patient-monitoring
4. Young, M. (2022, October 1). New studies suggest benefits of remote patient monitoring. Relias Media Continuing Medical Education Publishing. Retrieved from https://www.reliasmedia.com/articles/new-studies-suggest-benefits-of-remote-patient-monitoring#:~:text=The%20program%20reduced%20costs%20and,to%20remote%20pulse%20oximetry%20monitoring
5. NEJM Catalyst. (2018). Patient Satisfaction Surveys. The New England Journal of Medicine. Retrieved from https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0288
6. American Hospital Association. (2020). Creating Value by Bringing Hospital Care Home. Retrieved from https://www.aha.org/system/files/media/file/2020/12/issue-brief-creating-value-by-bringing-hospital-care-home_0.pdf
7. Zhang, Y., D’Haeseleer, I., Coelho, J., Vanden Abeele, V., & Vanrumste, B. (2021). Recognition of bathroom activities in older adults using wearable sensors: A systematic review and recommendations. Sensors, 21(6), 2176. https://doi.org/10.3390/s21062176
8. (2022, July 21). Early Alzheimer’s detection up to 17 years in advance. Retrieved from https://www.sciencedaily.com/releases/2022/07/220721132038.htm
9. S. Department of Health and Human Services. (n.d.). Falls and fractures in older adults: Causes and prevention. National Institute on Aging. Retrieved from https://www.nia.nih.gov/health/falls-and-fractures-older-adults-causes-and-prevention