Implementing a RPM-enabled transitional care pathway for adults with poorly controlled diabetes: a quality...

Area of Science:

• Healthcare innovation
• Diabetes management
• Health equity

Background:

• Adults with poorly controlled diabetes post-discharge have high readmission risks.
• Existing remote glucose monitoring models often exclude high-risk, underserved populations.
• Health systems need practical models for integrating remote monitoring into transitional care.

Purpose of the Study:

• To design and implement an equitable remote patient monitoring (RPM) program for post-discharge diabetes care.
• To address disparities in care for Black/African American and Hispanic/Latino residents.
• To improve hospital utilization for patients with high hemoglobin A1c (HbA1c) levels.

Main Methods:

• Integrated RPM into a nurse-led transitional care program using five Plan-Do-Study-Act (PDSA) cycles.
• Provided RPM services and care coordination for 90 days post-discharge.
• Evaluated enrollment, appointment attendance, HbA1c completion, and demographic representation.

Main Results:

• Patient enrollment in the RPM program increased significantly from 10.5% to 39.7%.
• Enrolled patients proportionally represented targeted demographic groups, including those with limited English proficiency and smartphone access.
• Follow-up appointment attendance reached 78.3% for primary care and 69.6% for endocrinology.

Conclusions:

• Iterative PDSA cycles facilitated an equitable RPM-enabled transitional care pathway for diabetes.
• Workforce capacity, workflow simplification, and pre-arranged ambulatory follow-up are key implementation insights.
• Health systems should prioritize adequate monitoring workforce and streamline protocols for scalable, equitable RPM implementation.