As hospitals are continually being penalized for excessive 30-day readmissions, chronic care management (CCM) has become a rising area of healthcare. Chronic care management in the form of transitions of care (TOC) programs are effective, but still not enough to hinder disease progression. In relatively recent years, CCM methods have started to integrate remote patient monitoring (RPM) systems for further assessment of care.
Hospital readmissions from chronic conditions are costing upwards of half of billion dollars or more, annually. These chronic care conditions are proving to be key sources of rising costs as well as lower quality of care. This could be due to several factors such as non-adherence, low health literacy, or use of several medications from different healthcare providers.
The most prevalent chronic conditions include:
These chronic conditions can be assessed according to certain health metrics. Qualitative metrics include diet, lifestyle, and family history. Other quantitative metrics as shown in the table below can also provide more direct monitoring opportunities. These metrics can be compared based on the chronic condition although many patients suffer from more than one chronic condition at a time.
|Chronic Condition||Health Metrics|
|Heart Disease||LDL-C, HDL-C, cholesterol, triglycerides|
|Chronic Obstructive |
Pulmonary Disease (COPD)
Peak expiratory flow
|Diabetes||Fasting blood glucose |
The benefits of CCM extend towards decreasing emergency room visits, hospitalizations, and long-term care admissions. This is due to consistent opportunities to follow up on patient health metrics and overall condition. If abnormalities in vital signs and symptoms are overlooked, the patient is at risk of worsening disease states and eventual hospitalizations.
Therefore, it is not only important to assess chronic conditions with every follow-up, but also provide education and intervention as necessary. Moderate ticks in blood pressure levels, heart rates, and breathing patterns can make all the difference in ensuring optimal patient care. Otherwise, events like exacerbations from asthma or heart failure could send a patient straight to the hospital.
Studies show that health data transmitted by patients remotely can increase the likelihood of positive patient outcomes. Patients with diabetes, who are receiving consistent chronic care management, have received timely interventions comparable to those after a regular clinic visit.1 Chronic care management can be boosted to an even higher level with the use of remote patient monitoring.
Continual advancements in technology have allowed the use of remote patient monitoring systems to improve the quality of care. Clinicians now have the ability to assess patient’s functional, medical, and psychosocial needs via remote platform systems. With easy access and oversight, remote monitoring programs can provide the necessary tools to enhance the management of chronic conditions.
Patients have the opportunity to keep track of their condition(s) by uploading vitals and health metrics to a secure platform. Clinicians and healthcare providers are then able to analyze patient conditions and provide the necessary feedback to slow disease progression. For instance, a hypertensive patient who is not taking their medications can easily be counseled after noticing a decline in blood pressure values.
Remote patient monitoring can further provide an effortless, low cost way to provide patient education and address adherence concerns. Patient health metrics can be closely tracked and attended to with a comprehensive care plan. This plan can consist of expected outcomes and prognosis, measurable treatment goals, and scheduled medication management visits. By immediately attending to these patient care elements, chronic disease progression can be slowed. Therefore, chronic care management (CCM) plus remote patient monitoring can be an optimal combination for better patient care.
Footnote: 1. Chase, H.P.; Pearson, J.A.; Wightman, C.; Roberts, M.D.; Oderberg, A.D.; Garg, S.K. “Modem transmission of glucose values reduces the costs and need for clinic visits”. Diabetes Care. 26 (5): 1475–1479. doi:10.2337/diacare.26.5.1475.