Using technology-enabled care models to reduce readmissions

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Alan Snell, M.D.
Alan Snell, M.D.


As healthcare reform is implemented and hospitals are facing stiff readmission penalties, they will be looking for new models of care and strong post-discharge partners to help reduce avoidable readmissions. Extending the care and support for patients outside the hospital is one way hospitals can help improve care for our large aging population with multiple chronic conditions. Programs that use technology, like remote care management, can enable better patient management and improve patient behavior to help reduce readmission rates. These programs increase an individual's interaction with health information and healthcare professionals outside the hospital, which has been shown to keep patients out of acute care.

At St. Vincent Health (22 hospital system in Indiana), we've seen this to be true in our remote care management program, which was initially funded by one of the Beacon grants. The program focused on reducing hospital readmissions for patients with congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). We were able to accomplish this by changing business and workflow processes to enable seamless care delivery in the home, enabled by the Intel-GE Care Innovations™ Guide.

Upon discharge, our patients with CHF and COPD were supported remotely by a nurse to help them better manage their disease. This multidisciplinary approach used clinical protocols designed to keep patients more engaged and clinicians more informed, including:

  • Daily monitoring of patient biometrics: blood pressure, body weight, and oxygen saturation
  • Review of patient responses to interactive daily questionnaires
  • Educational videos and materials relevant to patient health needs, delivered via the remote care management technology
  • Video conferencing with patients by nurses throughout the 30-day monitoring period

Behavioral factors, such as noncompliance with medications, lack of adherence to care plans, and not following recommended diets, frequently contribute to early readmissions.[1] Using technology as part of an overall clinical care plan has been shown to reduce readmissions.[2] In fact, in the two-year randomized clinical trial, our preliminary results show that the remote care management program reduced hospital readmissions to seven percent for patients participating in the program – that's a 60% to 70% reduction compared to the control group (20%) and the national average (22%).

In the future, our healthcare model will look radically different, and coordination between hospitals and long-term care and assisted living providers will become much more common and important. Technology-enabled models of care will become much more widespread across all of our organizations, and it is important that post-acute providers support and enable this type of care.  Keeping patients, or residents, healthy and out of the hospital is a goal we can all get behind.

Alan Snell, M.D., is the Chief Medical Informatics Officer at St. Vincent Health in Indianapolis, IN.

[1] Medicare Hospital Readmissions: Issues, Policy Options and PPACA.  Available at:

[2] Institute for Health Technology Transformation Webinar: “Beacon Community Research Study: Reducing Hospital Readmissions via Remote Patient Management.” Available at:

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