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Seamless Care Transitions

The Hospital Role in Avoiding Unnecessary Readmissions

Topics: Quality, Performance Improvement, Readmissions, Chronic Care Management, Methodologies, Continuum Integration, Risk Stratification

Practice 12: Advanced Telemonitoring

The Future of Remotely Monitoring COPD Patients

Sotiria Hospital, an 800-bed teaching hospital in Athens, Greece, went beyond phone-based interventions to introduce a comprehensive telemonitoring program. They created an e-Health Unit for COPD1 patients who were aged 60 and over, lived at a distance from the hospital, and had experienced an emergency admission.

Patients selected for the intervention wore biometric underwear, able to measure six clinical indicators and transmit data back to the hospital through the mobile phone network. The telemonitoring system was supplemented by home visits and videoconference with a hospital-based specialist where necessary. The program was discontinued when a research grant expired, but is noteworthy because it offered specialists the ability to evaluate patients in non-clinical settings, while also offering vulnerable patients the ability to safely live at home.

The future of remotely monitorin COPD patients

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Improving Clinical Outcomes, Empowering Patients

Sotiria’s telemontoring system successfully decreased not only the readmissions rate for patients in the intervention group, but also the length of stay and number of emergency department visits. Researchers also reported that patients felt more empowered and better able to treat their condition independently.

Clinical improvement after 30 days of telemonitoring intervention

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Practice 11: Post-Discharge Medication Audit

Practice 13: Volunteer Transition Partners

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