A Quality Improvement-based Approach to Implementing a Remote Monitored-Based Bundle in Transitional Care Patients for Heart Failure

Background Congestive Heart Failure (HF) is a leading cause of hospitalization and readmission, leading to increased healthcare utilization and cost. This is complicated by high incidence, prevalence, and hospitalization rates among racial and ethnic minorities, with a widening in the mortality disparity gap. Remote patient monitoring (RPM) has the potential to proactively engage patients once discharged to optimize medication management and intervene to avoid rehospitalization. However, it also may widen the equity gap due to technological barriers and bias. Methods A prospective, observational quality improvement (QI) iniative leveraging an amended tool from the Institute for Healthcare Improvement Model for Improvement was incorporated with an equity lens and five Plan-Do-Study-Act (PDSA) cycles at a single site. The intervention utilized a HF bundle that included RPM, clinical tele-pharmacy, Remote Therapeutic Monitoring, and Community Paramedicine. Results Between May 2022 and March 2023, 5 PDSA cycles were run involving 90 enrolled patients. In total, 38 (42%) patients received the complete HF bundle, 42 (47%) a partial bundle, and 10 (11%) only RPM. The patients with the complete bundle had a readmission rate of 2.6% compared to 14.3% in the partial bundle and 20% in RPM alone. The biggest impact of this program was the incorporation of Community Paramedicine. This program also noted an improvement in equitable enrollment after adjusting mid-program by avoiding cellular phone-enabled devices and transitioning to a hub-based model. Conclusions This single-site QI-based initiative implemented a HF-based RPM program that leveraged clinical tele-pharmacy and community paramedicine. This program identified a disparity of care gap regarding the equitable distribution of services and made mid-study adjustments to improve the disparity gap. This program found that the utilization of the HF bundle resulted in a decreased hospital readmission rate.