Post-Discharge Care for Heart Failure Patient Through Digital Remote Patient Monitoring

Abstract

Objective: This study evaluated a Remote Patient Monitoring (RPM) system for Heart Failure (HF) patients after hospital discharge. The program aimed to detect early clinical deterioration, reduce readmissions, and improve quality of life. Continuous monitoring and automated alerts enabled real-time connection between patients and healthcare providers, ensuring timely intervention and seamless continuity of care in alignment with national digital health transformation goals.

Method: HF patients discharged from the hospital were enrolled in a home-based RPM program, receiving a monitoring kit with an ECG-capable smartwatch, blood pressure monitor, pulse oximeter, and weight scale. Devices connected via Bluetooth to a secure app, transmitting real-time data to a clinical dashboard. Deviations from baseline triggered alerts prompting interventions such as medication adjustments (diuretics, beta-blockers, sacubitril/valsartan), adding anticoagulants, and conducting diagnostic tests or virtual consultations. The program followed a multidisciplinary model, with nursing staff monitoring, prioritizing alerts, and communicating with patients, while Advanced Nursing Practitioners (ANPs) and cardiologists for management. 

Results: A total of 30 patients were enrolled in the (RPM) program, comprising 24 males (80%) and 6 females (20%), with ages ranging from 21 to 72 years. Five patients (16.7%) were identified through RPM alerts as having new or clinically significant arrhythmias, including atrial fibrillation (AFib), non-sustained ventricular tachycardia (NSVT), and premature ventricular contractions (PVCs). Treated with anticoagulation in 2 (6%) and VT ablation in 1 (3%) Around 20 (67%) patients had either weight gain or edema leading to diuretic adjustment. Patient who had hypotension 10 (33%) had adjustment of sacubitril/valsartan. Other patients are under monitoring for optimization of HF medical therapy through virtual visits. 

Conclusion: the RPM model is effective and safe in providing continuity of care and improving quality of life. Early detection and prompt intervention to reduced hospital admission.