How Telehealth Helps Reduce Hospital Readmission Rates

It’s a concerning statistic. A study from the Canadian Institute for Health Information (CIHI) found that 1 in 12 patients is readmitted to a hospital within 30 days of being discharged.

In hospitals, physicians and nurses can monitor patients continuously. Unfortunately, care-related challenges are often compounded in less-controlled environments. At home, patients play a much larger role in managing their own health conditions. Errors and non-compliance are all too common—and the consequences can be serious.

When it comes to reducing readmission rates, setting patients up for success is critical. After the patient has been discharged, telehealth can help.

While many healthcare providers see telehealth as outdated, it’s anything but. Advances in digital technology have enabled providers to offer more effective videoconferencing and information-sharing capabilities.

The potential post-discharge benefits are significant. In this post, we’ll look at three major ways that telehealth can help reduce hospital readmissions.

1) Improved follow-up

An effective follow-up plan often includes patient participation. In many cases, self care activities—such as adhering to medication regiments and dietary restrictions—is crucial to healing. Symptom monitoring may also be key to preventing complications.

Physicians do their best to stress the importance of compliance to patients. Unfortunately, it can be difficult for those without medical training to absorb this information.

As just one example, many patients fail to report worsening symptoms immediately. Getting in touch with healthcare providers can be a hassle, leading many people to put it off.

Luckily, advances in telehealth make it easier than ever before for patients to follow-up. Videoconferencing apps can be especially useful.

A patient who’s suffered from a heart attack may not want to schedule an appointment after a mild twinge in her chest. But what if she could get in touch with a nurse simply by tapping her tablet screen?

By providing quick and simple access to healthcare professionals, digital telehealth solutions have the potential to help patients avoid complications—and resulting trips to the hospital.

Likewise, care coordinators and nurses can check in with patients between home care visits. These check-in sessions can highlight important health issues and changes that might not come up otherwise.

2) On-demand reassurance & clarification

How well are patients following instructions that could help keep them out of the hospital? It’s an important question. Unfortunately, busy healthcare providers don’t always have time to give it the attention it deserves.

All too often, patients return home to find that they’ve forgotten their self-care instructions. During a time that’s often marked by stress and confusion, it can be difficult to absorb verbal information from a healthcare provider. Many patients also struggle with written discharge instructions.

Comprehension is critical, because certain tasks can be more complex outside of a hospital environment. For example, a patient unaccustomed to using an oxygen mask by herself may have difficulty doing so. Telehealth apps can empower her by making it easy to reach out to a care provider for real-time video assistance.

Of course, comprehension is only part of the problem. Many patients are able to understand instructions, but forget to follow them. Medication is a classic example. In some cases, accidentally skipping doses can lead to complications—and re-hospitalization.

Digital telehealth solutions can solve this problem. Consider the benefits of a videoconferencing app with built-in medication reminders. When a patient fails to adhere to a reminder, a healthcare professional can follow-up with a video call to ensure compliance.

3) Supplementary appointments

In most cases, following up is about more than checking in. It’s true that nurses, personal support workers (PSWs), and care coordinators can assist with specific tasks—and monitor patient wellbeing. But post-discharge appointments with family doctors and specialists are usually also necessary.

That said, in-demand practitioners can’t always see individual patients as often as they’d like. And on the patient’s side, remembering and securing transportation to in-person appointments can be difficult.

Unfortunately, rescheduling isn’t always simple. Missed appointments—and long wait periods—can allow health complications to go unnoticed. The result can be poor health outcomes and eventual hospital readmission.

Telehealth enables practitioners to see more people in less time. The right digital videoconferencing solution can connect physicians with recently-discharged patients in an instant. As a result, it may be possible to provide more supplementary appointments for those who need it most.

Because videoconferencing is convenient, virtual appointments are easy to attend. With telehealth, there’s great potential to cut down on missed visits, which means more patients will receive the specialized follow-up care they require.

Featured image courtesy of Medical News Bulletin.

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COPD Education – Onboarding


To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Patient, Educator (Nurse, RT, the Physician could also be the educator)

One 60-90 min session with the Educator

  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
COPD Education – Continuous Maintenance


To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Patient, Educator (Nurse, RT or Physician)

A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
COPD Respiratory Status Follow-up


Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Patient, Educator (Nurse, RT or Physician)

Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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