Implementing a RPM-enabled transitional care pathway for adults with poorly controlled diabetes: a quality improvement initiative.

BACKGROUND

Adults discharged from the hospital with poorly controlled diabetes face elevated readmission risk, yet health systems lack practical models for integrating remote glucose monitoring into post-discharge care. Existing approaches often exclude patients at the highest risk who have limited English proficiency, adverse social determinants of health or limited smartphone access.

LOCAL PROBLEM: At a 292-bed community hospital in White Plains New York, patients discharged with haemoglobin A1c ≥8% showed higher rates of hospital utilisation. Local mortality data revealed disparities affecting Black/African American and Hispanic/Latino residents, prompting a programme design with equity as a core objective.

METHODS

We integrated remote patient monitoring (RPM) into our nurse-led transitional care programme through five Plan-Do-Study-Act (PDSA) cycles from April 2024- to January 2025. Patients received RPM services and care coordination for 90 days. Enrolment, appointment attendance, A1c completion and demographic representation were evaluated through each cycle.

RESULTS

Among 442 screened patients, 46 were enrolled (enrolment grew from 10.5% to 39.7%, p<0.001). Enrolled patients closely matched the eligible population across targeted demographic groups. Follow-up appointment attendance reached 78.3% for primary care and 69.6% for endocrinology. A1c testing completion improved to 48% in the final cycle. The most substantial gains in feasibility occurred after redistributing monitoring to a team-based model.

CONCLUSIONS

Iterative PDSA cycles enabled the development of an equitable RPM-enabled transitional care pathway for diabetes, achieving proportional enrolment across all targeted demographic groups. Key implementation insights included workforce capacity as the primary constraint to enrolment, workflow simplification through continuous glucose monitoring standardisation and the importance of pre-arranged ambulatory follow-up. Health systems implementing RPM for transitional care should prioritise adequate monitoring workforce, streamline device protocols and coordinate ambulatory integration from programme inception to enable scalable, equitable implementation.