Why Patient Stratification Matters in RPM

RPM is not a universal solution for all patients. Success depends on identifying individuals with:

• High clinical risk and modifiable conditions

• Gaps in self-management or care continuity

• Recurrent hospital or emergency department utilization

These criteria typically indicate patients who will benefit from close monitoring and timely intervention. In population health terms, RPM is a targeted intervention—not a blanket initiative.

High-Yield Populations for RPM Deployment

Based on published utilization data and practice-level experience, the following patient groups show strong alignment with RPM programs:

1. Patients with Uncontrolled Chronic Conditions

Patients with poorly managed diabetes, hypertension, or heart failure—especially those with recent medication changes—are primary candidates. RPM enables trend analysis and real-time course correction.

Example: A patient with Type 2 diabetes and an A1C of 9.2% may benefit from daily glucose readings and weekly outreach to adjust insulin dosing.

2. Recently Discharged Patients

Patients within 30 days of discharge from hospitalization for chronic conditions are at elevated risk of readmission. RPM provides a mechanism for early warning and support.

Example: Post-discharge heart failure patients monitored for daily weight gain and blood pressure can avoid fluid overload and acute decompensation.

3. Seniors with Limited Access or Support

Older adults living alone, with cognitive decline, or in rural settings may struggle to maintain condition control. RPM devices with cellular transmission support these individuals without requiring smartphone or Wi-Fi literacy.

Considerations: Practices should assess home setup, dexterity, and caregiver availability during enrollment.

4. Patients with Multimorbidity and Polypharmacy

The more complex the medical profile, the more valuable a passive monitoring system becomes. RPM allows care teams to watch for destabilization across multiple dimensions—BP, glucose, weight—without patient action.

Populations Less Suited for RPM

Certain populations may not benefit, or may require alternative models:

• Individuals with advanced dementia or severe behavioral health instability

• Patients without a stable address or who frequently change phones/devices

• Those with end-stage illness or hospice enrollment, unless RPM is used for palliative symptom tracking

Each case requires clinical judgment and documentation of appropriateness.

Social Determinants and RPM Equity Considerations

RPM introduces questions of access equity. Factors to assess include:

• Connectivity: Cellular-enabled devices mitigate broadband gaps but must be reliable in a patient’s zip code.

• Digital Literacy: While RPM can be passive, some models involve symptom input. Screen for comfort and comprehension.

• Language & Communication: Materials and call support should be multilingual, and culturally competent.

Addressing these variables up front improves enrollment success and downstream outcomes.

Clinical and Operational Criteria for Enrollment

To standardize RPM patient selection, leading practices use structured criteria. A sample framework includes:

• Condition-based Eligibility: Diagnosis of diabetes, HTN, CHF, COPD, CKD

• Utilization Trigger: Hospitalization or ED visit in last 60 days

• Complexity Score: Number of meds or chronic conditions >2

• Care Team Input: PCP or RN flags patient due to concern

Embedding these indicators into EHR prompts or discharge workflows ensures repeatable, equitable enrollment.

Key Takeaways

• RPM should focus on patient groups where monitoring alters outcomes—especially unstable chronic conditions and recent discharges.

• Selection criteria must consider both clinical appropriateness and operational feasibility (e.g., tech access, literacy).

• RPM is most effective when integrated into existing care coordination teams with defined eligibility rules.

Targeted, criteria-based RPM programs outperform blanket approaches. By focusing on patient populations that align with clinical risk and care gaps, health systems can maximize impact, reimbursement, and resource efficiency.

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