Remote monitoring and chronic care management for pulmonology practices
COPD and asthma exacerbations rarely arrive without warning. Home pulse oximetry, weekly symptom check-ins and steady support with inhalers and oxygen help your team act earlier, within your protocols.
The burden of COPD
U.S. adults are affected by COPD, with about 700,000 exacerbation hospitalizations a year1
COPD exacerbation admissions is followed by a readmission within 30 days2
of those readmissions happen within the first 15 days after discharge2
lower odds of COPD-related readmission with transitional care (OR 0.60)3
What we watch for in pulmonary patients
Oxygen saturation trends matter, but so do the details a patient mentions on a call: more sputum, more rescue puffs, sleeping upright. We capture both and route them to you.
COPD
Oxygen saturation and pulse trends, weekly symptom check-ins, action-plan reinforcement and early escalation when a pattern points to an exacerbation.
Asthma
Symptom control questions, controller adherence, inhaler technique and trigger review.
Supplemental oxygen
Adherence and home safety education, with equipment problems routed to your team.
ILD and pulmonary hypertension
Oxygen saturation and symptom trends reviewed, with changes reported to your office.
Tobacco dependence
Tobacco status on every call, cessation support and positive findings routed to your practice.
After a hospital stay
An early call after discharge, medication reconciliation and help keeping the follow-up visit.
Why the weeks after an exacerbation matter
COPD readmissions are front-loaded, which is why early, structured contact after a hospital stay is where support pays off most.
Published results reflect specific program designs and patient populations. Outcomes for any program depend on patient selection, engagement and how escalations are acted on.
Readmissions come early
In an analysis of 1,055,830 COPD exacerbation admissions, 19.2% were followed by a readmission within 30 days, and 58% of those readmissions occurred within the first 15 days.2
Transitional care lowers readmission
A meta-analysis of 13 randomized trials found transitional care reduced COPD-related readmissions (OR 0.60) and all-cause readmissions (OR 0.72); telephone follow-up was one of the factors that shaped the effect.3
Home telehealth at scale
The VA's home telehealth program, which included patients with chronic lung disease, was followed by 19% fewer hospital admissions across 17,025 patients.4
Aligned with GOLD and GINA
Both guidelines emphasize regular reassessment of symptoms, inhaler technique and adherence, which is exactly what weekly check-ins cover.
Diagnoses commonly referred from pulmonology
Pulmonary patients often qualify together with hypertension, heart failure or diabetes.
| Condition | ICD-10-CM |
|---|---|
| COPD, unspecified | J44.9 |
| COPD with acute exacerbation | J44.1 |
| Chronic bronchitis, unspecified | J42 |
| Chronic respiratory failure | J96.10 to J96.12 |
| Dependence on supplemental oxygen | Z99.81 |
| Moderate persistent asthma | J45.40 to J45.42 |
| Severe persistent asthma | J45.50 to J45.52 |
| Obstructive sleep apnea | G47.33 |
| Idiopathic pulmonary fibrosis | J84.112 |
| Pulmonary fibrosis, unspecified | J84.10 |
| Sarcoidosis of lung | D86.0 |
| Bronchiectasis, uncomplicated | J47.9 |
| Pulmonary hypertension, unspecified | I27.20 |
| Nicotine dependence, cigarettes | F17.210 |
Questions from pulmonology practices
Which devices do pulmonary patients receive?
Usually a pulse oximeter, plus a blood pressure monitor or scale when the patient also has hypertension or heart failure.
Do you provide home spirometry or manage CPAP and oxygen equipment?
No. The program uses pulse oximetry, blood pressure, weight and glucose devices. We reinforce adherence and safety for oxygen and CPAP and route equipment problems to your team.
How quickly do you contact patients after a discharge?
Patients you refer after a hospital stay get an early call to reconcile medications, review symptoms and confirm the follow-up visit.
Other specialty programs
Let's talk about your patients.
A short conversation is usually enough to see whether VitalityMed is the right fit for your practice.
- We review your specialty, your patients and what you want to improve.
- You see a sample monthly summary before you commit.
- Getting started takes one onboarding call and your clinical protocols.
Patients and families can call the same number.
Request a conversation
We'll reply by phone or email. Please don't include patient health information.
References
- Principal discharge diagnoses and timing of 30-day readmission among Medicare beneficiaries hospitalized for acute exacerbation of COPD. pmc.ncbi.nlm.nih.gov
- Nationwide analysis of 1,055,830 index admissions for acute exacerbation of COPD: timing and diagnoses of 30-day readmissions. pmc.ncbi.nlm.nih.gov
- Effects of transitional care on hospital readmission and mortality rate in subjects with COPD: a systematic review and meta-analysis of 13 randomized controlled trials. Respiratory Care. hub.tmu.edu.tw
- Darkins A, Ryan P, Kobb R, et al. Care Coordination/Home Telehealth: the systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemed J E Health. 2008;14(10):1118-26. pubmed.ncbi.nlm.nih.gov
Page last reviewed 2026-09. This page is for health care professionals and is not medical advice.