Best Practices for Keeping Patients Engaged in Long-term Remote Care

Remote patient monitoring (RPM) has helped close the gap between patients struggling to manage chronic diseases and physicians working to see better patient outcomes. 

However, the ability to stay connected via telehealth doesn’t address all of the challenges that arise when managing a life-long disease. One challenge doctors who have patients enrolled in RPM programs face is patient engagement. How can we make sure patients remain committed and engaged in their health, especially when they’re dealing with conditions like diabetes or COPD – diseases they’ll be managing for the rest of their lives?

Patients have access to medical devices such as scales, glucometers, and blood pressure monitors to keep track of their numbers. However, the responsibility is on the patient to take their readings. As medical professionals who interface digitally with these patients every week, part of our job is to determine the best way to keep patients involved in their health. The goal is to ensure that physicians have readings to analyze and create care plans based on.

We’ve listed a few best practices for nurses and other medical professionals who are looking to improve patient engagement in remote patient monitoring programs. These practices have ensured that patients are receiving the very best care.

Set Expectations & Hold Patients Accountable

When onboarding patients with chronic conditions into an RPM program, it is important to set expectations for patients. They need to understand that their condition is long-term, therefore their care plan is long-term. It’s important for them to know that they have support through the medical staff to help navigate their disease. 

Ana Parrish, Clinical Manager at SynsorMed, says it’s important for patients to know that when their health isn’t perfect, they have someone they can lean on for help. 

“It may be for several months that your blood pressure or your sugars look perfect. Then, you have that one time where you have that spike and you just want someone who sees it and says we see it, we hear you. What are the things that you’re doing? How can we help?”

When nurses call patients every week to check in on their progress, it creates a level of accountability for the patient. When there are changes in their readings due to poor habits, nurses can immediately hold patients accountable for their actions and their health. That frequent communication can lead to early intervention and prevent negative impacts to their health. 

“They’re not having that interaction with the medical professionals. So that’s where we kind of step in and say, you know, we’re still here, we’re still looking at those [readings]. If you need anything, we can help you. We can educate you. We can get that information over to your doctor,” Ana said.

Goal Setting

Another important factor in keeping patients engaged in their long-term care is to set goals. At Synsormed, our nurses set monthly goals with patients that are based on the status of their health and desired health outcomes. 

Ana described an example with a patient who struggled to keep her blood pressure down. The patient was having back pains and didn’t sleep very well. After talking to her, Ana learned that although the patient was in her 70s, she was taking care of her 99-year-old mother. Both the patient and her mother were in our RPM program. Between managing her own chronic conditions and being responsible for the care of her mother, this particular patient had a lot of stressors. 

“Our goal for this month was: What can we do to alleviate some of that stress that you have? We talked through that process and by the end of it, we came to the agreement that it might be useful for her to hire some kind of help. Maybe it’s a home health aide or nurse who comes in and just assists her by helping her mother,” Ana said.

Each patient’s goals are different based on their circumstances. Being able to listen to patients and build a rapport with them allows them to open up and share their struggles, which helps us help them. We’re able to set realistic, attainable goals that are tailored to their needs. 

Clear Communication between Patients, Nurses, and Physicians

It is important for nurses to provide feedback and guidance to their patients to improve their health, but it is equally important for nurses to listen and accurately document the concerns and progress of their patients.

Ana says her nurses practice clear and concise documentation so that they can reference notes in conversations with physicians. Our nurses also make use of escalation sheets that allow physicians to make adjustments to care plans for patients based on elevated readings.

“Just going into more detail and saying I spoke with this patient today, X, Y, and Z is happening just so that you know, and this could be affecting their numbers this week.” 

For providers that work with RPM companies, it’s important to make sure they’re getting the support they need beyond the software.

“I think because we send out those escalation [reports] weekly, it sets us apart.”


To learn more about how SynsorMed can help with your CCM, RPM  RTM and Virtual Care options please reach us at



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