Keeping patients out of the hospital requires knowing what puts them in the hospital in the first place. It’s not always obvious.

“One of the reasons why people get re-hospitalized … is not taking their medications properly,” said Tammi Mozier, vice president of education for the Granite Visiting Nurse Association.

The 126-year-old organization helps some 1,300 people throughout the greater Concord and Lakes regions stay in their homes as they deal with a variety of issues. It has recently rolled out a “telemed” program through Ibis Health, a Massachusetts-based medical company serving Medicare patients.

Ibis provides a computer tablet and, if needed, items such as blood-pressure cuffs, scales or a pulse oximeter that home patients can use to monitor themselves. The data is then sent to the company, where physicians and nurses can spot changes and either talk with the patient or alert Granite VNA, which might send out a visiting nurse.

The system doesn’t replace in-person visits, Mozier said; it lets them be more useful.

“By monitoring vital signs and having that data, recognizing small changes, that will facilitate intervention — having someone reach out to the patient, saying, ‘Hey, your blood pressure is up, tell me about the last 24 hours, what did you eat, what has been happening,’” she said. “It’s not waiting until the small problems become a big one.”

Just as important as daily health data, however, can be daily reminders, especially for patients who are dealing with emotional or mental vulnerabilities. A large part of Granite VNA’s clients are elderly.

“The reminder includes pictures of the pills they’re taking. It helps them be more consistent with their medications, which is very important,” said Mozier.

Granite VNA has run telemed systems on its own. Mozier said they looked at alternatives and chose Ibis Health after it became licensed to operate in New Hampshire.

A huge advantage over their own system, she said, is that Ibis can keep going even after a patient no longer needs Granite VNA and they are discharged from home care. Ibis Health can reconnect patients to Granite VNA if their situation changes, which can also help reduce hospitalization.

Also, Mozier said, “the platform that they have is very user-friendly. The setup is pretty intuitive.”

The service is covered under the Medicare Part B benefit. Ibis Health also accepts Medicare Supplemental plans. There is no upfront cost to join.