Introduction: Patients with severe COPD have a higher hospital readmission rate due to poor lung function or significant clinical symptoms. Appropriate intervention measures can effectively prevent patients from being readmitted to the hospital. Aims and Objectives: The study aims to prevent hospital readmissions for severe COPD patients through intervention measures such as discharge planning, case management, home telemonitoring, and patient education. Methods: Teach high-risk COPD patients or their primary caregivers to use communication measurement tools, and to continue using them for four weeks after discharge. Schedule weekly video appointments with the program coordinator to monitor their health status and provide care guidance and medical advice based on symptoms and related physiological signals and parameters. Results: In a study of 35 eligible patients, 92.6% were male, and 46.3% were between 41-60 years old, while 46.2% were aged 60 and over. Home digital monitoring significantly reduced hospitalizations, emergency visits, and total hospital days at three and six months post-intervention. After 3 months, mean hospitalizations decreased from 0.45 to 0.19, mean ER visits decreased from 0.48 to 0.06, and mean hospital days decreased from 6.61 to 1.94. After 6 months, mean hospitalizations decreased from 0.55 to 0.23, and mean ER visits decreased from 0.55 to 0.23. Mean hospital days decreased from 7.48 to 6.03. Conclusions: Establishing a home monitoring model for high-risk COPD patients at discharge can reduce hospital readmissions and shorten hospital stays.