How Health Systems Are Using RPM to Extend Cancer Care into Patient Homes

Soon after the COVID-19 pandemic hit, concerns regarding the sudden halt of in-person care grew. As hospitals swelled with novel coronavirus cases, many worried about chronic care needs not being met – especially among cancer patients.

These concerns were not unfounded. A study published in late November 2020 showed that the pandemic significantly delayed identifying new cancers and treatment delivery. A more recent study reveals that gaps remain in preventive cancer screenings.

But as in-person care restrictions proliferated, virtual care use grew. And though many providers were already leveraging virtual care strategies, like remote patient monitoring (RPM), the pandemic further spurred their use in the cancer care arena.

Some organizations were able to scale existing RPM programs for cancer care due to regulatory flexibilities that accompanied the pandemic, while others were able to stand up new programs through grants and new funding mechanisms.  

But implementing RPM efforts in the cancer care arena is not without its challenges, according to health system leaders who spoke with mHealthIntelligence. These challenges include a lack of technology access, clinician pushback, and nonexistent reimbursement structures.  

CANCER CARE PROVIDERS ARE USING RPM IN VARIOUS WAYS

Organizations that provide cancer care are employing RPM primarily to expand access to care and prevent adverse events.

At the University of Utah Health's Huntsman Cancer Institute in Salt Lake City, RPM underpins several programs, including the symptom management and hospital-at-home programs.

Huntsman's Symptom Care at Home program focuses on monitoring the symptoms of chemotherapy patients, said Kathi Mooney, PhD, co-leader of Cancer Control and Population Sciences at Huntsman Cancer Institute. Patients call an interactive voice response (IVR) system daily to report their symptoms and rate the severity. The system provides an automated response on managing the symptoms they are experiencing and alerts the care team if the symptoms become severe.

"We find that to be very helpful in terms of cancer symptom management," Mooney said in a phone interview. "You may see them in the clinic on a Tuesday and Wednesday morning, [but later] they wake up with something, and they're in the emergency department. So, the ability to remotely have the patient know what they're experiencing at home and be able to respond in the moment to that helps decrease the symptom burden and therefore decreases the escalations."

But all escalations cannot be avoided, and cancer is known to progress rapidly. To expand access to acute care and avoid emergency department (ED) visits and re-hospitalizations, the cancer institute launched a hospital-at-home program in 2018.

Through the program, patients receive on-site and telehealth-enabled nurse practitioner visits and on-site registered nurse and physical therapy visits. It also includes remote cardiovascular monitoring. Since its inception, 2,000 patients have been treated through the program.

According to Mooney, the program has helped extend hospital-level care to cancer patients around the state, which is largely rural. Further, a study by Huntsman evaluating the program showed that the odds of unplanned hospitalizations in the hospital-at-home group dropped by 55 percent compared to patients who received standard care in the hospital.

Like Huntsman, Ochsner Health System in New Orleans implemented RPM to support cancer patients undergoing chemotherapy. Launched in 2019, the program provides patients with various devices, including a blood pressure cuff and thermometer, Erin Pierce, nurse practitioner and manager of precision cancer therapies at Ochsner Cancer Institute, told mHealthIntelligence.

Patients pick up the devices for free from the O-bar, Ochsner digital technology hub, where technicians help them set up and use the devices. Patients submit vital signs twice daily through the health system's app. Clinicians intervene when needed to help patients before they find themselves back in the hospital.

"Our whole goal for all of this was really to decrease hospitalizations and ER visits and really keep people out of the hospital as much as possible because it's the last place cancer patients want to be," Pierce said in a phone interview.

The health system collected preliminary data on the program from January 2020 to December 2021, which showed a 33 percent decrease in ED visits and hospitalizations among program participants. The program won Ochsner a 2022 Association of Community Cancer Centers Innovator Award.

"The thing is, we know cancer patients are going to go to the emergency room, we know they're going to get hospitalized, they're prone to these things," Pierce said. "But again, what we wanted to do was see if we could decrease that amount, and that's what we were able to show."

Unlike Ochsner and Huntsman, Mount Sinai Health System in New York City began using RPM in cancer care last year after applying for and winning a grant from the Federal Communications Commission.

The health system's program provides wearable devices to cancer patients in the ambulatory setting who are receiving some form of cancer-related treatment, typically chemotherapy or immunotherapy, said Cardinale Smith, MD, PhD, chief quality officer for cancer at Mount Sinai Health System and system associate professor of medicine, hematology, and medical oncology.

The devices include arm cuffs that can track temperature and oxygen saturation, blood pressure cuffs, and tablets to connect patients with the care team and facilitate data exchange. The tablet has built-in internet access, helping the health system overcome one aspect of the digital divide.

"As we think about the digital divide and what some of the challenges are for certain populations to be able to use and access technology and novel devices…having tablets so that they can engage [in]and do video visits or communicate with their clinicians in real time was something that was important to for me," Smith said in a phone interview.

In addition to reducing unnecessary ED visits and hospitalizations, RPM use has enabled Mount Sinai to leverage patient-reported data to improve mortality risk.

"[RPM use] may improve survival because we're helping manage patients' symptoms more appropriately," she said. "And so, this is a way to reengage patients in real time about their symptoms as opposed to waiting until symptoms become severe."

OVERCOMING CHALLENGES TO ADOPTION AND USE

While deploying RPM strategies for cancer patients, providers faced various hurdles.

For Ochsner, the primary challenges were the high cost of devices and some patients' inability to understand and use technology.

To address the first hurdle, Pierce and her team relied on philanthropy funding and the Ochsner Excellence Grant, which provided $25,000, to buy the bulk of the RPM kits.

"We really strongly feel that this should be something that every cancer patient is offered, and we really want to be able to continue [providing these devices for free], so we're continuing to try to find funding," she said.

Though digital literacy has grown significantly, especially amid the pandemic, some patients still struggle with technology. Ochsner leveraged its O-bar – like Apple's Genius Bar, but for patients in Ochsner's care – to show patients how to use the technology and provide troubleshooting support if they have issues with the devices after taking them home, Pierce said.

To further widen access to RPM during the pandemic, Ochsner changed the type of data collected in the program. Instead of enrolling patients before they started chemotherapy so clinicians could collect baseline vitals for each patient, the health system began enrolling patients at any point in their treatment journey and moved to a threshold system to assess the data.

"We went from those baseline vitals from the individual and went ahead to just threshold vitals," Pierce said. "So, for instance, if blood pressure was at a certain range, or their heart rate, or their temperature, that's when a notification would fire to [clinicians]…compared to [firing when there were] deviations from the patient's original blood pressure."

The health system was able to enroll more patients in the program by making this switch, she added.

Though the availability of real-time data and alerts are some of the biggest boons of using RPM, they can also become a barrier.

"We, in this pandemic world, are dealing with workforce shortages, people who are tired, and the idea of having to monitor another thing is challenging for folks," said Mount Sinai's Smith.

Leaders may face pushback on RPM efforts from their clinicians, who are worried about adding to their workload. Clinicians may also worry about liability if they do not respond to an alert in time or if the device malfunctions and they act on the wrong data.  

"We really had conversations with our regulatory and legal groups to understand some of the other things that came up for physicians, specifically around liability," Smith said. "We had an initial rollout where we had the interested parties, who could speak to all of this, come and talk about it and what it meant."

And it's not just providers; patients may also have their own reservations, especially those uncomfortable with technology. Like Ochsner, Mount Sinai provided patients with additional support through oncology coordinators, who helped patients set up and use the devices, Smith said.

Huntsman Cancer Institute's symptom management program incorporated the IVR telephone system primarily to address technology access and use issues among its patients.

"That's one of the reasons we started with the IVR system because it decreased the disparity of not having access to a smartphone," Mooney said. "We also have added now an app and web[site], so that we're responsive to patients who said, ''I'd rather not use telephone audio,' [and said], 'I would rather just put it in through a text kind of method.'"

With the hospital-at-home program, Huntsman focused on breaking down barriers related to patients' social determinants of health. The institute partnered with community organizations, including cleaning services and food banks, to curtail sanitation and food security problems while acute care is provided in people's homes.

"We have tried to be very careful about not arbitrarily saying we couldn't provide service to a patient because there is the benefit of not disrupting them, of keeping them in the home, of not asking them to travel a distance in order to get care," Mooney said. "We have, for example, taken care of patients in mobile homes, in conditions where there was poverty." 

Further, Huntsman worked closely with the home health agency they contracted with for the hospital-at-home program to ensure the home healthcare workers were adequately trained to provide acute care in the home.

According to Mooney, the institute helped train the staff on conducting critical assessments and other treatments outside the traditional home healthcare services arena.

BARRIERS TO ONGOING RPM USE IN CANCER CARE

As healthcare providers increasingly apply RPM strategies to cancer care, they are facing challenges in the broader healthcare landscape that may hinder more significant progress.

Perhaps the most pressing issue is the uncertainty regarding reimbursement for RPM-based programs.

"The issue is, with new models of care such as remote symptom management or hospital-at-home, they are new modalities that don't have a structure within existing healthcare, and therefore there aren't payment models," Mooney said.

Within cancer care, the only type of established home healthcare reimbursement model is related to hospice services, spurring the need for new payment models for RPM programs that support other aspects of cancer care, she added.

Pierce echoed Mooney, saying that health insurance companies also need to look at expanding coverage to ensure that the high cost of devices does not deter patients from participating in these programs.

"I think it goes back to if this was more affordable, more people would be doing it," she said. "We know the benefit is there; it's just finding the coverage that we need, which is really why we need to get insurance involved with this."

One way to encourage the development of payment models and prompt coverage expansion is to collect data showing the clinical and financial benefits of leveraging RPM for cancer care. According to Mooney, gathering and sharing this data can support the wider use of RPM, which can ultimately expand cancer care beyond the hospital.

"I think it's very exciting with technology what we can do in the home," she said. "And I think we are demonstrating a number of ways to do it and do it safely. And it is just now the implementation of that. How do we scale it with appropriate reimbursements and regulations that are supportive to care being provided in the home?"