Keeping Health Equity Top-of-Mind in Remote Patient Monitoring Programs

Interest in home-based care is on the rise, spurred by the COVID-19 pandemic that resulted in health facilities becoming overwhelmed and struggling to ensure ongoing access to care. A key aspect of home-based care is remote patient monitoring (RPM), enabling providers to track patient outcomes and offer care outside their facilities.

But as providers set up new or expanded RPM programs, they must keep in mind the glaring gaps in care that different populations face.

In particular, racial minorities and people living in rural areas face numerous hurdles to care, including lack of insurance, lack of stable internet connectivity, lower incomes, no transportation, or extended travel distances to see their providers.

While these communities are most likely to benefit from virtual care services, like RPM, they are also the ones who may have the most trouble accessing it.  

For health systems, this means that they must keep an eye on health equity as they integrate RPM further into their care delivery workflows. But several challenges stand in the way, including reimbursement and technology access.

PROVIDERS ARE USING RPM IN VARIOUS WAYS

Philadelphia-based Jefferson Health has a decade-long history of investment in telehealth, and when the COVID-19 pandemic hit, the health system doubled down on RPM as well.

"Our vision of the future is healthcare with any address," said Stephanie Conners, chief operating officer of the organization, in a phone interview. "So that means caring for complex cases in other locations than tertiary or acute care [settings]. We believe that not only is that the future of healthcare, but it also will support the inequities in healthcare for those underserved communities that are not as quick to advance to a hospital setting and or to seek care."

The health system uses RPM to track acute and chronic conditions, including COVID-19 and cancer. This helped the system manage rising inpatient volume because of the pandemic and extend ongoing care to cancer patients at home.

"We had careful considerations around chemotherapy at home, but it was very compelling for us as we looked at…providing those intravenous capabilities in the home," Conners said. "Really allowed those patients the safety of their environment and not exposing them to the bricks and mortars side of healthcare when it wasn't necessary."

Similarly, RPM opened up inpatient capacity for Reno, Nevada-based Renown Health, enabling care in a more familiar environment.

"I don't need people to be in the hospital bed where there's workforce shortages or [they could] potentially get sick," said Anthony Slonim, MD, president and CEO of Renown Health, in a phone interview. "I can have them in their living room, eating their own food with their family and watching their own television. And that was the launch point for us around our remote patient monitoring strategy."

The health system uses RPM to treat patients with chronic diseases, like chronic obstructive pulmonary disease, and mitigate the workforce shortage facing the healthcare industry.

For the latter, the hospital staff is using sensors to track inpatients remotely, only going to the bedside when needed.

"It helps us to deploy staffing differently because we have this infrastructure built that can kind of keep an eye in the sky on our patients, even when they're in our hospital," Slonim said.

ADVANCING RPM EQUITABLY

Renown Health's facilities, which include four hospitals and numerous medical groups, and urgent care centers, are spread across Nevada. As a result, its footprint is largely rural.

"People who live in rural contexts have higher levels of [chronic and acute] conditions," Slonim said. "They have higher levels of challenges as it relates to access to care. They have higher addiction levels, higher mental health challenges…and they die at a higher rate. And while you don't usually think about the rural environment as having a health equity problem, you have to."

This is why keeping health equity top-of-mind was essential as Renown developed and expanded its RPM services.

RPM has enabled staff at the health system's larger hospitals, which have more resources, to augment the care provided in more rural facilities. This means more rural patients get access to specialist care and resources they may not otherwise have.

"The good news about technology and teamwork is that you can provide better quality at a lower cost," Slonim said. "That's the value proposition."

On the other hand, Jefferson Health cares for a predominantly urban population, but many of its patients are uninsured or have government insurance. Additionally, the health system is one of the largest providers in Philadelphia for refugees, Conners said.

To ensure that these traditionally underserved populations get access to RPM, Jefferson is taking a very systematic and methodical approach to selecting the conditions RPM is used to treat.

"It's one diagnosis at a time," Conners said. "Really understanding what will enable us to provide that total care [at home] has produced better outcomes in safety, service, and quality."

For now, RPM is being extended to congestive heart failure, cancer patients requiring chemotherapy, and COVID-19. 

Further, as Jefferson implements RPM services for chronic conditions, it is keeping a close eye on social determinants of health.

"We're paying attention to food insecurities and housing and cultures and environments," she said. "So that as we build these programs, we're building them to meet the needs of those unique populations."

In the coming year, the health system has big plans for its home healthcare services, which RPM will support. Last November, Jefferson Health announced a partnership with BAYADA Home Health Care to launch a joint venture focused on providing care at homes. This partnership will help Jefferson support patients in their homes even if they don't have all the resources they need, Conners said.

In addition, the health system is working with venture capital firm General Catalyst to develop technologies that boost virtual care and care outside the hospital.

BARRIERS TO EQUITABLE RPM

But even as providers try to develop their RPM programs through the lens of health equity, there are several hurdles standing in the way.

Reimbursement is one of the critical issues facing providers as they work to advance RPM. Though numerous regulatory changes and flexibilities enacted during the COVID-19 pandemic have spurred RPM use, not all payers are on board.

"Payers at this point don't fully recognize care in the home or remote patient monitoring," Conners said. "So as providers, we have an obligation to prove the concept, and that's what we've been working on doing with some of [our] chronic disease, post-discharge management programs."

Another major issue facing RPM providers is the widespread lack of broadband access. Not having reliable internet connectivity prevents people from taking advantage of growing virtual care options.

Unfortunately, broadband expansion lies in the hands of federal and state authorities.

"[Broadband access is] a large part of what the infrastructure bill from the federal government is supposed to address," Slonim said. "And so hopefully, over time, that will get better. Here, in Nevada, we've had some important improvements in infrastructure and broadband."  

As healthcare stakeholders wait for broadband expansion efforts to come to fruition, providers can work to democratize the devices used to support RPM — which tend to be low-cost, like scales and blood pressure cuffs — and make them more widely available, according to Slonim. 

"RPM is an important tool in the toolbox," he said. "It's not for everybody, but it certainly can be democratized in a way that improves access, particularly among vulnerable populations and segments of those who have struggled for a long time around inequities in their healthcare."