Scaling an RPM Program to Enhance Chronic Disease Management

As healthcare provider organizations see the positive clinical results associated with remote patient monitoring (RPM) programs, many are working to scale the services to reach a wider swath of their patient population.

There is mounting evidence showing the impact of RPM on patient care, particularly for patients with chronic conditions. Research indicates that RPM can help boost outcomes for diabetes, chronic obstructive pulmonary disease (COPD), and hypertension patients.

Health systems are responding by doubling down on RPM use, with RPM claim volume increasing by 1,294 percent from January 2019 to November 2022. The data, released earlier this year, also shows that essential hypertension had the highest share of RPM-related claims (51 percent) during that period, followed by diabetes mellitus with complications (10.4 percent) and diabetes mellitus without complications (6.4 percent).

Prisma Health is one of the latest providers to expand RPM services to tackle chronic diseases. Last month, the South Carolina-based health system announced plans to expand its year-old RPM and Chronic Care Management (CCM) program to include 81 new primary care physicians serving more than 20,000 high-risk chronic care patients.

"We see this being an opportunity that we can continue to expand as we look at new innovative care models, lowering that cost of care, but also bringing care directly into the home of the patients that we're serving," Angela Orsky, DNP, LNHA, RN, the health system's senior vice president, Value Based Care and Clinical Integration, in an interview. "Prisma Health is the largest healthcare system in South Carolina. So, we do have the opportunity to reach a lot of patients across the state of South Carolina through programs like this."

But expansion can be hindered by a variety of factors, including physician adoption. As Prisma Health moves forward with scaling the program, the health system is implementing strategies to curb these challenges. 

LAUNCHING THE PROGRAM

Prisma Health launched its RPM and CCM program following a partnership with virtual care company HealthSnap last June. While the health system had experience with RPM before this, using both home-grown and vendor-driven models, it wanted to reach a larger share of its patient population.

"When you look at the health status of South Carolina, we know that there's a lot of opportunity for us to help improve what care looks like across the continuum and outside of your traditional ambulatory site visits," Orsky said.

For this new program, Prisma Health was looking for an experienced vendor who could support services across the continuum of remote care, including device management, patient engagement, and billing and compliance. According to Orsky, HealthSnap "rose to the occasion."

The company's virtual care platform provides various capabilities to support RPM and CCM, including clinical decision support pathways, care plan builders, and patient-and population-level insights. It also provides two patented billing reports that automate the revenue cycle on the backend.

The company ships pre-configured and cellular-enabled devices to the patients and provides onboarding services for them as well.

"When you're dealing with low-tech literacy populations that are Medicare-age, and a lot of lower socioeconomic populations that might not have a smartphone or might not have WiFi in their homes — we can include any population into our programs," said Samson Magid, co-founder and CEO of HealthSnap, in the interview.

In addition, the health system wanted program operations to be integrated into its Epic EHR. Its internal team worked with the company to enable the integration.

"This isn't a workaround," Orsky noted. "This isn't a bolt onto our Epic EHR. In our physician practices, they can see all of the vital sign monitoring. They can see all of the clinical nodes. It sits as a node or an encounter in Epic, and we don't want to underestimate the value that brings to a physician who's looking for efficiency, less clicks, and the ability to holistically see what is occurring with their patient on the clinical side."

The program is open to patients with chronic conditions through its primary care clinics, but the health system has thus far seen a higher proportion of heart failure, respiratory issues, and diabetes patients. Prior to program implementation, care for these patients was more fragmented, requiring manual entry of information, which added to patient and provider burden.

According to Orsky, the new program is comprehensive, supported by licensed regional clinical staff members from HealthSnap who manage the care plan, day-to-day alert triaging, and documentation under the supervision of Prisma physicians.

CLINICAL RESULTS AND OTHER BENEFITS

The decision to expand came after clinical results pointed to the efficacy of the program.

Magid noted that 82 percent of the population enrolled in the program with hypertension experienced an improvement in their blood pressure. In addition, 67 percent had uncontrolled hypertension at baseline. Following the program implementation, that figure fell to 43 percent.

"Even more significant was the reduction in stage two hypertension," Magid said. "So, at baseline, 36 percent of patients were in the stage two hypertension category, and now only 9 percent are in the stage two hypertension category. So, we're talking 20 percent-plus reductions in uncontrolled hypertension and stage two hypertension."

According to Orsky, the remote patient monitoring component of the program combined with real-time intervention has led to these improvements. Without RPM, a typical hypertension patient would take their blood pressure readings at home and take the results to their provider for review at their next clinic visit, which could be more than a month away. RPM allows clinicians to gather and track this data in real time and adjust care plans.

"If it's adjustment of medications, if it's bringing them back into the office, if it's re-education, if it's plugging them into resources like a dietician or other specialty services," Orsky said. "You get this immediate improvement with wrapping your arms around that patient and doing interventions that are very successful."

Another benefit of the program has been greater patient engagement with clinicians. Orsky noted that through continuous metric tracking and ongoing communication, clinicians are able to build strong relationships with their patients, serving as a resource for them as they navigate their care journey.

EXPANSION PLANS & CHALLENGES

The health system is currently in the process of expanding the RPM and CCM program to 81 primary care physicians. This process requires collaboration with multiple stakeholders within the health system.

"This isn't something that you just turn on overnight," Orsky said. "There is a pathway to rolling out a new program, to ensuring that it does fit within practices workflow, that it doesn't fracture processes that they have in place, and that you've got this closed loop with your groups around what's working well and what's not working well."

A critical step in the pathway is getting buy-in from physicians and patients. Prisma Health and HealthSnap worked to educate physicians about the program, how it operates, and how it will impact their day-to-day workflow, Magid said.

Then, the partners focused on ensuring patients felt comfortable with the program and that it was not disrupting their healthcare journey. Orsky said they are using data analytics to help identify patients that could benefit from the services.

"We start with identifying patients that are seen within our practices who may have those chronic conditions, who may have some instability in some of their hypertension, let's say," she said. "We use our EHR analytics to identify patient populations, and then we provide those to our physicians for them to review them and make a determination on how they want to engage with their patients."

Eventually, the program will be used to meet specific population health needs. Prisma Health teams are already beginning to evaluate what the rollout would look like when targeting a particular population, such as cardiac care patients. Orsky noted that the health system does not see the program being a plug-and-play model.

Further, the platform supporting the program is customizable, allowing physicians to personalize metric thresholds and care pathways for each patient. According to Orsky, this provides a significant advantage for Prisma as it continues to expand the program to new populations with complex needs.

"We want our patients to have a good experience," Orsky said. "We want them to see the value in a partnership and the investment in improving their health outcomes."