Enhancing chronic cardiac care through RPM programs

Chronic disease management is complex and costly, especially in America, where barriers to healthcare access are widespread and trenchant. The virtual care boom of the last four years has propelled the use of technology to support promising new approaches to managing chronic conditions. Among these, remote patient monitoring stands out as an especially effective approach, allowing clinical care teams to keep a close eye on chronic disease patients between clinic visits and make adjustments to treatment plans in real time.

RPM utilization has soared in the last five years, with one report showing that RPM claim volume increased by 1,294% from January 2019 to November 2022. The report released by data analytics company Definitive Healthcare also shows that RPM was most used in the care of chronic cardiac conditions. The data revealed that essential hypertension accounted for the highest share of RPM-related claims at 51%, and cardiology providers had the second-highest share of RPM procedure claims at 21.3%.

As health systems look to implement RPM for cardiac care, many are partnering with virtual care companies that have the expertise, resources and staff to support the virtual care models. This summer, Intermountain Health in Utah and Kettering Health in Ohio announced partnerships with a digital health company to enhance cardiac care.

Though implementing these RPM-based cardiac care models posed challenges, leaders from both health systems highlighted the benefits of a technology-based approach to chronic disease management.

Why the health systems turned to RPM

According to the Heart Failure Society of America, heart failure -- when the heart can't pump enough blood to meet the body's needs -- affects around 6.7 million Americans over 20, and the prevalence is expected to rise to 8.5 million Americans by 2030.

Guideline-directed medical therapy (GDMT) can significantly benefit patients with heart failure; however, ensuring patient adherence is challenging. GDMT for heart failure involves patients taking four types of heart medications. Heart failure patients must also make healthy lifestyle choices, like losing weight.

For Intermountain Health, RPM offered a strategy to improve patient adherence to GDMT and lifestyle changes.

"We were hearing from our APPs [advanced practice providers] that take care of heart failure patients that they were really having a gap with GDMT adherence," said Kaley Graham, executive director of Intermountain's cardiovascular clinical program, in an interview. "They kept escalating [patients] to our clinical program. And so, our medical director of the cardiovascular clinical program at this time said, 'Let's just kind of do a market scan about what potential options are out there.'"

Through the market scan and word-of-mouth recommendations, Intermountain Health was introduced to Story Health. The digital health company offers virtual care platforms that enable virtual visits, RPM, data collection and automated clinical pathways to ease clinician burdens and drive patient engagement.

"Patients oftentimes get great, amazing care from specialists in the clinic or in the hospital, but often struggle to get access once they're outside of that appointment or outside of that encounter," said Tom Stanis, co-founder and CEO of Story Health, in an interview. "But so much of our life happens between visits. We really need to bring medical care to that setting as well."

Intermountain Health and Story Health entered into a partnership in January 2023, launching a pilot that provided heart failure patients access to the RPM program. Following the success of the pilot, Intermountain announced plans this year to expand the digital heart failure program and launch a pilot focused on hypertension patients.

Innovation's never completely clean. It's always a little bit messy, but that's what you have to do in order to really move the needle.

Kettering Health's partnership with Story Health is more recent, but Kettering leaders decided to collaborate with the digital health company for similar reasons.

"Kettering Health has been looking at the patients that need the most support as evidenced by frequent hospitalizations, readmissions and high cost of care, and we narrowed our focus to patients who are struggling with heart failure," said Jody Underwood, executive director of population health at Kettering Health, in an interview. "What we were finding is that they did not have the necessary support in the ambulatory section to reach out to all of our heart failure patients in the home setting. And we wanted a little bit of a window there."

After assessing several potential companies, Kettering Health decided on Story Health, noting that its platform's RPM capabilities and EHR-integrated GDMT module enable clinicians to track the patient's care journey.

How RPM programs can support chronic cardiac care

The RPM programs at Intermountain and Kettering start with the same step: patient identification and enrollment.

At Intermountain Health, primary care, cardiology and hospitalist providers refer patients to the program. Graham noted that these providers have clear insights into the heart failure patients in their clinics and are, therefore, best equipped to decide which patients would benefit from RPM.

Once the patient has been enrolled, Intermountain clinicians use the Story Health technology platform to set up a treatment plan. The platform includes a module that integrates into the health system's EHR, enabling clinicians to combine EHR data with RPM data gathered by various RPM devices, such as blood pressure cuffs and weight scales. Using this combined data, Intermountain clinicians can make real-time adjustments to treatment plans and medication doses.

Patients interact with the program primarily through text. According to Stanis, Story Health uses automated and live texting to ensure patients remain on track with their care plans. The company employs health coaches who support patients as they navigate affordability and access issues.

"These lower licensure clinicians are available to help patients with all the barriers they run into along the way," Stanis said. "[Patients] might not understand the instructions about what's supposed to happen [next]. They may get to the pharmacy and find out that their medications are very expensive and they can't afford them. What should they do about that? Well, there are options, and our health coaches are experts."

The health coaches also help patients remember medication and dosing changes and help manage any potential side effects of these changes.

At Kettering Health, patients are identified for the program through their Epic EHR's predictive analytics capabilities, which allows clinicians to determine which heart failure patients coming into the hospital are at high risk for service utilization and readmission, Underwood said. These patients are referred to the health system's heart failure clinic, where they begin their Story Health journey.

Underwood noted that the health system has seen a high adoption rate, with 94% to 95% of patients referred to the program enrolling in it.

Challenges and benefits of RPM-based cardiac care

Intermountain Health and Kettering Health faced numerous hurdles as they implemented the RPM programs at their respective organizations.

Underwood said patient-facing social determinants of health were the most significant barriers. Some patients who could benefit from RPM only had a flip phone, which is insufficient to enable participation in the text-based aspects of the program. In these cases, Kettering clinicians bring loved ones into the fold.

"Usually, people that are close family or close friends that are checking on them or neighbors or something have that smartphone available," she said. "And so, we'll say, 'Wait a minute, doesn't your daughter or your son help you? We could use their smartphone, and you two could get on their smartphone together and answer the questions.'"

It really does feel seamless for them. They enjoy it. We have patients who will purposely text us every single day just to kind of check in.

Another hurdle was that heart failure patients who would be a good fit for the program were often discharged to skilled nursing facilities, making enrolling those patients in the program more challenging. Now, Kettering is working with skilled nursing facilities to enroll those patients once they are discharged to their homes.

On the other hand, barriers to RPM implementation at Intermountain were on the provider side. Graham said that clinicians typically feel uncomfortable relying on technology, feeling they need to manage patient care directly. Intermountain leaders built trust in the technology by giving clinicians projected outcomes and early results data.

"Clinicians love data and love seeing it in those numbers," Graham said. "And so, getting to see that helps build that trust, helps build those relationships."

Not only that, but once the pilot was underway, clinicians also began to see the value of virtual support for heart failure patients. For instance, the program helped free up clinic space for patients who need to be seen in person, giving Intermountain clinicians more time with patients with more complex needs.

Underwood further noted that the data collected by the RPM platform is available to the patient's entire care team, even those not involved in their cardiac care. This offers clinicians a comprehensive view of their patient's care journeys, enabling them to make more informed care decisions.

From the patient's perspective, the biggest benefit is convenience, according to Underwood. Regardless of work commitments, childcare challenges, transportation barriers or even weather issues, patients can get the care they need through RPM and virtual visits in their homes.

"It really does feel seamless for them," she said. "They enjoy it. We have patients who will purposely text us every single day just to kind of check in."

In addition to enhanced patient experience, Graham noted that the RPM program has improved care outcomes. Intermountain Health saw reductions in emergency department admissions and hospital readmissions, as well as improvements in ejection fraction. Anecdotal evidence also points to improvements in quality of life, with patients stating they no longer feel tied down and can do more, she said.

The new hypertension pilot, which began in April, is showing promising results, though the health system does not yet have outcomes data to share.

"We're seeing a lot of patients that are actually doing much better with their blood pressure already," Graham said. "I'm excited to see outcomes data. Like I said, it's a brand-new pilot program, but so far, patients are really enjoying the fact that they're getting care in a different way, and it's actually helping manage their blood pressure."

Kettering Health also does not have outcomes data for its heart failure-focused RPM program, but the lead indicators are looking good. Underwood said that the health system is examining the percentage of patients adhering to GDMT, assessing echocardiogram data to ensure patients' ejection fraction is being preserved appropriately and measuring the degree of symptom burden to determine the efficacy of the program. The health system is looking to launch an RPM program for hypertension in the future as well.

While implementing new technology and care models to address prevalent chronic conditions is no easy task, the benefits to patients and providers alike make it a worthwhile investment. Advancements in care delivery are urgently needed as the U.S. population ages, prompting the need for greater access to healthcare.

"We have more and more elderly people that need specialty care, and we, as a culture, are dealing with this kind of demand crisis that we're going to have to rise to the occasion of," Stanis said. "And unfortunately, the way we did things in the past is no longer going to work, and it's going to take time, it's going to take all of us working together, and it's going to be sometimes challenging and painful, but that's the way that we actually innovate. Innovation's never completely clean. It's always a little bit messy, but that's what you have to do in order to really move the needle."

Anuja Vaidya has covered the healthcare industry since 2012. She currently covers the virtual healthcare landscape, including telehealth, remote patient monitoring and digital therapeutics.