Telehealth patients can test their blood sugar at home and a nurse at the computer center gets the data.
Telehealth patients can test their blood sugar at home and a nurse at the computer center gets the data. Image courtesy: RCCHC

This is the second of a two-installment story on a North Carolina-based organization’s successful use of remote patient monitoring. You can read part 1 here

By Amy Adams Ellis

Nurse Rhonda Cotton worked face to face with patients for 23 years at Vidant Roanoke Chowan Hospital, plus 10 years in a surgeon’s office and a few more in hemodialysis and home health.

Telehealth patients can test their blood sugar at home and a nurse at the computer center gets the data.
Telehealth patients can test their blood sugar at home and a nurse at the computer center gets the data. Image courtesy: RCCHC

But two years ago, she gave up bedside nursing to take a job with Roanoke Chowan Community Health Center (RCCHC) in Ahoskie. Her new position put her on the phone and in computer contact with patients in remote towns.

Initially, Cotton was a little dubious.

“I was used to evaluating patients by seeing and touching them,” she said. “With in-person nursing, there is the added advantage of using hands-on skills and visual observation. With remote patient monitoring, making an accurate clinical decision about a patient hinges more on asking the right questions and having good listening skills.”

Now, Cotton said, she finds immense satisfaction in helping patients increase their health care literacy. And she does it remotely.

Cotton came to work at the right place. RCCHC, located in a small town in northeastern Hertford County, has been in the forefront of a national effort to develop and expand telehealth solutions for people with chronic diseases.

Rocket science

The RCCHC folks didn’t invent remote patient monitoring (RPM), but they’ve been doing it longer than most, so they’ve figured out, through trial-and-error, what it takes to make a program work.

“There really is a little bit of rocket science involved,” laughed Kim Schwartz, RCCHC’s executive director.

Over time, they’ve honed a way to select the patients who’ll benefit most from RPM, based on their previous hospital admissions and ER visits, what chronic diseases they have, how complex those diseases are and how well they comply with taking their medications. They’ve determined how long patients should be monitored for optimum effectiveness.

And perhaps the biggest key to their success: their focus on the relationship between patients and their primary-care providers.

Nurse Jennifer Jones monitors patients' blood pressure, weight and blood sugar remotely.
Nurse Jennifer Jones monitors patients’ blood pressure, weight and blood sugar remotely. Image courtesy RCCHC.

The provider establishes the plan of care and determines how often vital signs should be monitored, including blood glucose, blood pressure, pulse oximetry and weight. It all happens within the “patient-centered medical home” model, which aims to improve patient experiences, in part by eliminating fragmented care and collecting information in a central location.

From a provider standpoint, telehealth allows finer tuning of medications with fewer office visits. And because the doctor isn’t relying on the patient to accurately remember and report their measures, it adds value to face-to-face visits.

“RPM gives the provider another window into their patient’s life,” Schwartz said. Perhaps more important, RPM patients feel more “connected,” so their compliance with treatment increases.

And nurses like Rhonda Cotton touch base with those patients at least weekly, sometimes daily, so they get to know them, and they can tell when something is going amiss.

“I’ve been amazed by how much I can tell over the phone – from their breathing, their mood, their voice – especially once I’ve really gotten to know them,” Cotton said.

For everyone?

The projected cost savings associated with RPM are enormous. Schwartz cited a Wall Street Journal claim that annual savings from remote monitoring could potentially total $10.1 billion for U.S. residents with congestive heart failure, $6.1 billion for diabetic patients and $4.9 billion for those with chronic obstructive pulmonary disease.

[pullquote_left]”I’ve been amazed by how much I can tell over the phone – from their breathing, their mood, their voice – especially once I’ve really gotten to know them.”[/pullquote_left]A 2011 study by the National Institute for Health Care Reform found that hospital readmissions within one month of discharge cost the U.S. more than $16 billion per year. Information provided daily through RPM can help providers avert costly health crises. For example, weight gain can signal fluid retention, a common symptom of impending heart failure; early detection increases the likelihood a patient will get necessary treatment before a crisis occurs that results in a trip to the hospital. All a patient needs to do is step on the scale every morning and the electronic device sends his or her weight back to a nurse like Cotton.

Although a round of RPM for everyone might seem like a no-brainer, there are barriers. Even though equipment costs are decreasing (the 25 units RCCHC purchased for $5,000 in 2006 would now run about $700), they’re still prohibitive for a typical private practice when combined with monthly server and monitoring fees.

There needs to be a centralized referral base, Schwartz said, and a way to qualify patients for a certified RPM organization, just like they have to qualify for any other specialist.

The biggest obstacle in North Carolina is the absence of a payor source, she said. As a member of the state’s Medical Care Advisory Committee, she’s worked tirelessly the past few years on developing a way to get paid by Medicaid for the remote work.

“Before the administration changed, we had come so close to finalizing a Medicaid billable code,” Schwartz said, noting that 16 states already have one. “But getting the right folks to respond to a payment structure right now is the challenge.

“We did submit a fully operational shared-savings model to the state through the [request for information] process this past spring,” she added, “so the state has a payment structure in hand.”

Over the ACA hump

For the time being, Schwartz’s focus has turned from policy to self-preservation, in the form of outside contracts.

“We’re ready to ramp this thing up and offer it to folks nationwide who want to start their own RPM programs,” she said. “We can get anyone rockin’ and rollin’ and seeing results in 90 days.”

Schwartz has motivation in the form of 75 local patients, like Don Craft, who gets his weight and blood pressure measured daily from afar.

His wife of 59 years, Elizabeth, said, “The monitoring gives me peace of mind. We enjoy a better quality of life because we’re staying connected; we’re not constantly worried about Don’s weight and blood pressure.”

“Without the monitoring, I’d probably weigh a lot more,” admitted Craft.

Don Craft checks his blood pressure.
Don Craft checks his blood pressure. Photo credit: Amy Adams Ellis

But to monitor a patient like Craft costs $70 per month, not to mention two full-time nurses, two part-time nurses and an administrative assistant at the monitoring center.

Those costs are currently being covered by payment RCCHC receives for providing technical assistance to outside providers and by pilot projects they’re conducting with two large private insurance brokers, among others. In a year, they’ll likely be monitoring up to 5,000 self-insured individuals nationwide – right from Ahoskie.

They’ve contracted to pilot RPM with 300 patients for a health department in Suffolk, Virginia. And they’ve incorporated their model into several programs for the federal Program of All-Inclusive Care for the Elderly (PACE). In fact, they’re on the verge of a joint venture to expand their PACE initiative throughout RCCHC’s three-county service area and eastward to the coast.

“The market is finally catching up with us,” said Schwartz. “People are realizing how much sense RPM makes. Once we get over this hump with the ACA, I think folks will see that telehealth is here to stay.

“Until then, we refuse to get comfortable where we are. We’ll keep moving forward, and keep redirecting the conversation.”

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