A nurse-led remote monitoring program at Erie County Medical Center (ECMC) in Buffalo, N.Y., has doubled the rate of blood pressure control among high-risk patients with hypertension. Lucia Rossi, vice president of ambulatory services and population health at ECMC, recently spoke with Healthcare Innovation about the keys to the program’s success and reimbursement issues.
Developed in partnership with vendor Brook Health, the program’s elements include:
• A dedicated nurse-led education protocol and 30-minute onboarding visits;
• Cellular blood pressure cuffs and an app that enable data sharing by patients;
• Proactive monitoring and outreach by nurses to coach patients through obstacles;
• Telemedicine visits with physicians to adjust medications when needed; and
• A culture change that has providers and nurses celebrating patients' progress.
Data from the program showed that blood pressure control dramatically improves as patients continue in the program. In just the first 12 weeks of enrollment, the percentage of patients with controlled blood pressure rose significantly from 37.4% to 67.7%. Hypertension control is an important value-based care metric and is proven to help reduce the incidence of strokes, heart attacks, chronic kidney disease, and heart failure.
Healthcare Innovation: First, could you describe Erie County Medical Center?
Rossi: Erie County Medical Center is one of the only Level One trauma centers in the State of New York. It is also one of the largest safety net hospitals. We're a public benefit corporation. What that means, of course, is that we take care of all patients, regardless of their ability or means of payment. So that drives a population of patients to us that we need to be creative and innovative to provide care for. We have 583 beds and a skilled nursing facility right on our campus. We are one of only two emergency psychiatric centers in the State of New York — so behavioral health, mental health, that's a big space for us as well. And we have 30 plus outpatient centers, both on our hospital campus and all over Western New York.
HCI: And what about your role as vice president of ambulatory services and population health?
Rossi: I spend a lot of my days working through everything we do, from our finances straight through to our clinical care and our patient experience and trying to strategize on how to make that better every day. I do a lot of physician interfacing, of course. The population health side of my title is the most near and dear to my heart. So we built that team probably about seven years ago, and we do exactly what it's meant to do. We take data analytics and we splice them together, essentially to analyze someone's social determinants of health or their health inequities, and the resulting impact of those with their medical status. So we may find that we have a pool of patients that are reporting that they do not live within two miles of a grocery store and they do not have a personal vehicle, and then we pull out those same group of patients that have diabetes and or hypertension or any chronic condition that is directly impacted by your diet or lack thereof, and then we make a plan to take care of them better.
HCI: Let’s talk about this collaboration between Erie County and Brook Health. Did you guys first have an idea for a project you wanted to do, and then went looking for a vendor to help you do it?
Rossi: We knew we wanted to do remote patient monitoring. We have a digital health committee here at the hospital that started a couple of years ago. It is made up of clinicians, operational leaders, and, of course, our IT team. We were researching ideas and remote patient monitoring was a big one. believe there are healthcare guru actuaries that say that by 2026, 85% of healthcare consumers will get at least one type of remote patient monitoring. So we really wanted to try to be at the forefront of that, and I feel like we have done that.
HCI: Was there a specific patient cohort that you knew you wanted to address first?
Rossi: Yes, hypertension and diabetes are a big thing everywhere in America, especially in African American patients. We have an around 48% African American patient population. We looked at diabetes, but home glucometers are a bit more complicated for the patients and the clinicians trying to manage them remotely. So we went with something that clinically was equally as important, but that we knew would be a better introduction into this robust technology for our patient population. So we picked hypertension. You know, 50% of the population has hypertension, and 50% of those folks are not controlled currently. But when you look at the African American patient population, 80% of them are not controlled. So we thought, all right, we were comfortable with this type of remote patient monitoring. We know that our patients also have transportation issues. Let's start here.
HCI: Were there several vendors in this space that you looked at?
Rossi: Being a public benefit corporation, we always have to do formal requests for proposals. We put out a slew of questions based on exactly what we were looking for, and then people responded to prove to us how they can meet those needs. But we did have a great relationship with a local insurance company that had already engaged with Brook. We followed our process, and they really did have everything that we were looking for.
HCI: Can you describe how the blood pressure monitoring program works?
Rossi: Prior to remote patient monitoring, we brought our patients in once every five weeks when they were an uncontrolled hypertensive. That was better than nothing, and it certainly made an impact. But for patients who take public transportation, that is very difficult, so that was the first thing that we wanted to start with. Another lessons learned: A lot of folks promoting this type of software, I think their mind goes to the technology, but a lot of it is the implementation. If you don't implement it properly, then you just find yourself with an expensive piece of software. Education for the patients was huge. We do have to bring the patients in for one last visit in person. We gave them an hour. There was a specifically trained enrollment champion nurse who sat with them and made sure that they understood everything, that all of their questions were answered, that they knew how to use their devices, showed them how to use them, etc. So that was definitely a huge piece in the beginning.
HCI: Were the patients enthusiastic initially when you described this as an option?
Rossi: Absolutely. We wanted to make sure that they felt that this was making their lives easier, not more complicated. So we did what's called a behavioral intention survey at the beginning, and that is a Likert scale questionnaire that asks the patients on a scale of one to five, how easy do you think it is to participate in your hypertension care? How easy do you think it is to get to your appointments? How easy do you think it is to get to your check your blood pressure every day? Do you intend on taking your medication? And then, when they have been in the program for six months to a year, we re-survey them and can easily see if their clinical outcomes are changing, and that's great,. But in terms of sustainability and longevity for them, we can't remotely monitor every single patient that we have. We have about 3,500 uncontrolled hypertensives. That would take $10 million in staff resources to do that. So we need to make sure that they're comfortable and understand how everything works so that they can continue to do this without the hands-on monitoring that comes with it.
Initially, the physicians, the nursing staff and all of the other staff — it was in a very interdisciplinary team, because every single wheel in the machine makes it go — they developed a protocol so we all knew which way the boat was rowing, right from the beginning. For instance, if someone’s blood pressure was between this and this, they needed to go to the emergency room. The big sweet spot for us is that their blood pressure is controlled. If it was a little elevated, that would trigger a telehealth visit with the physician. We were able to continue that remote work via telehealth, so that meds could be adjusted. They could get on telehealth with the pharmacist, too. In addition to that protocol, there was a protocol based on their acuity. Are they getting a weekly touch base with the nurse? Are they getting biweekly? Are they getting every two days? So everything was really scripted, and again, that with the staff education and the patient education really makes a difference.
HCI: Did this require shifting the clinical time and workflow of the nurses? Did people have to have dedicated time to this particular program?
Rossi: People often ask whether we got new resources — and we did not. We are going to, because we've been able to secure some funding to do so, but initially we knew we had to create such a big efficiency with this that we could allocate the same pool of staff's time that we have. Using this product eliminated a lot of chasing after patients to get them to their appointments, medications, recalling them when they “no-showed” for their visits. So we were able to create some efficiencies that allowed us to use the same staff, but they do all have specific, set carved out time — for instance, this nurse on this group of remote patient monitoring patients on Monday. This nurse is on Tuesday. So again, everything is very scripted out.
HCI: What does the reimbursement look like for remote patient monitoring?
Rossi: I know that a lot of our local payers are very supportive, and if the reimbursement isn't there yet, collectively, we've had a lot of donations from Independent Health, Highmark, and Univera for this program, because they do believe in it. But right now, as a whole, the reimbursement is not there. I think that this is a critical, pivotal change in healthcare to be able to provide remote patient monitoring. With telehealth, for example, they got that to a point where it was reimbursed the same as an in-person visit, and we really need to get there with remote patient monitoring.
HCI: Well, are there any other ways that you could get financially rewarded for the improvements? Are there any value-based payment programs where these better clinical outcomes are rewarded?
Rossi: Yes, absolutely. But given that it's our first year doing this, that's a very complicated equation to map out. We have to let it happen and then map it backwards, because you have one total-cost-of-care budget for value-based payment, and that includes everything that goes on with your patients, not just their hypertension. Right now, as far as I've seen in our local market, there's not a specific hypertension budget in any of our value-based payment contracts. Later down the line, I can clearly quantify decreases in ED utilization, expensive medications, and hospitalizations. But now we're in the phase where we are going to have to calculate it backwards in a little bit and see how that turned out.
