Remote Patient Monitoring (RPM) for Primary Care

The Opportunity

BJC Medical Group’s Accountable Care Organization (ACO) plays an important role as it cares for a population at the highest risk for emergency department visits and inpatient admissions. The ACO manages patients with chronic conditions, usually those who’ve had a recent emergency visit or hospitalization, those with multiple health issues, or those needing complex care that requires close monitoring and frequent follow-up and intervention. To effectively care for this population, many healthcare systems are integrating more remote patient monitoring (RPM) solutions. Monitoring patients at home requires a solution that includes peripheral devices to obtain biometric measurements in the patient’s home, software to communicate the data to care teams, and the care team to intervene when necessary. The challenge facing the Lab was to find an RPM solution to better serve ACO patients and provide necessary interventions to reduce hospital admissions.

Our Approach

The Lab implemented a proof of concept to design, develop, test, and deploy RPM solutions within the ACO. The patients who enrolled in this proof of concept were initially identified as being diagnosed with congestive heart failure, chronic obstructive pulmonary disease (COPD), or hypertension. Working with the selected vendor, the program included Bluetooth scales and blood pressure cuffs, symptom surveys, and condition-specific education in order to identify new or worsening symptoms based on vital sign data and self-reported surveys.

The Solution

As of April 2022, 261 eligible ACO patients had enrolled in the home monitoring program using HRS equipment. Data from HRS’s Monthly Outcomes Reports has shown that use of the RPM system for early detection and intervention to prevent disease worsening has resulted in reduced ED and hospital visits for the patients enrolled in the pilot.