After several months of tracking her daily health screenings as part of the remote patient monitoring program at Roanoke-Chowan Community Health Center (RCCHC) in Ahoskie, North Carolina, Deborah Walker’s* nurse case manager Crystal noticed that Deborah’s blood pressure was up every Wednesday morning.

To better understand why the peculiar pattern was occurring, Crystal asked Deborah about her activities on Tuesday night. She found out Deborah belonged to a sorority and that each Tuesday, the group ate dinner together at the same restaurant.

Crystal pulled up the menu of the restaurant and asked what Deborah usually ordered. She suggested Deborah try some of the more heart-healthy dishes on the menu. After their discussion, Crystal noticed that Deborah’s levels on Wednesday mornings became more consistent with the rest of the week.

This situation is what RCCHC CEO Kim Schwartz calls a “teachable moment” in which the real-time tracking and data from the remote patient monitoring program helps improve the patient’s knowledge of their chronic condition, empowering them to take charge of their own care.

High Need Breeds Innovative Solutions

Positive results like these among their patients with chronic disease – particularly diabetes – is just one of the reasons why RCCHC was selected as one of seven winners of the 2014 “Innovations in Care” Award as part of the BD Helping Build Healthy Communities initiative, implemented together with Direct Relief and the National Association of Community Health Centers (NACHC).

The awards seek to recognize innovative approaches to the prevention and treatment of diseases that disproportionately affect vulnerable populations in the U.S.

Schwartz said RCCHC was an early adopter of remote monitoring for patients with chronic conditions like cardiovascular disease, diabetes, and hypertension. With a background in telehealth, she helped kick-off the program at RCCHC in 2006. Though many still consider remote monitoring to be “cutting-edge” in medicine, for RCCHC, the innovative project came out of high need.

RCCHC is a federally qualified health center (FQHC) serving 14,000 patients annually with four locations in northeastern North Carolina that are completely rural. Schwartz said there is no public transportation, so getting to the health center regularly is difficult for many patients.

Additionally, many cannot afford frequent visits. In the four counties served by RCCHC, 53 percent of the population have incomes at or below 200 percent of the Federal Poverty Level (for a family of four, an income of $47,700) and nearly 20 percent of residents in their service area are uninsured.

To have more frequent contact between the patient and primary care provider and also help detect potential problems early and keep patients from going to the hospital or emergency room, they needed data tracked daily.

How Remote Patient Monitoring Works

The program identifies patients with chronic conditions and provides them with monitoring equipment installed in the home at no cost to them, which is possible because the program is entirely funded by grants, such as the BD Helping Build Healthy Communities Award. Schwartz said the majority of the participants are Medicare patients and that the consistent monitoring keeps them from needed a higher level of care.

Some patients receive the equipment and instructions at the clinic, but most of the time, their nurse case manager comes to their home to set up the equipment for them. Everything is connected wirelessly to a server that Schwartz says is about the size of a hamburger. After a patient has done all their needed screenings (blood pressure, pulse, body weight, blood sugar level), the device transmits the readings and data.

A nurse care manager directly communicates the information to the primary care physician via their electronic medical record. Rather than taking a guess at what’s happened with the patient in the three months between appointments, providers now have hard data that’s tracked daily and not able to be disputed.

Schwartz said it takes about six months of participation to reinforce the change in the patient. The program overall has brought about tremendous progress for health in the surrounding area. Schwartz said there’s been a 75 percent reduction in hospital admissions/re-admissions among participants in the program.

Restoring Lives Through Partnership

While the program is producing measurable results, for Schwartz the most important evaluation is the lives changed.

She gave the example of a patient who is a minister living with hypertension and chronic obstructive pulmonary disease (COPD). His condition became exacerbated and he couldn’t figure out why. Eventually, he wasn’t able to leave his home anymore because of complications.

After being part of the remote monitoring program, he was able to work with a nurse and primary provider to better understand lifestyle changes that needed to be made. He’s now preaching again, which has restored his emotional and spiritual wellness. Schwartz said he told her, “What keeps me well is being able to do my life’s work.”

Schwartz said the partnership is what allows patients with chronic conditions to lead a full life. “We love Direct Relief and BD.”

Direct Relief has supported RCCHC since 2009 with 38 shipments of medicines and supplies valued at more than $175,000 (wholesale). RCCHC is also part of the annual Hurricane Preparedness Program and was recently brought on as a Replenishment Program partner.

*Patient name has been changed to protect privacy.