Six months after Advocate Aurora Health (AAH) launched a pilot in 2021 to use remote patient monitoring to target health equity issues with its hypertension control efforts, the health system hit the pause button to re-assess the program and address some barriers to adoption.
AAH is a nonprofit health care system with dual headquarters located in Milwaukee and Downers Grove, Illinois. As of 2021, the AAH system has 26 hospitals and more than 500 sites of care, with 75,000 employees, including 10,000 employed physicians. Between Illinois and Wisconsin, AAH has 3 million patients and just under half are in some type of value-based care program. They operate one of the largest ACOs in each state. AAH has announced plans to merge with North Carolina-based Atrium Health to create a six-state, 67-hospital system.
Amanpreet Sethi, M.D., a practicing family physician, is an ACO medical director at AAH. Speaking at the NAACOS Fall meeting, she described the origins of the pilot.
“Many of us recognize hypertension to be an extremely important chronic disease that affects several millions of our beneficiaries and patients that we serve. There are many downstream effects and what that means is increased costs to our healthcare system,” she said. “With the pandemic, we recognized quickly that our patients were not coming in to seek care, but we're still responsible and accountable for the quality that we provide to these patients. We started to think outside the box: How do we still deliver care to our patients who are for whatever reason — whether it be fear or just the fact that we were shut down at one point and could only offer telephonic or virtual visits? We started thinking about this specifically related to the hypertension metric. What could we do?”
Around the same time, she said, the organization also started thinking about health equity. “We saw in our data that there's this disparity with our white patients at about 19 percent uncontrolled versus our Black population at closer to 27 percent uncontrolled, followed by Hispanics at closer to 21 percent,” Sethi said. “We have a health equity task force looking specifically at our Black and Hispanic populations and what we can do to bridge that gap. We were charged with reducing that gap by 10 percent in the first year, followed by 20 percent the next year.”
As they developed this pilot project, they thought why not target a certain sector of the population while still delivering that quality and trying to meet their quality measures. “What we talked about is remote patient monitoring,” Sethi said. More and more of the literature supports the benefits of this, including in diabetes with continuous blood glucose monitoring, but hypertension is another area where health systems are seeing more benefits.
Because some patients already head blood pressure monitors, the AAH team decided to create two tracks of the pilot: One would have a remote Bluetooth-enabled blood pressure monitor that AAH would send out to them. If they still opted to be in the program, but wanted to use their own device, AAH offered the non-RPM condition management program with its specialty care nurse managers. “Once we got the buy-in from the patient, we would enroll them and then that would require our third-party vendor who offered the blood pressure monitors to onboard the patients,” she explained.
Once they started getting blood pressure numbers coming in, they had to figure out what they would do with them and who's going to be responsible for those numbers. “These were all full-risk patients who were not in any other kind of care management program, because obviously we don't want to duplicate efforts unnecessarily,” Sethi said. “They had to be on our uncontrolled blood pressure registry — blood pressure greater than 140 over 90. We really wanted to target and work on this health inequity that we're seeing and so we have certain high-risk Zip codes where these patients reside.” That involved two areas in Illinois, mainly in Chicagoland and the Milwaukee metro area.
Often, they would see many comorbidities with these patients. “We wanted to be able to focus on the hypertension without ignoring comorbidities, but we didn't want to be overwhelmed with the burden that comes with significantly uncontrolled diabetes. We wanted them to have an A1c of less than 9, and then the specialty care nurse could help do more focused education,” Sethi said. “The initial pilot and patient engagement started in May of 2021. But before too long, she noted, the number of patients that were actually enrolled declined and continued to decline. “Right there, that tells you a story,” she says. “We were definitely hoping for a greater participation, but didn't necessarily see that. However, we did have a fair number that did agree to do that non-RPM piece."
They found several reasons why patients may have said they don't want to be participate. A lot of patients feel they know what they need to do and they don't need anyone's help. “Despite our nurses being trained in motivational interviewing, there were just times where they just cannot convince the patient,” she said. “The other big piece of this is difficulty reaching these patients. Often, they will have numbers that are not working, or they're working people who are just not available. Unfortunately, a lot of our care happens Monday through Friday 8 to 5, but patients are doing other things during that time. A fair number didn't actually have internet access,” she said. Some patients actually had their blood pressure controlled by the time of the outreach.
Of the patients who chose to do remote patient monitoring, over half were able to be controlled, but it took longer than was expected — twice as long, “so it was closer to the 150-day mark before we saw a significant improvement,” Sethi said. The other track of patients who had their own device at home that was not necessarily Bluetooth-enabled, they would have to tell the AAH team what their numbers were. “They had a much faster control rate,” she said,” and part of the reason we think is because if they already had a blood pressure monitor, the chances are that they're a little bit more engaged than those patients who didn't have anything. Their average days enrolled to control was 78 days.”
Sethi highlighted the key barriers they identified. First, they found it difficult to engage with these patients telephonically. It seems like a simple task to ask a patient for a phone number, but these numbers change sometimes or they have limited minutes on their phone plans, Sethi said. “Sometimes if they don't recognize the number, they're not going to pick it up, and I don't blame them, I do the same,” she said.
Also, there is a lag time from when they agree to enroll and when the vendor contacts them. “We need to really meet our patients where they are, not just physically — like outside of our four walls, but also, some patients are very eager and say they will check their blood pressure every day. That was ideally what we were hoping for. But other patients said no, sorry, I can maybe do it once a week for you if you want. We had to say, okay. Ideally, we would recommend daily but we'll take what we can get. Every patient has their own story.”
Still another issue is that with the particular vendor they used, the numbers did not automatically interface with the EMR. “We literally had to have somebody monitor the dashboard and then manually enter the number into our EMR,” she said. “Obviously, it is something that was a big barrier actually.”
Also, they had to devise a plan for when the data was out of range. When they first onboarded patients, they gave them a stoplight sheet. If the person had a significantly elevated blood pressure, they want to give them some direction, because it might be a weekend or an evening time where the nurse manager isn’t necessarily monitoring the dashboard to give them some guidance as to what to do.
Physician engagement was an issue. “Another barrier we had is that we chose to work more with our affiliated practices and what we found is it's difficult to educate when you have a doctor here and a few doctors there," she said. "We tried to send letters ahead of time to explain the program, but it's just not physically possible to go face to face and talk to that many provider offices." The lack of physician engagement in the program did cause some delays in care in certain instances, especially when there were significantly elevated blood pressures, requesting medication adjustments. "Our goal is to avoid sending these patients to the ER and we did actually have a couple of instances where we had no choice but to tell the patient to seek medical attention elsewhere because of lack of response from the PCP’s office.”
Sethi said they have to make sure that patients have access so that when there are these issues, they can be dealt with in the outpatient setting and there's a streamlined process to get those addressed so that they don't have to send patients elsewhere unnecessarily.
“After about six months of the program, we hit the pause button and said OK, let's re-evaluate what we're doing,” Sethi recalled. “We had to really work on our primary care engagement. Care management was our strongest piece of this. I would say the monitoring was okay, but that the data capture and the analytics piece definitely wasn't. The other piece that we quickly realized that we're missing is pharmacy. We redesigned the program and decided to focus on one large practice, rather than multiple independents. We really got the opportunity to get in front of a group and make sure that everyone's on board and answer questions because it really does make a difference. When your doctor can tell your patient about the program or encourage them to participate, it goes a long way.”
Sethi stresses that technology is just one piece of this. “You have to make sure that any type of program you're going to use, you have support systems around it,” Sethi said. “I think often we forget there are people who still require that human touch. There's a value to that. The more automated we get for some people, that's great; it's convenient. But I would say that anytime you have the opportunity to incorporate that human component, it goes a long way.”
After the pilot project revamp, they are seeing a better blood pressure control rate in RPM. “The other big difference we're seeing is that our adherence rate is actually better in the RPM versus the non-RPM,” she said. “We're up to 300 patients now between both programs. It has been a slow ramp-up, but nonetheless we're continuing to increase.”
A lot of the patient comments about the program, she said, speak to the value of the care nurse navigator. She recently had an e-mail from one of the pharmacists, who said that there was a patient who was so grateful and bragging that she has her own personal nurse and pharmacist checking in on her. That trust was developed because that pharmacist adjusted a medicine to improve a side-effect she was having.
“As a PCP I appreciate these extenders, people who can help. I'm very busy. I usually can offer 15 to 20 minutes to my patients,” she said, “but what these patients really need is someone who can sit and listen to their story and address all the issues. I really think this multidisciplinary approach, along with the technology, so that they don't necessarily have to come into our four walls, is key.”