TrueCare, a nonprofit community health center serving North San Diego and Riverside counties in California, is beginning to seeking to improve hypertension control for patients through a remote blood pressure monitoring program.
With support from a federal Health Resources and Service Administration (HRSA) Hypertension grant, TrueCare is deploying a platform from an Atlanta-based company called Rimidi that brings patient-generated blood pressure data into the clinical workflow and makes that data actionable via configurable clinical decision support cards and alerts.
Rimidi integrates with cellular-enabled blood pressure cuffs, which transmit data from the device directly to the platform, meaning patients do not need Wi-Fi, smartphones, hubs or apps for their doctor to be able to see their home blood pressure data. Cellular devices were a key reason TrueCare chose Rimidi, as 94 percent of the patient population they serve is below the 200 percent federal poverty level.
“Our patients historically have not had access to life-changing healthcare technology such as remote patient monitoring. Knowing the value of RPM in improving patient engagement and outcomes, we wanted an RPM solution to help us better manage our growing hypertension patient population, of which 79 percent are of racial or ethnic minority,” said Denise Gomez, M.D., a primary care physician and director of Adult Medicine at TrueCare, in a statement. “Through Rimidi, patients have been able to easily monitor their blood pressure without using phone data and care teams have been able to easily track patient progress within our workflow, allowing the proper actions to take place to improve patient health outcomes.”
To begin the Rimidi deployment, TrueCare designed an RMP program workflow and worked with Rimidi to configure the platform to meet their specific needs, including setting customized alert thresholds, automated text messaging in a patient’s preferred language, and clinical decision support cards to identify when patients are consistently not taking their readings.
TrueCare patients are referred to the RPM program by a primary care provider if they have uncontrolled blood pressure, defined by TrueCare as greater than 140/90 mmHg. Upon referral, patients meet with TrueCare health coaches who provide them with instructions on how to use the cellular-enabled blood pressure device, as well as education about their current BP medications, diet, and exercise. During this meeting, the health coaches add the patient to the Rimidi platform and connect their cellular-enabled device to monitor the patient’s daily readings in near real-time. TrueCare began the program in January 2023 and has ramped up implementation each month. As of April 2023, TrueCare has 70 patients enrolled in the program, adding on average 10 more patients per month. To date, 34 patients have graduated from the program, meaning their blood pressure has been controlled. If the blood pressure goal is not met, a TrueCare pharmacist or the patient’s provider is alerted and medications are adjusted. On average, TrueCare is seeing approximately 30 monthly readings per patient, indicating a high level of compliance. In addition, providers have been able to reduce medications for patients due to improved hypertension control, and because the program has helped identify White Coat Hypertension, when patients have high blood pressure in the clinic but not at home.
“We are honored to work alongside TrueCare to ensure that medically underserved patient populations are benefitting from care delivery innovations and digital health,” said Lucienne Ide, M.D., Ph.D., founder and CEO of Rimidi, in a statement. “We will always advocate for additional funding mechanisms for community health centers to scale and sustain existing programs, and ensure our technology continues to meet the unique needs of their patients.”
The next phase of TrueCare’s RPM program will see a continued patient enrollment expansion, especially since TrueCare recently opened an Older Adult Health Care location to address seniors living with chronic and complex medical conditions. TrueCare is also planning Rimidi integration with the organization’s Epic OCHIN EHR. The integration will allow the TrueCare care team to see home blood pressure readings in the context of other clinically relevant data from the EHR—including in-clinic labs and vitals, current medications, and a calculated ASCVD risk score.