From home to clinic: Remote monitoring and Chronic Care Management Network

Roanoke Chowan Community Health Center (RCCHC) serves a primarily African American population in a rural community in eastern North Carolina that is dominated by agricultural production. Patients from local underserved communities suffer from high rates of diabetes, which is one of the leading causes of death in the region.

RCCHC’s Chronic Care Management Network provides daily remote monitoring for patients with chronic conditions like diabetes, hypertension, and cardiovascular disease. Patients are referred to the program through their primary care providers and, once enrolled, equipment is installed in their home to measure blood pressure, weight, and blood glucose daily. Biometric data is tracked based on the patient’s individualized plan of care from the referring provider, and a summary report is submitted to the physician every two weeks.  Through continuous monitoring, information indicating outliers is identified, such as elevated weight or high blood pressure readings, and nurses are notified who then communicate with the patients and referring provider for care adjustments.

The program helps expand access to coordinated care and improves the quality of life in patients in medically underserved rural counties in North Carolina.  This effort has proven to actively engage patients in their health care and improve their ability to manage their chronic disease, resulting in overall health benefits and cost containment for the larger health system. This presentation will provide steps to how the Chronic Care Management Network was implemented, challenges presented, and outcomes since inception.