Online Program

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

Monday, November 2, 2015 : 8:50 a.m. - 9:10 a.m.

Mike Bruce, Roanoke Chowan Community Health Center, Ahoskie, NC
Katie Lewis, Direct Relief, Goleta, CA
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.

Learning Areas:

Basic medical science applied in public health
Chronic disease management and prevention
Program planning
Provision of health care to the public

Learning Objectives:
Describe in-home technology that can aid in clinical care of chronic diseases. Explain the components of a successful integrated care program for chronic diseases aimed at an underserved population.

Keyword(s): Chronic Disease Management and Care, Health Care Delivery

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: Mike Bruce is the CEO of InScope Health who formed a public-private partnership with RCCHC to deliver remote patient monitoring to individuals across the US. He oversees programmatic and care coordination teams across the continuum of care to provide the best health outcomes possible.
Any relevant financial relationships? Yes

Name of Organization Clinical/Research Area Type of relationship
InScope Health LLC Chronic Care Employment (includes retainer) and Stock Ownership
BD Chronic Care Consultant and Pending industry grant for RPM programs

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.

Back to: 3060.0: Integrated care