Treating chronic disease and population health just became easier for Sentara Health.
The Norfolk, Va.-based health system rolled out a remote patient monitoring and chronic care management program in partnership with HealthSnap.
The initiative launched across 12 primary care sites and will expand to include 389 providers and more than 85,000 eligible patients, according to a Sept. 10 press release. The effort aims to strengthen chronic condition management for hypertension, diabetes and heart failure.
“As we know, it’s becoming more difficult to manage chronic disease,” said Carol Hawkins. “Chronic disease is a huge source of human suffering and cost for health systems. Traditional care models don’t meet the needs of chronic care patients well. So we were looking to address that with real time monitoring of health conditions, hoping to bring patients improved health and increased satisfaction with their care.”
The care delivered during in-office visits is a small portion of the care patients with chronic disease need throughout their lives. The HealthSnap program will support them through their care journeys and connect the dots in between visits to manage and monitor devices and escalate care when needed.
The health system decided to have a centralized remote patient monitoring team to support traditional primary care providers, taking into account their workflows so the team doesn’t add extra burden on primary care providers. The RPM team oversees eligibility review, interventions and escalations with clinician oversight, as well as billing. Throughout the process, Dr. Hawkins and her team have communicated with participating clinicians for a seamless transition.
“We are continuing to find that you can’t really communicate enough,” she said. “Our goal is to continue to reach out in different ways to providers and care teams so everyone knows what’s happening. We also have an RPM advisory council we’ve developed, including primary care physicians and operational directors.”
Sentara, an integrated nonprofit health system based in Norfolk, Va., operates 12 hospitals and employs 34,000 people. Its health plan division serves more than 1 million members in Virginia and Florida.
“We’re trying to figure out how to harmonize what we’re tracking for value-based contracts,” Dr. Hawkins said. “We are balancing between fee for service and value-based care contracts. We are trying to move toward value-based care and we are looking at ways we can move into that space. This is one of those areas where we can do it; it’s something that’s really necessary for population health management, but there is still a fee-for-service component to capture those costs and do this type of program. We need to expand our integrated care model, and that will in turn strengthen our value-based care capabilities.”
The RPM and CCM platform will be integrated into Sentara’s care model to support clinical teams between visits and help improve patient outcomes. Dr. Hawkins hopes to expand the conditions treated within the program over the next few years. Sentara joins more than 150 health systems and provider organizations using HealthSnap’s virtual care tools. The Miami-based company said it has remotely monitored more than 100,000 patients across 33 states.
Will your health system be next? Dr. Hawkins has some words of advice.
“Take an assessment or inventory of your own capabilities and what you truly have,” she said. “Figure out what you have and don’t have, and look for something you can scale. See what other large health systems have done to successfully scale programs and financial models. You can also gain feedback from other partners that have already worked with them and how these mesh with what you’ve developed.”
