Development and implementation of a remote patient monitoring program for high-risk CHF patients

By Avni Thakore, MD, FACC, chief medical officer, CHS Physician Partners Medical Group; Charlene Greene, MSHCM, CPHQ, program manager, CHS Physician Partners; Jasmin Rampath, MPH, project manager, CHS Physician Partners; Ana Garcia Chocarro, MA, PMP, project manager, CHS Physician Partners; and Olivia Pascucci, project coordinator, CHS Physician Partners

Remote patient monitoring (RPM) allows patients to be monitored remotely from the privacy of their homes. Providers can track patients’ physiologic parameters between office visits and implement changes to treatment regimens, behaviors and care plans as appropriate when readings are outside established parameters.

Patients can be monitored for a variety of physiologic parameters (e.g., weight, blood pressure, glucose, oxygen saturation) through scales, blood pressure (BP) cuffs, glucometers, pulse oximeters or other devices. RPM enables providers to determine whether a patient’s chronic condition is worsening. The goal of RPM is to engage patients in managing their care, improve best practices and decrease costs associated with chronic conditions by reducing unnecessary hospital and emergency department utilization.

In 2018, the Centers for Medicare & Medicaid Services (CMS) issued a bundled CPT code, 99091, to reimburse providers for RPM. The bundled code reimbursed providers for:
Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified healthcare professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.

This code required physicians or other qualified professionals to provide 30 minutes of care and monitoring for each patient to bill.

In 2019, CMS issued three additional codes to reimburse providers for RPM. The new codes unbundled payment for this service and included care provided by clinical staff. The three codes defined what was billable:

• 99453 — Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry) initial setup and patient education on use of equipment.
• 99454 — Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, blood glucose), initial device(s) supply with daily recordings(s) or programmed alert(s) transmission, each 30 days.
• 99457 — Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.

In 2020, CMS issued an additional code that enables providers to bill for additional 20-minute increments (at 40 and 60 minutes, respectively) up to two times per month. The new code allows reimbursement for time previously not reimbursed. It is described as:

• 99458 — Remote physiologic monitoring treatment management services, additional 20 minutes of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month (may be billed up to two times).

Project initiation/workflow development

A team of physicians, care coordination nurses, project management staff, data analytics staff and IT staff set up a work group to develop the program. The work group identified a chronic condition to focus on, congestive heart failure (CHF), and selected physiologic parameters for monitoring blood pressure and weight. The team decided to implement the program in 10 primary care practices. A cardiology practice was subsequently added. The work group then designated a centralized RPM nurse who would monitor all patients via an online dashboard.

Over a period of six months, the work group executed the following tasks:

• Identified practices to participate in the program
• Designated a clinical practice champion in each practice to participate in the initiative
• Developed workflows for the program, in which a centralized RPM nurse would monitor all patients enrolled in the program, and follow up with the clinical practice champions as needed (see Figures 1 and 2)
• Identified patients in each practice who met preliminary criteria for participation
• Developed time aggregation reports, an RPM visit type, and template notes in Epic/EHR for practices to enroll patients in the program and bill the RPM codes (99453, 99454, 99457)
• Acquired equipment needed for the program (BP cuffs, scales, gateway hubs)
• Held a kickoff event with all practices during which we provided live education on CHF and RPM, gave hands-on training with the equipment, demonstrated the dashboard, and reviewed enrollment packets and the billing process
• Quick-reference clinical protocols and referral pathways were designed by our clinical team and reinforced at the kickoff event and in follow-up meetings with the practices.

Implementation of the workflow

Clinical practice champions were given preliminary patient panels (see Figure 3) for validation. The validation process confirmed or excluded patients from participating in the program. Upon completion of the validation process, practices were asked to:

• Reach out to patients to offer enrollment in the program
• Schedule patients who agreed to participate for in-office enrollment.

Once patients were scheduled for enrollment, practices were provided RPM kits (equipment) and enrollment packets. They were also asked to define each patient’s BP and weight parameters prior to enrollment.
On the day of enrollment, clinical practice champions were:

• Supported by the RPM nurse to complete the enrollment packet with patients (for their first enrollment)
• Supported by a representative from the equipment vendor to train patients on the equipment and to enroll patients on the dashboard.

Following enrollment, patients were monitored by the centralized RPM nurse and communication was forwarded to clinical practice champions (via EHR messaging) for follow-up with patients, as appropriate.

Early findings and measures of success

The workflow functioned as intended, but many patients preferred to be contacted by staff at their primary care provider’s office, as opposed to the “central” RPM nurse. In consideration of patients’ preferences, the centralized RPM nurse was discontinued from the program. The program was reorganized (see Figure 3) for staff at each practice to monitor patients’ readings and communicate directly with patients/caregivers, as appropriate.

The measures of success include enhanced medication adherence, reduced time to guideline-directed medical therapy (GDMT), reduced ER admissions and hospitalizations, and improved patient quality of life (measured by the Minnesota Quality of Life Questionnaire). At this time, patients have been enrolled for six months or fewer in the program. Since the program was implemented, primary care physicians and the community cardiologist report feeling more comfortable managing CHF patients, as the program design includes easy-reference clinical protocols and a clear referral pathway for physicians to utilize when appropriate. Early findings appear to indicate increased patient engagement, low ER/hospital utilization and a trend toward reduced time to GDMT. Patients must be enrolled for a minimum of 18 months before endpoints and performance will be assessed.

Conclusions

The innovative design of the RPM program leverages the intersection of population health data analytics, advances in healthcare technology and existing care delivery models to effectively manage our high-risk, high-spend patients in the community setting. The program design is also unique in that it positions the primary care physician as the “quarterback of care” for the patient, enabling them to drive timely and effective medical decision making for our most fragile patients using real-time, reliable data and clinical notifications embedded in their daily EHR workflow.