Thursday, 21 Sep 2023

Community Health Systems improves chronic condition outcomes with RPM

Photo: Community Health Systems

Community Health Systems operates more than 80 affiliated hospitals and more than 1,000 outpatient sites of care in 16 states.


The massive health system recently set three goals:

Improve patient outcomes by monitoring and actively managing patients with chronic diseases, with a specific focus on remote medication titration to get more patients to guidelines.

Extend primary care through day-to-day monitoring, technology and services that enable early intervention when needed.

Give patients peace of mind and more assurance their conditions are appropriately managed.

“For patients with chronic conditions, it is difficult to get them in to see their primary care providers as frequently as needed for proper monitoring and follow-ups,” said Dr. Eric Cheung, a family medicine specialist practicing in Foley, Alabama, who serves as chief of staff for South Baldwin Regional Medical Center and clinic medical director for South Baldwin Medical Group.

“We were looking for an end-to-end system that offered patients more support, but also helped triage issues that needed direct physician intervention from those that would result in unnecessary office visits,” he added.


When Community Health Systems was evaluating remote patient monitoring vendors, it looked at the patient experience, the clinician experience, the ability to scale and the financial model.

“For us, Cadence’s total partnership model resonated,” Cheung explained. “First, they brought a clinical care team – not just monitoring technology – that has enabled human interactions along with vital sign monitoring. This supports our clinicians while also supporting their patients.

“Their technology fits into our existing workflows in our EHRs, which has been critical to provider adoption.”

Dr. Eric Cheung, South Baldwin Regional Medical Center

“Next, their technology fits into our existing workflows in our EHRs, which has been critical to provider adoption,” he continued. “And finally, their financial model ensures we are able to successfully deploy the program at scale, and that works well in both fee-for-service and value-based arrangements.”

Access to more high-quality, actionable information for providers, with minimal impact to current workflows, also was imperative for staff.

“We track this through increased visibility on patient vitals at home, as well as the number of escalations to our primary care physicians from the Cadence Care team,” he noted. 

“Outcomes of our program included more patients achieving and adhering to guidelines (medication titration frequency), patients reporting increased access to care and high satisfaction with quality of their care (tracked quarterly via survey), and increased patient engagement including average number of vitals in 90 days, clinical phone encounters, monthly one-on-one phone time between the Cadence Care team and patients.

“Further, there has been a reduction in ED visits – tracked before and after Cadence – across its program at large, a metric Community Health Systems itself is measuring currently,” he added.


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In just over a year, there has been an enormous impact from the Community Health Systems Care Management at Home program.

“In my practice, dozens of patients have reported they like the program and feel more confident and supported in managing their chronic conditions,” Cheung said. “Through our EHR integration, Cadence identifies patients who would benefit from remote monitoring using eligibility criteria customized by our clinical team.

“Our clinicians have full authority to determine which patients to enroll in the program and will make recommendations from there,” he continued. “Clinicians will place orders for patients either during an appointment or directly through the EHR, after which the patient is then contacted by the Cadence Care team to enroll.”

Strong communication has been a cornerstone of this program, he added.

“Our communication touchpoints have included educational content deployed from the corporate team to regional clinics and hospitals,” he explained. “And physicians in the pilot markets – like ours – have shared their positive experiences with other physicians just starting to use RPM, which is powerful.

“Cadence also takes a very boots-on-the-ground approach, which resonates with the health system because the in-person element is very helpful for elderly patient populations,” he continued. “The vendor’s enrollers are on-site at our clinics to answer questions and onboard our patients in-person and are always available for any questions, troubleshooting or clinical interventions.”


The Community Health Systems Care Management at Home program went live in April 2022, originally launched in Arkansas and some of the Alabama markets. Since then, there has been high growth and adoption.

Dr. Lynn T. Simon is president of clinical services and chief medical officer at Community Health Systems. Among many other things, Simon leads clinical operations for medical informatics and spearheads work to implement and scale AI and other technological systems that enhance patient care and workforce support across the organization.

Thus far, Simon explained in detail, the health system has been able to:

Scale to more than 60 clinics and more than 120 participating providers with more than 3,000 patients actively enrolled today.

Enhance patient engagement as patients are better connected with their primary care providers. More than 80% of patients are using Cadence devices 16 days or more a month. And 84% of patients agree/strongly agree that the program “provides the highest quality medical care in a way that is easy to understand.”

Improve patient outcomes through evidence-based therapies that help patients with medication adherence and avoid preventable, acute episodes and hospitalizations. Patients who enroll in the hypertension management program with a systolic blood pressure above 160, for example, see an average decline of nearly 25 points in the first 16 weeks of the program.

Reduce our clinicians’ workload with the vendor’s team managing daily monitoring, triaging alerts and deploying data-informed decision making. There are approximately five alerts requiring escalation to physicians per 100 patients per month, so most patient alerts are effectively managed without escalations to the patient’s primary care provider.

Decreasing the cost of care across the continuum. Cadence has seen a 14% decrease in total cost of care with other ACOs, and Community Health Systems is now doing claims analysis to check its progress.

Setting up growth that will double or even triple the number of patients currently using RPM by the end of the year while maintaining excellent patient outcomes and provider satisfaction.

“The vendor’s clinically led, technology-enabled platform is proactive and preventive, helping us to bring greater peace of mind to people managing chronic conditions, and more actionable data to the providers helping them,” Simon noted.

“The RPM technology facilitates more proactive patient care and follow-ups and helps us intervene as necessary so that patients’ clinicians – the Cadence Care team and the patient’s primary care physician – can make adjustments to the care plan for their chronic illness as needed,” she continued. “The technology uses a patient’s relevant vitals and healthcare data, allowing patients’ care teams to deliver effective management of medications, therapies and lifestyle.”


In the beginning of a remote patient monitoring program, organizations should consider how they will encourage adoption, Simon advised.

Prior to launching, we worked to identify physician champions from among our medical directors, which really helped get the program off the ground,” she recalled. “Building physician trust through data and word-of-mouth also has been critical.

Through consistent communications, partnership and support of both parties, we are seeing physicians more readily opt in as they learn about the great patient outcomes and minimal workload impact on the clinician and office staff,” she added.

Integrating remote monitoring and care management at the point of care also is critical to maximizing the clinical value of the program, she offered.

“Streamlining patient communications and eliminating obstacles in onboarding is important to the overall adoption of the program,” she said. “We would also advise that if you are outsourcing care delivery, integration with the EHR is preferable to make sure all information is available in real time for the clinicians both in the practices and the care team interacting with the patient.

That way, the care delivery team can ensure patient education and treatment decisions are aligned with the care plan that the primary care physician has set forth through their long standing relationship with the patient, and that any changes in the treatment plan are readily communicated back to the PCP so he or she can be prepared to speak to such changes during regular visits with the patient,” she concluded.

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