Page 4 Case Studies in Telehealth Adoption Partners Health Care Connecting Heart Failure Patients to Through Monitoring

4 The commonweAlTh Fund

for expectant mothers, and wellness programs, such readmissions provides the heart failure program with
as Step It Up and Virtual Coach, that emphasize activ- a clear business case in terms of the negative financial
ity and exercise among elementary school children implications from poor care outcomes. For manage-
and overweight people, respectively. The center offers ment of diabetes, HbA1c is a well-accepted clinical
video-based, real-time consultations and an online marker used to measure success. One program that has
second-opinion service, Partners Online Specialty been successfully piloted and implemented at scale
Consultations. CCH recently spun off a health service across Partners is the Connected Cardiac Care Program
company, Healthrageous, to provide self-management (CCCP). It provides home telemonitoring and patient
tools that offer personalized support and motivation in education over a four-month period to enable patients
health and lifestyle management. to collect frequent readings and become more engaged
CCH focuses on applying technologies to con- in their care.
ditions that have standard clinical measures of success Exhibit 2 outlines two connected models of
or offer a clear business case in terms of the potential care that are currently being deployed at Partners to
cost savings or return on investment. For example, the address congestive heart failure, as well as diabetes
Medicare payment reductions associated with 30-day and hypertension.

Exhibit 2. Connected Health Models of Care at Partners
The Diabetes Connect and Blood Pressure Connect programs offer patients and their care providers a way to
track their blood sugar or blood pressure readings and to collaborate on establishing a shared care plan between
ofice visits. These programs differ from the Connected Cardiac Care Program (CCCP), which uses a centralized
telemonitoring model. Diabetes Connect and Blood Pressure Connect operate on a distributed model where each
practice comes up with its own structure and protocols for managing patients. Nurses, certiied diabetes educators,
pharmacists, or primary care physicians can monitor patients’ data. The driver to adopt is greater provider eficiency
and quality outcomes, and less focus on cost savings. The programs help manage patients by providing structured
data frequently and engaging patients actively in their care management. Both programs are available at several
primary care practices afiliated with Massachusetts General and Brigham and Women’s Hospitals, and through the
Partners Community HealthCare network of physicians and hospitals.

Connected Health Program Summary Description
A centralized telemonitoring and self-management and preventive care program for heart
failure patients that combines telemonitoring capabilities with nurse intervention and
care coordination, coaching, and education. The daily transmission of weight, heart rate,
Connected Cardiac Care Program pulse, and blood pressure data by patients enables providers to more effectively assess
patient status and provide "just-in-time" care and patient education. The program has led
to an approximate 50 percent reduction in heart failure–related hospital readmissions for
participants.

Provide practices with tools for the self-management and monitoring of patients with
Diabetes Connect diabetes and hypertension. A recent clinical study with 75 enrolled patients found that
participants in Diabetes Connect achieved an average drop in HbA1c of 1.5 percent, while
Blood Pressure Connect 22.3 percent of participants enrolled in Blood Pressure Connect achieved a 10mmHg or
greater drop in systolic blood pressure, compared with 16.7 percent among nonparticipants.

Source: Center for Connected Health.