Scaling Remote Patient Care: The Mechanics of a Paradigm Shift in Chronic Disease Management
Publication Title
NEJM Catalyst
Document Type
Article
Publication Date
10-15-2025
Keywords
washington; renton; gig harbor
Abstract
The United States is facing a convergence of health care pressures. There is a surge in chronic diseases, with most individuals aged 65 years or older having multiple chronic conditions. There is also a growing deficit of clinicians to care for an aging population, creating access challenges and suboptimal outcomes. While there is a strong desire for health systems to transition to more value-based care contracting, financial constraints and uncertainty create challenges for health systems to commit to this transition at scale. To address these challenges, health systems and clinicians need an effective, scalable solution for chronic disease management with measurable outcomes addressing the Quadruple Aim. Comprehensive remote patient monitoring — coupled with technology-enabled, guideline-directed medical therapy through remote patient care (RPC) — has the potential to fill this gap by enabling continuous, real-time vitals monitoring and timely clinical care outside of the traditional health care environment. Implementing comprehensive RPC is challenging. Health systems must overcome three critical obstacles: (1) Improving clinical outcomes without creating more work for an already overburdened clinical workforce, (2) Creating a scalable program that can be deployed across a multistate health system, and (3) Delivering a financially sustainable model that increases access for all patients, especially rural and underserved populations. To this end, Providence co-developed such a program with Cadence, which provides RPC for patients with hypertension, heart failure, and type 2 diabetes by leveraging a nurse practitioner-led team of multidisciplinary clinicians that act as a fully integrated practice extension for the primary care clinician. Program-eligible patients are identified with a proprietary algorithm for enrollment according to the provider’s discretion. The clinical solution includes virtual visits during which behavioral, lifestyle, and pharmacologic recommendations are made according to national guidelines to optimize patients’ vitals, symptoms, and medications. Patients’ vitals measured at home are also monitored by a clinical team available 24/7/365 to appropriately triage and provide clinical care, as well as address individual patient needs and questions. The program, which is financially supported by fee-for-service remote patient monitoring Current Procedural Terminology codes, operated across four states and nine markets supporting more than 2,500 patients as of the study period, including 37% from rural or underserved areas. Over 19 to 28 months (depending on the chronic condition), the program has shown relative increases in the percentage of patients achieving goal blood pressure (< 140/90 mmHg) by 43% (to 60% from 42%); all four pillars of guideline-directed medical therapy for heart failure with reduced and preserved ejection fraction by 107% (to 31% from 15%) and 300% (to 24% from 6%), respectively; as well as an overall reduction in blood glucose levels for patients enrolled for diabetes. The RPC program also has contributed to reductions in health care costs and utilization, including inpatient admissions.
Specialty/Research Institute
Health Care Administration
Specialty/Research Institute
Health Information Technology
DOI
10.1056/CAT.24.0521
