Fraud Blocker Remote Patient Management | Care Mountain | Care for Seniors

Remote Patient Monitoring

Our Remote Patient Monitoring Programs: We offer specialized RPM and CCM (chronic care management) services for a range of acute and chronic conditions, such as heart failure, diabetes,  hypertension, and COPD.  

We provide in-person and remote care teams staffed with Nurses and assistants working under clinical supervision of our Director of Nursing and our Physician Medical Director.

We collaborate with leading Hospitals, Physician Groups, Physician practices and Independent Living Communities across DFW to:

  • Onboard eligible patients into RPM & CCM programs for CHF, Diabetes, Hypertension, and COPD patients.
  • Provide remote monitoring devices to patient at home.
  • Each devices is fully connected on 5G out of the box. Start patient with 1st reading in person at clinic or in patient home.
  • Track and ensure longitudinal health metrics with necessary daily/weekly readings for patients recovering and/or transitioning from Hospital based acute care to home via RPM.
  • Monitor critical health metrics (e.g. BP, FF/PP BG, SPO2, weight) seamlessly and easily with partner Hospital and Physician offices. If their health status changes, our Nurses will coordinate with physician, NPs to provide intervention (e.g. changes in titration levels for Rx)
RPM_CM
Shot of female doctor talking with earphone while explaining medical treatment to patient through a video call with computer in the consultation.

Our Remote Patient Monitoring Programs: We offer specialized RPM support for a host of acute and recurrent/chronic conditions, such as heart failure, diabetes,  hypertension, chronic obstructive pulmonary disorder (COPD), post acute recovery, and fall or stroke rehabilitation. We can offer specialized expertise integrating RPM and HH capabilities to support your patient population across the Dallas Fort Worth metroplex with RPM.  As part of that, we will collaborate with partner Hospitals, Physician Groups, Physician practices and Independent Living Communities to:

  • Onboard eligible RPM patients into our specialized RPM programs for CHF, Diabetes, Hypertension, and Stroke patients.
  • Provide remote monitoring devices to patient at home.
  • Each devices has built in SIM card (AT&T 5G) and works out of the box. Get patients started with taking 1st reading in person at clinic or in patient home.
  • Provide in-person and remote care teams staffed with Nurses and assistants working under supervision of our Director of Nursing.
  • Track and ensure longitudinal health metrics with necessary daily/weekly readings for patients recovering and/or transitioning from Hospital based acute care to home via RPM.
  • Monitor critical health metrics (e.g. BP, FF/PP BG, SPO2, weight) seamlessly and easily with partner Hospital and Physician offices. If their health status changes, our Nurses will coordinate with physician, NPs to provide intervention (e.g. changes in titration levels for Rx)
RPM

Our RPM Partners: DFW Hospitals, Physician Groups, Physician Led Clinics

  1. Nationwide, RPM usage skyrocketed with volume increasing 1300% (Jan’19 to Nov’22).
  2. Heart disease, diabetes, chronic lung disease are most prevalent chronic illnesses and RPM users. Specialists in Internal Medicine, Cardiology see larger volumes of such patients with relatively intensive care needs.  
  3. We partner with leading Hospitals, Physician Groups, Physician Led clinics and Independent Living Communities across Dallas Fort Worth to provide custom programs that combine our field Home Health Nurses with centralized teams staffed by experienced RPM Nurses.

Proactive Clinical Interactions

A combination of in-person and virtual visits means frequent real-time opportunities for education, symptom management and intervention.

Centralized Clinician-Led Team

Experts are in place to monitor every alert so that intervention can occur at the earliest signs of a health change.

Connected Devices and secure AT&T private data network that meet JCI Standards

Patients receive connected device(s) that are ready to use out of the box for accurate vital signs monitoring. These are delivered to patient's home within 24 hours of doctor’s order. US based, secure, private data network with several layers of security that meets JCI standards for Hospital and Physician group security. Readings from our devices are transmitted accurately and securely every time.

Our RPM & CCM Capabilities help prevent readmissions:

Hospital readmissions are often preventable. With remote patient monitoring (RPM) and chronic care management (CCM) programs, Providers can regularly access and monitor leading clinical indicators to keep patients healthy at home and avoid preventable admissions especially post procedure.  For example, we have seen our RPM helps cut readmission rates of congestive heart failure patients by 50%.

Key levers that we deploy to improve patient satisfaction, provider satisfaction and reduce readmissions:

  1. With our skilled nursing staff, patient education is an integral part of preventing readmissions a higher ratio of nursing staff has also been shown to be effective in reducing readmission rates. Specific questions related to diet, medication compliance, and water intake should be asked.
  2. Ensure patient’s follow up appointments, and remote monitoring of longitudinal health vitals (e.g. for Heart Failure patients)
  3. Optimize medications, improve outcomes and reduce hospitalization. This includes not only the choice of meds (e.g. Beta-blockers, ARBs) but also the adherence, compliance tracking and interplay with diet, exercise, water intake. 

Example Case Studies from our RPM Experience:

  1. Finding the Root Cause of Hypertension via RPM: A 48 year old Female patient in a physician group practice complained of frequent dizziness and fluctuations in her at-home blood pressure readings. During her office visit, the physician could not diagnose the cause of the dizziness since in his clinical opinion the meds were correct. He ordered RPM services and a skilled nurse began monitoring and reviewing her daily blood pressure readings and quickly identified a pattern that the patient’s blood pressure dropped in the evenings by 20%. She called the patient to assess the situation and discovered the patient was taking her prescribed hypertensive medications twice in the evening. The patient had misunderstood the pharmacist’s directions which consistent with the prescription bottle asked for the medication once a day in the mornings.
  2. RPM to support AFib patient: One of our physician group’s referred patients was an overweight 78 year old Male on blood thinners and beta blockers – the physician had corrected a beta blocker overdose and referred to us for careful RPM and medication tracking. Given the patient’s past history of a previous Atrial Fibrillation (AFib) hospitalization, our skilled nurses monitored the patient’s pulse rate and blood pressure via RPM while conducting periodic medication assessments, and coordinated with the physician for EKG testing. As the physician iterated and titrated the patient’s meds, , our RPM team worked in close coordination to stabilized to good health over 7 weeks and is stable since. 

Mass General Brigham's RPM led hypertension and cholesterol optimization program:

  1. In one of the largest RPM studies, Mass Gen researchers enrolled more than 10,000 patients in their hypertension and cholesterol optimization program, and collected more than 424,000 blood pressure readings and 139,000 laboratory reports on their health metrics. The results were impressive! Patients achieved an average systolic blood pressure decline of 9.7 mmHg, and an average cholesterol level decrease of 37 mmHg, both fairly significant changes. Alexander Blood, the lead author from the Hospital’s Division of Cardiovascular Medicine, credits the success of their RPM to the ability to access patients outside the four walls of the practice. “We meet the patients where they are, communicate and co-manage their health through the channels they preferred, including home health, connected devices, patient portals, text, email, or phone calls while the patient is at home.”

Contact our RPM Team

Email us at [email protected]