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Innovation Grant Funds New Remote Monitoring Model of Care for Patients with Chronic Illness


For patients struggling with one or more chronic illnesses, intense monitoring and follow-up is necessary to help better manage their self-care and avoid preventable emergency room visits and readmissions. Emerging new models of care that introduce telemonitoring technologies can help patients stay connected with their care teams and be more successful in managing their health while reducing costs.

With funding from a Trinity Health Innovation Grant, Lourdes Health Network in Camden, New Jersey, launched a pilot project in November 2015 to test how virtual monitoring of patients with chronic conditions could improve their health and well-being while reducing cost and utilization of acute health services. The need for a new model was high because complex patients with chronic conditions were just five percent of Lourdes' accountable care population, yet represented more than 30 percent of total costs with an average of $84,645 per year per patient.

Lourdes partnered with Bayada Home Care to select high-risk patients with diabetes, congestive heart failure or COPD and who had an admission within the last 60 days. Once identified, patients were provided with remote monitoring equipment from Vivify to use in their homes to capture biometric data, which was shared with their primary care physicians. 

Also, population health nurses held weekly video chats with the patients as a means to check in visually and answer their questions. This created an ongoing, data-supported collaboration plan between the patient and the health system, resulting in a unique model of care.

"We leveraged technology to empower our population health nurses and physicians with daily biometrics so they could improve their patients’ outcomes with early interventions, but we didn't know if the patients would be comfortable with the telemonitoring tools or approach," said Donna Antenucci, COO and vice president, Clinically Integrated Network at Lourdes. "It turns out that they were highly receptive and engaged in the program."

Lourdes deployed the pilot in its Medicare Shared Savings Program (MSSP) accountable care organization (ACO). The pilot served 63 patients over eight months and included more than 400 virtual visits of approximately 10 minutes each. Compliance with the monitoring tools was high at 87 percent, even though the average age of participating patients was 76.

The results of the pilot were impressive. The monitoring increased care coordination and care quality while reducing health expenditures. The inpatient admission rate per 1,000 dropped 74 percent for patients in the pilot, while inpatient per member per month costs dropped 53 percent. Patient satisfaction with the program was high with 96 percent of the participants surveyed willing to recommend the program to others.

The program had other benefits as well. Patients developed deeper relationships with their population health nurses via the video chats, which reduced isolation. Patients were able to observe real-time data on how their body responded to behaviors that directly impacted their chronic conditions. Nurses and physicians valued the ability to review trended biometric data for proper titration of medications and valued how the program enabled them to stay on top of health behaviors. In many cases, the care team was able to catch developing problems – some potentially life-threatening – and correct them so that the patient avoided a preventable emergency room visit.

"I'd recommend this program for replication at other RHMs," continues Antenucci, "but success depends on following a few key steps." She encourages ministries to begin by determining appropriate criteria for patient enrollment and also establishing clear criteria for discontinuance so that the equipment can be used with the next sets of patients. Ministries should invest in education of nurses and physicians up front in order to better deploy skilled, trained staff to execute the project. Finally, the program will need support from local leadership that includes a budget for leasing the equipment and cleaning costs to prepare it for the next user.

"We appreciate the innovative work that was done by Donna and her team at Lourdes, and their success provides valuable lessons for others who might consider such a program," says Anna Marie Butrie, vice president, Innovation Program and Services. "Leaders in our System who are willing to take the risk to try out innovative new ideas are the backbone of our innovation program."


About Trinity Health Innovations

Trinity Health Innovations provides pathways, funding and support that enables innovative IDEAs to grow and flourish and scale across the health system. The I.D.E.A. model — Identify, Develop, Explore and Advance — spurs this work.


About Trinity Health

Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation, serving diverse communities that include more than 30 million people across 22 states. Trinity Health includes 93 hospitals, as well as 120 continuing care programs that include PACE, senior living facilities, and home care and hospice services. Its continuing care programs provide nearly 2.5 million visits annually. Based in Livonia, Mich., and with annual operating revenues of $16.3 billion and assets of $23.4 billion, the organization returns almost $1 billion to its communities annually in the form of charity care and other community benefit programs. Trinity Health employs about 131,000 colleagues, including 5,300 employed physicians. Committed to those who are poor and underserved in its communities, Trinity Health is known for its focus on the country's aging population. As a single, unified ministry, the organization is the innovator of Senior Emergency Departments, the largest not-for-profit provider of home health care services — ranked by number of visits — in the nation, as well as the nation’s leading provider of PACE (Program of All Inclusive Care for the Elderly) based on the number of available programs. For more information, visit You can also follow @TrinityHealthMI on Twitter.