researchers demonstrated that patients with chronic
disease and behavioral health issues are high-utilizers
of healthcare. According to their personal inpatient
discharge research, Riverside Health
System found approximately 40% of their patients have
a behavioral health condition that may interfere with
recovery from an acute illness.
In rural areas, management of these chronic disease and
behavioral health conditions is made even more complex by
access issues and scarce resources. Nonprofit Bay Rivers
Telehealth Alliance (BRTA) collaborates with area
organizations in Virginia's Tidewater area to research
how remote telehealth monitoring can offset these
challenges with its "Bridges to Care Transitions-Remote
Home Monitoring and Chronic Disease Self-Management"
Two rural hospitals were participants in a remote
telemonitoring project. Patients enroll at the time of ER
or hospital discharge. Telemonitoring equipment, capable
of sharing standard vital signs (blood pressure,
oxygenation, weight), is drop-shipped to the patient's
home. Soon after, a health coach visits the patient and
uses an evidence-based assessment to further assess and
build patients' understanding of both their behavioral
health and chronic disease challenges.
Specific to this project is a behavioral health wellness
assessment. This approach aims to discover eligible
patients for the Health Ideas model, a program that
provides a health coach for 6 months. If a high-risk
patient is identified during screening, they are referred
to a behavioral health organization for further care.
Remote monitoring is intended for a recommended 90-day
period. Health information is transmitted to the partner
health system's coordination center where incoming data
are assessed by nurses. Any values outside an expected
range are evaluated by phone or home or office visit.
Patients not transmitting their data are contacted and
patients may also call their health coach or the
monitoring center with any questions. Two-week trend data
are integrated into the patient's electronic health
record allowing primary care providers to review this
information in a process similar to the workflow for new
lab or X-ray results.
Due to encouraging early results showing improved
readmission rates and decreased ER evaluations, BRTA,
project partners, and third-party payers are meeting to
explore reimbursement models.
This project involves close collaboration with several
The program is supported by the Federal Office of Rural
Rural Health Care Services Outreach Project grant.
Additionally, BRTA was recognized as a Health Resources
and Services Administration (HRSA) 2018 Rural Health
Champions for use of evidence-based models in "betterment
of rural community health."