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Telehealth Monitoring in Home Health

  • Need: For recently hospitalized patients with complex, chronic illnesses, telehealth remote patient monitoring allows for more effective management of patients' conditions between provider visits.
  • Intervention: Telehealth remote patient monitoring gathers and trends vital signs and other data and delivers disease-specific education and surveys to homebound patients.
  • Results: Telehealth remote patient monitoring has reduced hospitalizations, reduced emergency department visits, reduced healthcare costs, improved clinical outcomes, and improved quality of life for complex patients with chronic illnesses.

First Health of the Carolinas logo Home health providers offer a range of services that include skilled nursing care and rehabilitative therapies. FirstHealth Home Care also offers a comprehensive chronic disease management program that includes a robust telehealth remote monitoring program. FirstHealth Home Care, a nonprofit Medicare-certified organization with a staff of 65, operates in North Carolina’s Moore, Richmond, Montgomery, Lee, Hoke, and Scotland counties. With nearly 3,000 admissions and 35,000 visits a year, their average daily patient census is 275. FirstHealth Home Care is part of FirstHealth of the Carolinas, a comprehensive health care system in the mid-Carolinas.

In 2009, FirstHealth Home Care received a three-year $750,000 Telehomecare Network Grant from the Federal Office of Rural Health Policy (FORHP) in order to expand its innovative approach. This funding provided for 120 telemonitoring units, as well as a full-time telehealth coordinator and community liaison. Based on the success of that project, FirstHealth was awarded nearly $1,000,000 from FORHP in 2012 to create the FirstHealth Center for Telehealth and to begin monitoring high risk patients in other care settings.

The FirstHealth Center for Telehealth now monitors high-risk heart failure patients for Medicaid managed care participants. It also monitors high risk patients in the local PACE (Program of All-Inclusive Care for the Elderly), a program for older adults who would otherwise be in a skilled nursing facility but are able to remain in their homes with support. Additionally, the FirstHealth Center for Telehealth monitors patients in its Complex Care Management Program, a program for patients with one or more chronic illnesses who are not eligible for home health but require ongoing monitoring and supervision. As a result of their expanding monitoring efforts, FirstHealth has already seen a 40% reduction in hospitalization rates for Medicaid managed care participants.

In 2015, FirstHealth received $300,000 from the North Carolina Quality Center, funded by the Duke Endowment. The funds allowed them to expand complex care management for patients with diabetes, heart failure, and COPD.

In October 2014, FirstHealth converted their telehealth monitoring devices to ones that offered more flexibility and customization. These new devices are small, easy-to-use tablets that enable patients to send their vital signs over a 4G network. Disease-specific educational videos and surveys are delivered to patients via their telehealth devices. Nurse case managers in the field receive email alerts on their smart phones if a patient has an issue. From their phones or laptops, a nurse case manager can either voice-connect or video-connect with the patient, allowing nurses to make a more comprehensive assessment of the patient's conditions.

Since the information now goes directly to frontline staff, FirstHealth has been able to reduce the number of support staff from three full-time employees to one. Not only has this new technology allowed FirstHealth to be more efficient, it has facilitated greater effectiveness.

Services offered

FirstHealth’s Telehealth Program monitors:

  • Blood oxygen levels
  • Weight
  • Blood glucose
  • Temperature
  • Blood pressure
  • Pulse

Approximately 1,000 patients are monitored through FirstHealth, averaging 100 patients each day. Comparing 2011 to 2015, hospitalization rates have shown significant improvements:

  • 47% reduction in all hospitalizations
  • 63% reduction in heart failure hospitalizations
  • 21% reduction in COPD hospitalizations
  • 47% reduction in diabetes hospitalizations
  • 50% reduction in 30-day re-hospitalizations
  • 38% reduction in 60-day hospitalizations

While the technology continues to improve, the demand for comprehensive data analytics remains a challenge. Effective integration of these technologies with EMR's to provide real time data is also a challenge.


For another organization considering starting a telehealth program, networking with peers is a good starting point. Seek out organizations that are actively practicing and succeeding in their model.

Contact Information
Patty Upham, Director
FirstHealth Care Transitions, FirstHealth of the Carolinas
Home health
States served
North Carolina
Date added
July 24, 2012
Date updated or reviewed
April 21, 2016

Please contact the models and innovations contact directly for the most complete and current information about this program. Summaries of models and innovations are provided by RHIhub for your convenience. The programs described are not endorsed by RHIhub or by the Federal Office of Rural Health Policy. Each rural community should consider whether a particular project or approach is a good match for their community’s needs and capacity. While it is sometimes possible to adapt program components to match your resources, keep in mind that changes to the program design may impact results.