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Rural Health Information Hub

Bay Rivers Telehealth Alliance

  • Project Title: Bridges to Care Transitions
  • Grant Period: 5/1/2015 – 4/30/2018
  • Program Representative Interviewed: Donna Dittman Hale, Executive Director, Bay Rivers Telehealth Alliance
  • Location: Tappahannock, VA
  • Program Overview: The Bay Rivers Telehealth Alliance, which assists local healthcare organizations with grant resource development, has implemented a telehealth program to support COPD patients through remote patient monitoring technology and coaching. Patients measure their biometrics from their home on a daily basis, such as blood pressure and pulse oxygen levels, which are digitally transferred to their health record at their primary care provider's office. The remote monitoring system also regularly prompts patients with questions about their COPD symptoms and mental health. This telehealth program and coaching allows patients to more accurately monitor their COPD without the resource burden of increased healthcare utilization and empowers them to better self-manage their condition. Guided by the Coleman model as well as the Stanford model for Chronic Disease Self-Management, the remote patient monitoring program has resulted in reduced hospital admissions and emergency department visits while increasing unplanned doctor's visits.

Read more about the Bridges to Care Transitions program in our Rural Health Models and Innovations section.

Models represented by this program: