New York City-based Montefiore Einstein’s remote monitoring program for patients with uncontrolled blood pressure has lowered patients’ systolic blood pressure by an average of 10 points within six months, a drop leaders estimate cuts their risk of heart attack and stroke by about 20%.
The system began the initiative in 2020, piloted the program in 2021 and expanded it systemwide last year. In 2020, the system launched a remote monitoring program, which provides patients with a cellular-enabled blood pressure cuff that automatically captures and sends measurements to the clinical team, Sharon Rikin, MD, director of ambulatory quality improvement for medicine at Montefiore Einstein and associate dean for quality at Albert Einstein College of Medicine, said on an upcoming episode of the Becker’s “Cardiology and Heart Surgery Podcast.” A multidisciplinary care team coaches patients on home monitoring, medication adherence and diet and lifestyle, and reviews their readings monthly between office visits, adjusting medications if they’re not at goal.
In the last year, the program enrolled more than 5,000 patients, and by six months of participation, 86% of those patients were still participating. On average, mean systolic blood pressure among these patients has fallen by 10 millimeters of mercury by six months.
“To put that in context, for every 5-point reduction in systolic blood pressure, the risk of heart attack and stroke decreases by 10%,” Dr. Rikin said. “So on average, for patients in our program, we’ve seen a 20% reduction in the risk of heart attack and stroke.”
The medical record integration Montefiore built at the outset has been key to scaling the program quickly, giving providers panel-based ordering and easy access to patients’ clinical and vitals data, Allison Stark, MD, vice president and chief medical officer of the Montefiore Care Management Organization, said in the podcast. Payers have supported the program as a way to improve HEDIS quality metrics, and the system is automating billing to help sustain it, she said.
The program is available at 14 of the 20 Montefiore Medical Group primary care sites, with plans to expand to the rest in the next year. Leaders are also looking to expand the program to other specialties that manage patients with high blood pressure, such as cardiology and neurology, Dr. Rikin said.
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