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Mount Sinai Health System

Addressing Digital Health Equity to Improve Cardiovascular Health Outcomes using Pharmacist‐Led Remote Patient Monitoring

Cathleen Mathew, Pharm.D., CDCES, AE‐C; Nicole Tang, MPH; Leanna Narain, Pharm.D.; Jacquline Mullakary, Pharm.D., BCACP, CDE, AE‐C; Ruchi Tiwari, Pharm.D., MS

Mount Sinai Health System
New York, NY

The Condition Management program was created in June 2020 to improve cardiovascular health for those with uncontrolled conditions while addressing the challenges of healthcare access through technology. The holistic care model integrates remote monitoring and timely pharmacologic treatment designed and led by ambulatory care clinical pharmacists, comprehensive lifestyle education and customized care plans delivered by registered dietitians and care coordination services to onboard patients to the program and devices in collaboration with referring providers. The program provides enhanced access to comprehensive medical care, patient‐centered education, and linkage to community‐based health and social support resources as identified. The mission focuses on patient‐ centered clinical services using innovative technologies that improve access to care, positively impacting social determinants and improving overall clinical outcomes. Through services such as remote patient monitoring (RPM), therapeutic optimization, and clinical coaching, the program strives to help patients monitor, manage, and maintain their conditions.   

The Condition Management program began by focusing on ambulatory hypertensive blood pressure management for geriatric and medically underinsured adults. The program has quickly scaled system‐ wide, now serving a centralized RPM and disease management program for hypertension, heart failure, hypertensive disorders in pregnancy, COPD and post‐COVID monitoring.  

An internal quality improvement matched cohort analysis of 218 patients examining the effects of RPM on blood pressure control and healthcare utilization versus usual care in‐clinic was conducted. Demographic breakdowns showed the following:

  • 35% of patients examined identified as Black, and 30% Hispanic
  • 89% were 65 years and older
  • Median household income Median household income <$50,000

Results from the evaluation found that 61% of patients in the RPM group achieved blood pressure control (defined as less than 140/90) from baseline at 3 months compared to 43% of patients in the usual care group (p=0.010). At 6 months, 72% of patients in the RPM group achieved blood pressure control, compared to 53% of the usual care group (p=0.005). Black RPM patients and RPM patients 65 years and older saw on average a 10‐point and 8‐point decrease in systolic blood pressure at 3 months, respectively.  RPM patients experienced on average a 7‐point decrease in systolic blood pressure from baseline to 3 months post enrollment. 90.2% were able to sustain the 7‐point difference for an additional three consecutive months. The significance to the population health goals of our organization is evident as RPM patients were found to have lower rates of emergency department (ED) and inpatient visits over 12 months.  RPM patients experienced 25 all‐cause related ED visits compared to 33 ED visits by usual care patients (p=0.396). We observed an overall reduced total cost of care for patients enrolled with RPM as compared with usual care.  RPM patients experienced 19 hospitalizations compared to 56 by usual care patients (p<0.001). This equated to approximately $21,976 and $814,000 estimated cost savings for ED visits and hospitalizations, respectively for RPM patients over 12 months.  

By creating a patient‐centric, equity‐focused, and well‐rounded patient experience, clinical pharmacists can leverage their existing skills to become further assets for healthcare organizations by developing a scalable and reimbursable digital ambulatory care service.