Telehealth Implementation and Evaluation in Rural and Underserved Communities: RPM Implementation at Vanderbilt University Medical Center (VUMC)

Project Overview

Workplan Goal: Establish a collaborative program between Primary Care, Population Health Pharmacy, Nephrologist, and Care Management teams to improve blood pressure control in a CKD population by utilizing technology to monitor and manage patients with hypertension.

Chronic Kidney Disease (CKD) affects approximately 34% of people ages 65 and older while having a more significant impact on non-Hispanic black individuals and Hispanic individuals. Within Vanderbilt University Medical Center’s (VUMC) Medicare Shared Savings Program (MSSP) ACO, patients with stage 3 CKD are hospitalized at a rate more than two and a half times greater than average for the total ACO population. Patients with stage 3 or higher CKD also contribute a disproportionate percentage to the total cost of care when compared to their share of Medicare beneficiaries within the ACO population. Nationally, hypertension and diabetes are two of the largest contributors to CKD. Within Vanderbilt's MSSP population, approximately 97% of patients with CKD also have a diagnosis of hypertension. Based on the greater utilization of inpatient services, higher cost of care, and potential for health inequities for patients with CKD, we are proposing a chronic disease management program that utilizes remote patient monitoring to manage hypertension for patients with CKD.