A technological case management tool enables case managers to engage in remote patient monitoring at 15 times the caseload they handled previously.

  • A remote monitoring system gives case managers a warning when patients’ symptoms and vital signs are outside expected ranges.
  • Technology using a phone app is convenient for patients, allowing them to report their symptoms through text messaging or phone call.
  • For one health system, the tool helped reduce emergency department visits by 30% among a Medicare Advantage population.

Community case management and care coordination services are important in the care of at-risk seniors. But healthcare organizations sometimes find it challenging to leverage resources.

One potential solution is to use technology, such as remote patient monitoring, to increase case management efficiency and improve outcomes.

Using a remote monitoring system can streamline services by warning case managers when patients’ vital signs are outside expected ranges. It is efficient and does not waste resources, says Carla Moore Beckerle, DNP, APRN, ANP-BC, vice president of clinical programs at Esse Health in St. Louis.

The tool helped Esse Health’s care managers reduce emergency department (ED) visits by 30% and reduce medical claim costs in a Medicare Advantage program by 19%. (More information is available at this link: https://conference.cmsa.org/session/6003/.)

“Two years ago, we had a task force in our company, with physicians and executive leadership, to discuss how to be innovative around technology,” Beckerle says. “One of the things we wanted to do was make a difference with our patients regarding their chronic disease aspect.”

The organization found a solution with automated patient-reported symptom collection technology. The solution uses patients’ own phones and can be expanded easily to fit the patient population. Patients simply send their symptoms via text message or phone call. They answer clinically relevant, evidence-based questions, said Jason Roche, MPH, director of marketing for CareSignal in St. Louis. Roche spoke about remote patient monitoring at the Case Management Society of America (CMSA) 30th Annual Conference and Expo virtual conference, held June 28-July 2, 2020.

For example, if the technology was used to monitor patients with chronic obstructive pulmonary disease (COPD), it would ask them about their breathing status. If it was used to track diabetic patients, it would ask about their blood glucose levels.

When patients report symptoms or measurements that are not in the expected range, the tool sends the information to their case manager or a clinical care team.

“Once people are enrolled, they receive text messages, and they can respond with their blood sugar and blood pressure values,” Roche explained. “The care team receives all that member data. It shifts case management from the traditional outbound of picking up the phone and calling patients to check on them to an inbound model of where they now receive data from hundreds of patients.”

Place Resources Where Needed

The tool enables case managers to put their time and resources where they are more needed. “We stratify that data and identify for care managers which patients are in the red, where an alert is sent to the care manager, and which are in the yellow, and those in the green, meaning they are doing fine on an ongoing basis and do not need any outreach,” Roche said.

“What’s exciting about using more accessible technology is it can reach a whole wide variety of patients,” Roche continued. “The technology is designed to engage even the most challenging patient population.”

The technology allows nurse case managers to increase their patient load by up to 15 times. One case manager monitored 100, but when the remote monitoring app was used, her caseload increased to 1,500 patients. “That care manager was still highly satisfied, not burned out, and not overwhelmed,” Roche said. “It speaks to the power of being able to get this data in a manner that’s automated.”

For instance, remote patient monitoring can keep low-resource Medicare and Medicaid patients engaged with their own health and self-care activities. “It allows the person who is using the app to learn and manage their care and symptoms, address their symptoms, and be proactive, instead of being a passive recipient,” Beckerle says. “This tool has allowed our patients to be more engaged with their care and more engaged with their outreach.”

Outcomes are better because patients are paying attention to their symptoms thanks to the continual communication through the app. “It brings the issue of their chronic disease to the top and forefront of their minds, and they address it,” Beckerle says. “That is the biggest win we’ve had, and we didn’t have to add 30 case managers. You can’t have an infinite number of individuals in any company because you can’t afford it. There are smarter ways of doing things, and this is one of the smartest ways we do it.”

Health Center Case Study

STRIDE Community Health Center, a federally qualified health center in Denver, uses the remote monitoring tool to extend the reach of its care team. Results of a quality improvement study revealed STRIDE’s patients with diabetes enrolled in CareSignal receiving the text prompts experienced a 2% average decrease in their A1c levels. About 19% of high-risk diabetic patients improved their blood glucose levels, while 77% of those with rising risk maintained their levels. Forty-five percent of high-risk patients with hypertension showed improvement. Patient engagement at three months was 60% for patients with diabetes and 50% for patients with hypertension.1

“STRIDE risk-stratifies the patient population and identifies which members need additional support,” Roche explained. When case managers receive their report of patients who need help with maintaining their health, they can call the patients and find out what might be hindering their improvement.

Esse Health’s remote monitoring program relies on the Johns Hopkins Adjusted Clinical Groups (ACG) system to identify at-risk patients with specific diagnoses, Beckerle says. The ACG model uses data from medical claims, electronic medical records, and demographics to predict a person’s health over time. (For more information, visit: https://www.hopkinsacg.org/.)

“It indicates what kind of risk a person would have of hospitalization and death,” Beckerle says. “That’s our tool to say, ‘This is where we’ll outreach.’”

Once the tool identifies at-risk patients, they are enrolled to receive text messages — or, if they prefer, a phone call — at a regular interval. Both text messages and phone calls are made at a time that is convenient for the patient.

“If they don’t get up until 10 in the morning, we don’t text or call them at 8 a.m.,” Beckerle says. “We center it around when they want, and that increases their participation.”

When patients’ data show they are outside the parameters of the disease process, their case manager receives a trigger message and calls the patient.

“It’s all telephone — no home visits,” Beckerle says. “But, if they need a home visit, it has to be someone from our team.”

Often, the patient needs to see a physician. The case manager shepherds that process and helps the patient make a timely appointment. If the patient had to wait for an appointment — without the case manager’s quick intervention — the patient might give up or end up visiting the ED, she says.

Case managers sometimes have to involve the team to solve a patient’s health obstacles. For example, a patient with COPD may experience breathing problems because of a son who moved back home and smokes inside, Beckerle says.

“The son might also be an alcoholic who is using and stealing from his dad for his habits. He’s not only physically harming his dad, but also is stealing from him,” she says. “We would be alerted because the man is on the app, and the case manager calls him to find out why his numbers are off. She talks to him and sends a task to the social work team. A social worker goes out and deals with the issues by getting the son removed from the house.”

This fictional scenario is similar to what the case management team sometimes has to deal with, Beckerle notes.

Medicare Advantage

Following a value-based model of care for the Medicare Advantage population, case managers are proactive and will send patients who are struggling with maintaining their health to their primary care providers.

“If patients need more interventions, they can be referred to a specialist,” Beckerle says. “We take a lean approach, and we make sure we’re being efficient.”

Esse Health has enrolled about 1,200 high-risk patients on the remote monitoring program, and there is high engagement. “Because we are a care management team, we are a high-touch model and have employees in hospitals, skilled nursing facilities, and we have social workers doing home visits,” she says. “My team is addressing the needs where the patient needs them.”

Patients enrolled in the remote monitoring program could be on the system for a few months to longer than a year. “For chronic conditions, like type 2 diabetes, you don’t solve it in a couple of weeks,” Roche said. “We see members stay on the system, and as they improve their clinical outcomes, we reduce the messaging we send them.”

At first, the remote monitoring technology will send a patient with uncontrolled diabetes five messages a week. This declines as the patient improves. “The goal is to keep those members engaged as long as we can. If they are engaged, they don’t need as many messages,” Roche explained.

The messages include feedback and encouragement. For instance, a message might say, “Your two-week average is 10% lower than the last two weeks. Keep up the great work,” he said.

For an example of the technology’s messaging, case managers can text “case” to the app’s number of (844) 837-9996, Roche noted.

If a patient’s numbers and symptoms are worse, the app might ask if they would like to receive educational messages about healthy eating and physical activity.

“The goal is to create informed and empowered patients who are able to self-manage their chronic conditions with the support of their care team,” Roche said. “It doesn’t replace the expertise of the care management team, but simply augments what care managers do by providing them with real-time data.”


  1. CareSignal. Case study: How the largest FQHC in Colorado prepared for the shift from fee-for-service to value-based care. https://www.caresignal.health/stride_fqhc_casestudy