Continuous Care Programs are improving patient outcomes

July 1

Continuous Care Programs are improving patient outcomes, and HealthyConnect at RCP is here to support these new programs!

Continuous care programs like Remote Patient Monitoring (RPM), Chronic Care Management (CCM) and Principal Care Management (PCM) are making huge strides in improving patient health outcomes. These programs are redefining how healthcare is being delivered and patients are reaping the benefits. From the use of in-home medical devices to virtual care visits, patients are seeing less complications with some of the most prevalent adult conditions like hypertension, heart failure and diabetes. Patients enrolled in the HealthyConnect program with RCP have personally witnessed the benefits of participation.

The Use of Digital Health Interventions in Cardiovascular Patients

A study recently published in the International Journal of Cardiology found that Digital Health Interventions (DHI), such as telehealth, remote patient monitoring and smartphone apps, significantly decrease all-cause mortality, cardiovascular mortality, and days of hospitalization for patients with acute heart failure. With over 7200 patients’ data reviewed, the results showed that patients with DHI had less all-cause mortality (8.5% vs. 10.2%), lower cardiovascular mortality (7.3% vs, 9.6%) and less days lost to HF-related hospitalizations compared to those without access to DHI. The CDC notes that cardiovascular disease is the leading cause of death amongst both genders and most racial and ethnic groups. Heart disease costs the US almost $363 billion a year in healthcare services, medicine and loss of productivity due to death. In an effort to decrease these statistics, healthcare organizations and insurance companies alike are looking to innovation in technologies as a means to improve health management, patient engagement and preventative medicine.

Here at RCP, we witness first-hand the power of remote patient monitoring (RPM) in preventing cardiovascular complications. One of our cardiologists, Dr. Chesnie, enrolled a very healthy, retired athlete into RPM. 

The patient routinely engaged in RPM by taking daily readings of his blood pressure, pulse, oxygen, and weight. On this particular day, the RCP nurse coach recognized his heart rate was much higher than usual- 160 bpm vs. his normal 60 bpm. She assessed the patient over the phone and discovered he was asymptomatic. However, this heart rate was concerning and she escalated the finding to Dr. Chesnie. An EKG in the office revealed the patient was experiencing atrial fibrillation. The provider was able to immediately start medications and avoid additional cardiovascular complications like congestive heart failure. Dr. Chesnie stated, “The potential of a bad outcome was thwarted specifically because he made a choice to enroll in this home monitoring program, and I was able to interact with him very quickly to take care of the problem.” The patient continues to engage in the program and is grateful for the quick response from his care team. 

The Impact of Continuous Care Programs on Diabetes

In the last 20 years, the number of adults diagnosed with diabetes has more than doubled as the American population has aged and become more overweight. Not only is diabetes widespread, but it is also extremely costly. Diabetic patients spend almost twice as much as non-diabetic patients on their medical health and suffer from more comorbidities like heart disease and kidney disease. In an effort to counteract these statistics, healthcare providers are looking to new programs that enhance patient access and engagement in the management of their diabetes.
In 2019, researchers conducted a study to determine the impact of continuous care programs on health outcomes and cost of type 2 diabetes. Over a 5 year period, patients with more continuous care access had significantly less diabetic complications (0.54 vs. 0.88) and spent less on their healthcare ($3,496 vs. $3,973) than those with less continuous care access. This study highlighted the benefits of continual care for these patients just when chronic care management and remote patient monitoring were ramping up. Now almost four years later, continuous care programs are becoming integral parts of healthcare delivery. 

Two HealthyConnect patients with diabetes have experienced the same benefit from continuous care programs and intentional nurse education and coaching. One particular patient set a personal goal to lower his A1C by his next appointment, which was only three months away. It was a lofty task, but the nurse and patient were up to the challenge! 

 The nurse provided specific education and coaching tips that he could easily fit into his normal routine- specific meals, foods to avoid, and an activity plan. The patient not only dropped his A1C from 6.8 to 6.5, but he also lost 6 lbs and was able to cut his blood pressure medicine in half! The patient couldn’t wait to update his nurse and set their next goal. 

Another diabetic patient joined Remote Patient Monitoring (RPM) in February of 2022. The patient was assigned a dedicated nurse coach and glucometer to track blood sugars at home. The patient’s A1C in January of 2022 was 13.7% and often experienced blood sugars well above 500 mg/dL. The patient was scheduled for a procedure and was at high risk for post-procedural complications due to the nature of their diabetes. However, with intentional nurse coaching and provider communication, the patient received extensive education on managing diabetes, tips on food choices and the importance of medication compliance. Not only did the patient’s A1C decrease to 6.0% in May 2022, but they also avoided any infections or complications with the procedure!

Continuous care programs and digital health interventions are not just changing healthcare- they are changing patients’ lives tremendously. Here at RCP, we are helping pave the way for physicians and healthcare organizations alike to incorporate these new technologies in their practices and increase their patients’ access to quality care and improve their overall health. With HealthyConnect, we are all change agents!


“Diabetes Quick Facts.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 17 Dec. 2021, 

Elbadawi, Ayman, et al. “Digital Health Intervention in Patients with Recent Hospitalization for Acute Heart Failure: A Systematic Review and Meta-Analysis of Randomized Trials.” International Journal of Cardiology, 2022, 

“Heart Disease Facts.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 7 Feb. 2022,


Cardiovascular, Continuous Care, Diabetes, HealthyConnect

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