Written by: Center for Care Innovations

Top Takeaways

  • Include care team staff follow-up and engagement with patients to ensure success.
  • Put a supply system inventory in place to prevent tablet loss.
  • Have a plan on how to retrieve tablets if patients no longer need monitoring.


Safety net health clinics are bringing the power of Bluetooth technology to their patients in the fight against high blood pressure, elevated glucose, and the battle of the bulge.

During the rapid pivot to telehealth visits during the pandemic, safety net clinics embraced simple, efficient, and cost-effective remote patient monitoring (RPM) solutions to help serve high-risk patients managing chronic medical conditions such as diabetes and hypertension. Clinics are rolling out so-called “connected” tools for remote monitoring that are easy to use and allow patients to do routine health checks from the comfort and privacy of home. The data, thanks to the beauty of Bluetooth and other wireless tech, is automatically sent to the patients’ providers.

There’s no relying on patient keeping a written record or remembering to send details to their doctor’s office — something that takes a lot of provider legwork out of the equation.

Remote patient monitoring, as CCI reported last year, is a popular telemedicine innovation. With patients taking charge of their routine health checks outside the walls of traditional health settings, it has the potential to lower health care costs, improve chronic disease management, and reduce preventable trips to emergency departments. It’s been made possible with the relaxing of formerly restrictive Medicare rules, which have eliminated many barriers to such services. Federally qualified health centers (FQHC) have leaped at the opportunity to join the connected health party to better care for their vulnerable patients. 

Two health centers utilizing the latest in digital innovations in the health data collection field—Neighborhood Health Care and Northeast Valley Health Corporation—are members of a cohort exploring ways to deliver high quality, compassionate, and culturally sensitive virtual care that is accessible for all as part of CCI’s Connected Care Accelerator initiative, which includes 40 safety net clinics across California.  RPM tools are especially important in diseases that require continuity of care and the consistent tracking of vital signs.

“We’re using a small fraction of the services this robust software platform offers,” says Jeff Glenn, Neighborhood Health Care’s chief operating officer, of the product the center picked to partner with to do this work.  “We are probably only using 50% of its functionality. We see a lot of potential here.”

Real-Time Records

Neighborhood Health Care, an FQHC based in Escondido in Southern California, wanted to extend the virtual care solutions it was offering remote patients to support their efforts managing chronic conditions. Neighborhood annually serves 75,000 mostly Latino, low-income patients across San Diego and Riverside counties through 19 mainly urban clinic locations.

During the pandemic Neighborhood Health Care has distributed blood pressure cuffs, glucose meters, computer tablets, and other home monitoring equipment to hundreds of high-risk patients and care team staff have trained them on how to use the devices. Neighborhood created videos for virtual instruction, conducted in-clinic training, and called on its remote services team to reach its most isolated patients.








Neighborhood also partnered with the telehealth service, VitalTech, to ensure that the data collected by patients is instantly available to providers, too. The cellular-based software program pairs with a slew of gadgets to help patients manage multiple medical conditions. Its remote patient monitoring tools include blood pressure cuffs (which Neighborhood uses in this initiative), pulse oximeters, and thermometers. These Bluetooth-enabled devices send digital readings to a platform that produces real-time data analytics and health alerts to the care team.

There are several such products on the market designed with the medical community in mind. After reviewing multiple demonstrations of comparable products, Neighbor’s Medical Director of Informatics Kulin Tantod said: “I want the VitalTech product; it is the BMW of the choices. Glenn explains that the platform includes a lot of relevant features. It integrates well with the health center’s cellular provider and has the potential to integrate with a health center’s electronic health records, too.

To date, Neighborhood has distributed 250 tablets and expects to have another 250 in patients’ hands in December.  The heath center plans to place around 2,000 remote monitoring kits in the community, says Glenn, and it expects to have meaningful metrics on the impact of this innovation by the end of the year.

Improving Health Care, One Vital Sign at a Time

As with every safety net clinic around the state, the COVID-19 crisis dramatically altered the delivery of care at Northeast Valley Health Corporation, a nonprofit organization and FQHC centered in the San Fernando and Santa Clarita Valley dedicated to providing sustainable health care for vulnerable Southern California communities. 

NEVHC provides over 320,000 annual health care visits for 73,050 patients at 14 clinics. While the pandemic pushed this provider and its care teams into adopting virtual care at a remarkable pace, one issue proved a persistent pain point: Obtaining blood pressure values and documenting blood pressure (BP) readings during virtual visits.










That’s a major concern because the organization serves a mostly low-income Latinx population, and many of the health center’s patients are disproportionately impacted by chronic health conditions, including high blood pressure, diabetes, and obesity.

To address this problem, the health center launched a connected blood pressure program that it called “Monitoring Your Way to Health.” It’s not the organization’s first foray into remote patient monitoring (RPM), noted Debra Rosen, director of health education and quality improvement at Northeast Valley Health Corporation, in a recent interview. “Our center previously leveraged RPM to support patients with asthma outside of medical visits, and we also provided unconnected home BP monitors and glucose monitors,” she recalled.

The organization piloted its remote patient monitoring program with 50 patients with hypertension via the clinical management platform Rimidi. The platform uses blood pressure monitors that connect easily through cellular data to a platform within NextGen, Northeast Valley Health’s electronic health record. With the platform in place, the organization has been able to better support clinical decision making, mitigate gaps in care, and efficiently achieve quality measures, according to Rosen. 

In the pilot, the healthcare provider wanted to find out if a patient with a connected monitoring system would be more likely to engage in their care and keep their blood pressure under control. In six months from January 2021 to August 2021, patients using connected blood pressure monitoring who had control over their blood pressure jumped from 38% to 70%. During the same time frame, patients with unconnected blood pressure monitors dipped slightly in terms of control from 54.4% to 51.7%, and those under typical in-person care remained about the same at around 50%.

That’s a measure of the program’s initial success. “Overall, I feel that remote blood pressure monitoring is a great way to give patients the ability to keep track and monitor their health at home, and makes it more helpful for them to discuss their concerns with their provider,” says a Northeast Valley Health family medicine care coordinator.

It takes engagement and encouragement by the care team with patients to ensure the success of a remote monitoring program. Recognizing the digital divide, the team works to remove any obstacles associated with this tech innovation, adds Rosen.

The organization would like to grow the program. Should funding be available, Northeast Valley Health would like to expand remote patient monitoring use to glucose monitoring and weight management as well.

“While we are still overcoming hurdles mostly related to ensuring that we are using new solutions such as RPM to the best of our ability, said Rosen, “the benefits of such tools far outweigh the challenges.”

The COVID-19 pandemic upended the way California delivers health care. Health care systems completely restructured their services to keep both their patients and employees safe. Federal policymakers acted quickly to expand coverage and payment for virtual care. The California Department of Health Care Services also dismantled previous barriers to telehealth and began requiring Medi-Cal managed care plans to pay providers for telephone and video visits at the same rate as in-person visits.

As a result, many California health care providers rapidly pivoted from in-person visits to virtual patient visits. For these organizations, this shift has been transformational, as they’ve adopted new technology, overhauled workflows, and redefined team member roles.

The Connected Care Accelerator —  a partnership between CCI and the California Health Care Foundation, with additional funding from the Blueshield of California Foundation — selected 40 safety net healthcare centers in California to participate in a 12-month program that provided funding, methods, tools and hands-on technical assistance to enhance virtual care initiatives. In a series of case studies, CCI showcases the most sustainable and impactful solutions and shares advice for fellow safety net clinics who want to integrate similar virtual care strategies.



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