Southcoast Health slashes CHF and COPD readmissions rates with telehealth and RPM

Photo: Jim Feen

Southcoast Health System, based in New Bedford, Massachusetts, has employed a multi-pronged approach to solving different issues through telemedicine.


While early goals involved keeping care accessible and safe during the pandemic, staff have worked to focus on continuous improvement and adding programs that would build for long-term value in care delivery.

“One of the first telemedicine solutions we utilized involved tele-triage to reduce PPE demands in our emergency departments and ensure patients were directed to the appropriate level of care,” recalled Jim Feen, senior vice president and CIO at Southcoast Health System. “Patients seen this way showed a variety of symptoms and this method helped decide which cases may be more appropriate for an urgent care setting or perhaps even a referral back to primary care.

“There were automations built within our existing Microsoft Teams platform that allowed for seamless tele-triage screenings to be initiated by triage nurses in our ED,” he continued. “We have other use-case scenarios.”


More innovative use cases involved looking at the increasing demands for psychiatric/behavioral health services up against increasingly taxed provider resources. These fluctuations and increases in needs for behavioral health services both at the peak of the pandemic and to date are well documented nationally. The Southcoast region has been no exception to these challenges.

“Both the selection and upcoming implementation of the Neuroflow platform at Southcoast Health is a strategic effort to leverage digital technology to help our behavioral health providers and staff remotely manage the growing and currently underserved behavioral health needs across Southcoast patients,” Feen explained.

“We view Neuroflow as an enabling technology to risk stratify patients in real time who need care interventions based on patient interaction with various assessments that are offered within this platform,” he continued.

Starting this fall, the platform will enable the behavioral health providers and staff to remotely identify and take targeted action to avoid behavioral health crises before they happen through Neuroflow’s digital feedback loop and intervention support tools, he added.

“Our primary goal with this tool is enabling broader surveillance with patients using the technology to remotely identify patients who need targeted behavioral care in the moment, without requiring traditional face-to-face visits and/or telehealth visits if determined clinically appropriate by the patient’s care team,” Feen said.

“While the goal is to manage more patients remotely by targeting patients with highest risk factors who need intervention the most, a secondary goal of the tool is to avoid unnecessary ED visits and/or acute care for patients who are successfully managed before the onset of an acute event,” he added.

In an entirely different space, a building block toward the health system’s hospital-at-home effort is its remote patient monitoring capability with colleagues in the Southcoast Visiting Nurse Association.

“While hospital-at-home is not a formalized program at Southcoast quite yet, we leveraged an FCC telehealth grant to expand remote patient monitoring devices including tablets with integrated stethoscopes, blood pressure monitors and pulse oximeters to expand telemedicine capabilities of our VNA,” Feen said.

“These devices are used to target patients with certain chronic diseases such as CHF or COPD and allow for interventions to occur when risk factors are observed by a team of VNA nurses who analyze trends for each patient captured through the RPM,” he added.


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Since Southcoast Health System’s telehealth efforts have a number of different use cases, there are a variety of different roles involved.

“A key learning for us in our journey over the last 28 months that will carry into the future is there is no ‘easy button’ or one-size-fits-all approach when it comes to successfully implementing or integrating a telehealth solution into the care delivery approach,” Feen said.

“For Teams, while tele-triage is a standalone feature to streamline the triage and telehealth process for our ED groups, it became acceptable to simplify a solution to keep it highly efficient and not have the process integrated within our Epic EHR system,” Feen noted.

“Yet that same approach would be very different when considering the integration needs of a Neuroflow or RPM use case, which has much deeper clinical integration needs for the staff who are trying to manage complex populations through the tools,” he continued. “Verifying workflow assumptions and requirements is key, and getting staff involved early who are ‘at the controls’ in these care delivery processes is an absolute must-do.”


For Southcoast patients who use the remote patient monitoring services, staff have achieved a hospital readmission rate that is 50% lower than the other patients on VNA services. For patients with CHF or COPD who would typically have a hospital readmission rate of 20%, this rate falls to between 5-10% for those patients who are covered by RPM services.

“In May of this year alone, we had 175 patients on RPM and the readmission rate back to the hospital was down to 5%,” said Patty Buiocchi, senior vice president of the Southcoast Health Visiting Nurse Association and Health-At-Home.


Southcoast Health System was awarded an FCC telehealth program grant of $1,000,000 for laptops, mobile devices and remote patient monitoring equipment to expand the hospital’s telehealth capabilities and provide quality care services to patients at home.

“Our hope is the FCC award funds will help us solidify the foundation of telehealth at Southcoast making care more accessible and efficient for our community,” Feen said. “These advancements will allow us to provide more timely and accessible care and over the longer term help achieve goals toward lowering total cost of care by reducing unnecessary ED visits or acute admissions/readmissions.

“It also will help with balancing provider utilization in the face of extreme patient demand and resource constraint in the case of the behavioral health services use case,” he concluded.

Twitter: @SiwickiHealthIT
Email the writer: [email protected]
Healthcare IT News is a HIMSS Media publication.

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