Partnership Success: DiaSante | CCN Health’s

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Program highlights:
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• 90+% patient compliance in taking >= 16 days of device readings for two consecutive years.  Industry average 70%.
  
  • CPT 99454 - $43/patient/month national average
• Patient calls were conducted with 100% of patients engaged in monthly phone calls
  
  • CPT 99457 $48/patient/month national average
• 10+% of patients received greater than 40 minutes of engagement.
  
  • CPT 99458 $40/patient/month  national average.

DiaSante is a technology-based healthcare solutions provider collaborating with provider organizations to successfully implement and scale chronic disease management programs such as Remote Patient Monitoring (RPM), Chronic Care Management (CCM), and Principle Care Management (PCM). 

DiaSante has partnered with CCN Health’s chronic disease management platform due to it being highly customizable, easy to use, and supporting multiple chronic disease management programs all in one place.

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The Challenge

The Manette Clinic is a primary care clinic with locations in Bremerton and Poulsbo, Washington - relatively remote and underserved areas. Like many private clinics, Manette is competing with larger health systems when it comes to recruiting and retaining such talent to  deliver their personalized healthcare model including insurance and direct primary care (DPC) memberships.

Tanya Spoon, DNP, ARNP, FNP-BC. recognized how expanding their services to include RPM & CCM would lead to better patient satisfaction, clinical outcomes, and drive new net revenue  to enable their team to increase patient touchpoints,  recruit more top notch providers and expand their reach in their community.

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“Tanya Spoon, DNP, ARNP, FNP-BC. recognized how expanding their services to include RPM & CCM would lead to better patient satisfaction, clinical outcomes, and drive new net revenue”

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The Solution

The clinical and financial benefits of successful RPM & CCM programs are large, but like any service they also require work and resources.  Partnering with DiaSante allows Manette Clinic to quickly implement these programs while minimizing staffing and other start-up costs.

DiaSante’s team

1. Partners with provider’s Business Office to identify eligible patients based on qualifying chronic conditions and insurance.
2. Reaches out to eligible patients to educate them on the benefits of RPM and CCM, gathers patient consents, and enrolls them in the programs.
3. Provides care coordination as an extension of the clinic under the ordering physician.
4. Makes monthly patient engagement phone calls and chart reviews to communicate care plan adjustments between patient and clinical staff.
5. Reviews and escalates any changes in condition based on patient-specific threshold-based alerting and trending data.

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“ Partnering with DiaSante allows Manette Clinic to quickly implement these programs while minimizing staffing and other start-up costs.”

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Tenovi FDA-cleared Blood Pressure Monitor

DiaSante supports many devices, taking into account patient population, goals, and location. For this program, DiaSante deployed Tenovi’s FDA-cleared Blood Pressure Monitors paired with their proprietary 4G Cellular Gateway.

1. FDA-cleared with industry-leading accuracy
2. Multi-carrier SIM, antenna tuned to the USA, and Wi-Fi fallback plan.
3. Premium Cuff with 3 sizes: 16-36 cm, 22-45 cm, 40-52 cm
4. Tenovi Cellular Gateway has a proprietary non-obtrusive visual reminder system to increase adherence to taking 16 or more days of data per month.

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Charm Health EHR Integration

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CCN Health is an approved technology partner with Charm Health.  All blood pressure and heart rate measurements are automatically documented in Charm Health patient charts. Monthly PDF summaries are pushed as clinical documents and stored in patient charts.

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This seamless flow of data enables DiaSante to handle daily RPM tasks in CCN Health, while Manette’s clinical team has immediate access to the data right in their EHR.

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Results

Quantitative Results

• 90+% patient compliance in taking >= 16 days of device readings for two consecutive years.  Industry average 70%.
  
  • CPT 99457 - $43/patient/month national average
• 100% of patients engaged in monthly phone calls.
  
  • CPT 99457 $48/patient/month national average
• 10+% of patients received greater than 40 minutes of engagement.
  
  • CPT 99458 $40/patient/month  national average.

Qualitative Results

• Early detection of A-fib, hypertension, and hypotension due to dehydration.
• Trending data combined with threshold-based alerts leading to accurate medication adjustments.