MaineGeneral achieves 0% heart failure readmission rate with RPM | Panda Anku

MaineGeneral Health in Augusta has had high, increasing readmission rates for congestive heart failure. In January 2020, the organization launched a remote patient monitoring pilot and partnered with provider Health Recovery Solutions to monitor CHF patients after hospital discharge.


After discharge, patients often need support to understand their symptoms and warning signs after returning home. Remote patient monitoring allows patients to monitor their blood pressure, weight, oxygen saturation, symptoms and medication intake in real time at home with a dedicated nurse actively attending to patients when needed.

During the pilot, MaineGeneral Health learned that patient monitoring and follow-up is taking more clinical time. For this reason, a full-time employee was hired to monitor the patient panel. As the program grew to more than 100 patients, the organization expanded eligibility for referrals for patients with chronic conditions or COVID-19 and hired additional clinical staff.

“When COVID-19 struck, patients avoided coming to the office whenever possible,” said Laura Mrazik, telemedicine coordinator at MaineGeneral Health. “Patients needed a mechanism to connect with their GPs for chronic or acute care needs when virtual care was appropriate.

“We shifted our priority to finding an easy-to-use solution for our outpatient practices to conduct virtual visits,” she continued. “Patients with COVID-19 symptoms have been able to remain off-site for their routine follow-up visits for chronic conditions without exposing patients or staff.”


MaineGeneral had already selected the RPM provider before COVID-19. However, the pandemic exacerbated the need, especially as patients began delaying care.

“The patients are informed in the hospital about the possibility of monitoring,” explained Mrazik. “Upon discharge, a member of the care team comes to their home and sets up the device for them – which includes a data-enabled tablet programmed only for the provider’s application, as well as a Bluetooth-connected heart rate monitor, pulse oximeter and weight scale.

“In May and June 2022, MaineGeneral achieved a 0% CMS CHF readmission rate, compared to 20% and 26.7% in the same months last year. In addition, the overall CHF readmission rate has reached 0% in four of the last nine months.

Laura Mrazik, MaineGeneral Health

“The units are programmed with disease-specific survey questions to flag high-risk symptoms and daily reminder alarms to take medication and record vital signs,” she added. “Early intervention by staff nurses has resulted in readmission avoidance through timely medication adjustments, identifying a dead pacemaker battery, determining that a patient needs to be on medication for high blood pressure, and more.”

In an effort to find video technology that was easy for patients to use, MaineGeneral eventually selected HIPAA-compliant Zoom as the video conferencing component for virtual care in outpatient facilities. The organization implemented virtual visits across all primary care, integrated behavioral health, and pediatric behavioral health service lines.

“This funding was also used to buy tablets for patients in the hospital who were unable to visit their families due to the new visitor bans,” Mrazik said. “We deployed zoom-enabled tablets to allow patients to stay in touch with family and friends during an inpatient stay.

“In an effort to solve the need to limit patient exposure and connect with patients virtually, MaineGeneral planned workflows, purchased equipment, improved processes and expanded telehealth services in remote patient monitoring and virtual outpatient visits,” she added .


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When monitoring patients remotely, recorded patient data is transmitted in real-time to a central care team. When a problem is identified, the team can provide immediate support through video conferencing with the patient, education, or consulting with the patient’s GP or specialist to determine if clinical intervention (eg, medication change) is needed.

MaineGeneral Health monitors patients for an average of 90 days before completing the program. The vast majority of patients are between 61 and 90 years old.

“The program has grown from an active caseload of 25 to monitoring 225 patients at a time,” noted Mrazik. “MaineGeneral started with 50 units just for CHF patients and progressed to a rotation of 300 units to monitor patients with chronic conditions or COVID-19.

“Care teams refer patients from an inpatient setting, home care setting, or their outpatient practice,” she continued. “We mainly monitor patients with CHF, with COPD, hypertension, pneumonia and COVID-19 as the other most commonly seen diagnoses,” she continued.

A grant from the FCC has enabled MaineGeneral to invest in staff time to expand its active patient count while maintaining the integrity of the program. The organization integrated Health Recovery Solutions with Homecare’s electronic health record system, allowing homecare workers to actively view vital signs, notes, and procedures.

“We have deployed 500 Zoom licenses across care settings, including primary care practices, integrated behavioral health practitioners, and our specialty pediatric behavioral medicine practice,” explained Mrazik. “Patients connect virtually with their care team when appropriate for chronic or acute care needs by participating in a visit scheduled through MaineGeneral’s Zoom license. We have integrated Zoom with Stratus to ensure patients have access to on-demand interpretation services during a virtual visit. “


While MaineGeneral monitors patients with chronic conditions, most patients in the program have CHF. In parallel with the program’s RPM growth, the organization standardized CHF education and post-discharge follow-up to support efforts to reduce readmissions, including granting home care managers for 30 days after discharge.

“During May and June 2022, MaineGeneral achieved a 0% CMS CHF readmission rate, compared to 20% and 26.7% in the same months last year,” reported Mrazik. “Furthermore, the overall CHF readmission rate has reached 0% in four of the last nine months.”

Because patient experience is at the forefront of the organization’s decision-making, she has seen the impact of having a high-quality clinical staff and a strong supplier relationship on a telemedicine program, she added.

“MaineGeneral’s adherence rate to taking vital signs—BP, weight, O2 saturation—has consistently remained higher than the vendor’s ledger on average,” she continued. “MaineGeneral RNs monitor the provider’s clinician portal, which stratifies patients who have already taken their vital signs based on normal or out-of-range readings and those who have not yet recorded for the day.

“The RNs call patients daily if they haven’t already made a record,” she said. “Another downstream effect of staff and technology synergies was high patient satisfaction scores. Overall, MaineGeneral’s most recent RPM satisfaction ratings show that 90% of RPM patients are satisfied or very satisfied with the impact of the program and their ability to actively participate in their health.”


MaineGeneral Health received $603,315 to equip providers with all-in-one workstations capable of video conferencing and devices to remotely monitor patients to conduct virtual visits and reduce exposure.

“We leased RPM devices, including the tablet connected to patient data, and Bluetooth-enabled peripherals like blood pressure cuffs, scales, and pulse oximeters,” explained Mrazik. “The FCC funds purchased remote patient monitoring equipment and covered the yearly license fees for 200 devices, allowing MaineGeneral to quickly expand our programs.

“We plan to continue expanding the RPM program to reach an active enumeration of 300 patients,” she continued. “MaineGeneral has been able to invest dollars in clinical staff to expand this service, setting up units in patients’ homes and monitoring and tracking patients’ vital signs as needed.”

The Zoom licenses and IT equipment for virtual visits (all-in-one desktop PCs and web cameras) expanded the telemedicine services. This FCC funding was an integral part of MaineGeneral’s expansion of a sustainable telehealth program as the organization continues to refine processes, incorporate new integrations and expand services to meet the needs of the community and care teams, she concluded.

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