The morning after her emergency room visit, Mozelle Bryant did not expect a call from her doctor’s office. Yet, when she picked up the phone, she heard the familiar voice of Eric Palos, a Friend Family Health Center patient advocate. Because of Bryant’s high blood pressure reading at the ER, her doctor requested she come in for a checkup.
In her 10 years as a Friend Family patient, this was the first time Bryant had received such a call. On October 15, 2013, she headed to the clinic in Southeast Chicago for an appointment with Dr. Geetha Govindarajan.
With a long history of high blood pressure, Bryant thought she knew what to expect that day, including the usual information about managing her condition. “I wasn’t taking my meds, not like I should,” she said. Instead, Govindarajan shared new information.
Follow-up phone calls were just one change in the clinic’s evolving approach to care. Now part of the Medical Home Network, Friend Family could offer Medicaid patients such as Bryant new options to improve their health. One service, called Remote Home Monitoring, could even help Bryant take control of her blood pressure without leaving home.
The new services were the result of a decision made six months earlier.
In May 2013, the Illinois Department of Healthcare and Family Services enlisted the Medical Home Network to improve care for 160,000 Medicaid recipients on Chicago’s South and Southwest sides. As an official care coordination entity, MHN began providing the infrastructure, tools, and training to allow health professionals to improve current services or offer new ones.
MHN also fosters first-time collaboration between local clinics and hospitals. Through software that securely transferred patient information, doctors can improve monitoring and follow-up services. This is how, for instance, Bryant’s doctor knew about her visit to the ER.
To learn more about Remote Home Monitoring, Bryant met with Friend Family’s Program Health Educator Amy Vranicar. Patients who participate in the program, Bryant learned, receive a blood pressure monitor to use at home every morning and evening. Their readings are then sent back to their primary health clinic through a secure server. The feedback, Vranicar said, would allow Bryant and the team to better track her condition, address emergencies quickly, and understand the impact of daily nutrition and exercise choices. Vranicar would call each week to check on Bryant’s health, medications, diet, and daily relaxation techniques.
After the discussion, the decision to enroll was simple. Bryant wanted results not only for herself, but also for her 16-year-old daughter Mandy.
Mom, I want you to be around when I graduate,” Mandy once told her.
After just a couple of months in the program, Bryant felt a new sense of empowerment to improve her health for herself and her daughter, as well as to fulfill her pledge to Vranicar and her doctor.
I committed to her that I would work on my diet and take my meds and since I’ve been doing that, I’ve been feeling great. I’ve been losing weight and when they gave me the blood pressure monitor, I felt obligated to take my meds and I felt like I was proving a point here. When I get up every morning, I take my blood pressure and it encourages me to know that [the reading] comes right here to the office. I feel like a child with a toy. I want [doctors] to see that I am committed. Now I feel great. My blood pressure is great. My blood pressure has been 170/99 and to get a blood pressure of 112/60—wow—it does something for me.” Mozelle Bryant
Bryant is just one of many promising cases emerging from Friend Family’s remote home monitoring program, according to Vranicar.
We started the program in May and some of the patients—most of the patients—all had crazy high blood pressure. The majority of them now are exactly where we want them to be, at the numbers or close to the numbers. They improved tremendously over six months and that’s all it was—six months.” Amy Vranicar
According to Govindarajan, the program works in part by increasing patient awareness. “They’re more cognizant about their body and more in tune to the impact of physical and mental stresses on their life,” she said.
In addition, Remoted Home Monitoring allows health care providers to better understand patients’ lives and coach them through obstacles.
Most patients are not able to visit clinics in the intervals we want them to,” Dr. Govindarajan said. “This project gives us insight into their day-to-day existence and the barriers they face.”
Friend Family is just one of 110 primary care offices—known in the MHN community as “medical homes”—offering this service to patients. The program is not only rewarding for the patients who enroll, but also for medical professionals. Leilani Hernandez, a patient advocate at Friend Family, said she feels inspired by the level of care Remote Monitoring allows her and her colleagues to provide.
Knowing there’s a program like this that exists for people who do need that help, it’s just phenomenal. I think of people, like my mother, who have diabetes, high blood pressure—who have had strokes and are in terrible health. She had no one working specifically to reach out to her to get things in order. It’s so important for people like that, who need that push, to know a person actually cares… I think it’s important that people know what impact it has. I think that’s what MHN has done for a lot of patients.” Leilani Hernandez
Six months into the Remote Home Monitoring Program, Bryant sees significant improvements in her health. “I turned my life around,” she said, citing newly reversed roles at home. “Now I’m the one encouraging my daughter to watch the sodium.”
Bryant is working with her doctor at Friend Family to slowly reduce—and hopefully one day discontinue—her medications. When asked whether she would recommend the program, she responded enthusiastically.
If there’s another person like me who needs the support, Remote Home Monitoring would help them. You know, it’s great being able to know that someone else cares about you—somebody else is reading what you’re doing. Yes, I think it’s a great program.” Mozelle Bryant
Story | © 2014 Megan Morrison | Comer Family Foundation