When healthcare professionals work toward a shared vision of a healthier community, amazing things can happen. 

In addition to the main hospital campus, Parkland’s many facilities throughout the county provide healthcare services for the community. Among these are the sixteen Community Oriented Primary Care (COPC) health centers which are spearheading a program that’s paving the way for a new approach to chronic disease management. 

COPC Nurse Directors Juanita Chism and Mary Lam worked closely with COPC Medical Director Dr. Kassa to bring Parkland’s Remote Patient Monitoring (RPM) Program to fruition. What started as a graduate school project idea became a robust program changing the lives of patients dealing with high-risk hypertension. 

Every aspect of the RPM Program was created with intention and care, including the patient area of focus. Parkland’s Community Health Needs Assessment (CHNA) helped inform this choice. 

The CHNA report identifies the main health issues that Dallas County faces as Parkland’s way to determine where the greatest need exists in the community. Dr. Kassa’s work as one of the team leaders that created the 2022 CHNA report inspired the RPM Program’s focus on high-risk hypertension, which remains one of the eight main areas of greatest need in Dallas County. Hypertension can quickly devolve into heart disease, and research has shown that African American and Hispanic communities are disproportionately affected by this condition with the highest rates of heart disease-related death. 

“I really wanted a high-risk group to focus on patients who are frequent emergency department visitors for hypertension, so we created the CHMA high-risk hypertension registry,” Dr. Kassa explains.  

Two nurse navigators were brought on the team to sort through the extensive registry. These nurses identify eligible patients and schedule them for in-person onboarding sessions. During the initial assessment, patients are taught how to operate their at-home blood pressure monitoring devices. Parkland Health Foundation helped fund the purchase of the Bluetooth-enabled devices, which allow patients to consistently remain in communication with their healthcare team. Nurse navigators can easily access blood pressure information as patients input their readings into an online charting system directly from the device. 

“Nurse navigators do close follow up and education,” Dr. Kassa explains. With the proper equipment, patients can communicate more effectively with nurses to maximize the program’s benefits and their health.   

One look at the data reveals the undeniable success of the RPM program. 95.2% of patients who completed the program showed an improvement in their blood pressure. Patients also had significantly lower rates of admission into the emergency department after going through the program. 

However, beyond the numerical improvement in patient outcomes, the program has profoundly shaped how patients engage with healthcare systems at large. Patients who do not typically have access to this type of care were initially uneasy about working with medical professionals and felt that managing their condition at home was a daunting task. 

“We wanted to build a trusting and lasting relationship early on with [patients] knowing that they already have additional barriers to care with everything going on in their lives,” Mary says. “We really want them to know that we are their advocates in terms of being able to coach and give them advice that is evidence based so that they can make their decisions and be more informed.”   

“For a program like this, we offer that type of platform for patients to be able to talk to us and feel comfortable sharing some of these challenges that they’re facing, some of the fears that they may have, whatever it may be,” Juanita adds. 

The structure of the program allows patients to proactively instill healthy lifestyle changes in the long term and be more involved in their own medical decisions through frequent, personal dialogues with providers. After completing the program, patients are more empowered to take back control of their health. 

Dr. Kassa agrees that “empowering patients is the goal of the program” so that patients may go forward with more confidence and awareness about their health. 

Philanthropic contributions played a huge role in getting the program off the ground. 

“We are so grateful to the Foundation because that is how we established the Remote Patient Monitoring Program,” Dr. Kassa explains, as the first 100 blood pressure devices were funded by Parkland Health Foundation.  

There are plans to expand the impact of the RPM Program to include other conditions, but more resources are needed to explore these possibilities. 

“In order to do diabetes and asthma, we would need additional funding,” Mary explains. These initiatives would require specialized devices such as a weighing scale for diabetes patients which can connect directly to the online charting system, and a pulse oximeter device for asthma patients. 

A proposal for the Care Companion plan as an extension to the RPM Program to focus on moderate-risk hypertension patients is already underway. 

Mary, Juanita, and Dr. Kassa are excited for the future of the RPM program, and the Foundation looks forward to supporting their efforts to advance the quality of care for all Dallas County residents.