St. Mary’s Healthcare System for Children, New York’s largest provider of post-acute care to children and young adults with medical complexity, has been awarded a $928,668 grant to improve care for children who receive services at home through the implementation of remote patient monitoring program. The grant — funded by the Centers for Medicare and Medicaid Services and awarded by the New York State Department of Health — enables St. Mary’s Home Care to deploy an Interactive Voice Response (IVR) program, with the three-fold goal of reducing avoidable hospitalizations, increasing medication adherence, and increasing overall patient/family satisfaction.

The program has a three-fold goal of reducing avoidable hospitalizations, increasing medication adherence, and increasing overall patient/family satisfaction.The pilot program includes 500 patients identified as most at risk for admission or readmission to hospitals and other institutional settings. In addition to receiving traditional nursing and rehabilitation home care visits, patient caregivers receive regular automated calls from an IVR system inquiring about the child’s medication adherence, falls, emergency room visits, occurrences of major medical events, and other changes in condition. The responses to the brief 2-3 minute calls automatically generate reports, flagging responses that require immediate outreach by the telehealth nurse manager or other home care staff. The calls provide an additional opportunity to enhance communication and improve the collection of patient information, thus identifying potential areas of risk and enabling the case manager to step in with appropriate and preventive interventions. Additional expected outcomes are increased communication among clinicians, accelerated medical interventions, and improved organizational efficiencies.

The grant was awarded as part of the Balancing Incentive Program’s (BIP) Innovation Fund, which fosters community inclusion by shifting care from institutional settings to the community. St. Mary’s was among New York’s leading healthcare providers that competed for a pool of $45 million in BIP funding, as authorized by the Affordable Care Act.