Last week, an early participant in the Medicare Shared Savings Program, which provides financial incentives for coordinating care of and improving outcomes of Medicare beneficiaries, went live with a telemonitoring program to keep tabs on patients with chronic diseases.

Primary Partners, a physician-owned accountable care organization (ACO) in Clermont, Fla., is contracting with New York-based AMC Health for comprehensive home telemonitoring and remote care services to help reduce complications, hospital admissions and readmissions in patients with congestive heart failure, diabetes, chronic obstructive pulmonary disease, hypertension or some other common chronic ailment.

Select patients are monitored with wireless devices that communicate via Bluetooth with a cellular portal. An algorithm determines if a reading is out of range, based on thresholds primary care physicians determine for each patient. When something is abnormal, AMC contacts the patient by phone, either with interactive voice response or a live nurse to determine if there needs to be a change in the care plan of care, AMC Health Vice President Nawaz Jadavji tells MobiHealthNews.

"As independent practices, we can tailor care plans based upon the patient need," explains Sheila Fuse, CEO of Primary Partners, which launched in April 2012 with 22 participating physicians. It now has more than 60, all in private practice.

The primary care physician makes any changes, but a nurse from AMC follows up with patients to make sure they understand their conditions, according to Jadavji. This is meant to help prevent ER visits and hospital admissions. "We are making telemedicine part of the process of care," Jadavji says.

"This is what telemedicine allows," adds Fuse.

Primary Partners is among the first group of 27 ACOs in the country under the Medicare Shared Savings Program and is paying for the telemonitoring services. Under the Medicare program, if the ACO and the physicians are able to deliver more effective care at lower cost, particularly in the area of reducing hospital readmissions, they split the money they save with CMS.

"As an ACO, we can see which patients need it," Fuse says. "We are working with our high-risk patients to address gaps in care."

AMC Health does most of the work, selecting the patients in consultation with Primary Partners physicians, enrolling and disenrolling them and installing, maintaining and uninstalling the monitoring equipment. "The ACO doesn't need to hire staff," Jadavji says.

AMC also provides the first level of monitoring. The practices are contacted if anything crosses set thresholds, such as a 2-pound weight gain for patients with CHF, according to Fuse.

The remote care is particularly helpful for keeping tabs on patients immediately after discharge to manage the transition. "Our physicians want to see patients when they get out of the hospital, ideally within three days," Fuse says. Data from the monitors also come in handy for follow-up visits. "When the patient comes in, we are able to see a much more comprehensive view of the patient," Fuse notes.

Before the program started, the ACO tried to engage patients and affiliated physicians in planning for remote monitoring by reviewing with some of them how the equipment would get shipped out, installed and used. "We have actually experienced what the patient experiences in getting the equipment installed," Fuse says.

Though it is a small organization, Primary Partners was able to get the first patients hooked up within eight weeks of signing its contract with AMC, and that includes two weeks of downtime around the holidays, Jadavji reports.

AMC Health already has reported success with its technology in a two-year test at Geisinger Health Plan in Pennsylvania. Geisinger was able to cut 30-day readmissions by 44% by providing telemonitoring to CHF patients, compared to those without access to the remote care system, according to AMC.

Jadavdi says AMC Health President and CEO Nesim Bildirici got into the healthcare business because Bildirici's father had CHF but received poor care because providers were unable to communicate the proper information in a timely manner.