Remote Patient Monitoring (RPM), Chronic Care Management (CCM) and Transitions of Care (TOC)

Overview:
Through collaboration between the Virginia Department of Health (VDH), the Virginia Pharmacists Association (VPhA), Care Connections Rx (CCRx), ClearRxM, and CPESN Virginia Pharmacies, this initiative leverages Remote Patient Monitoring (RPM), Chronic Care Management (CCM), and structured transitions-of-care (TOC) programs to improve patient outcomes across Virginia.

Program Highlights:

  • Pharmacists provide RPM, CCM, and TOC services
  • Patients receive ongoing monitoring, education, and follow-up through local CPESN pharmacies.
  • Community pharmacists monitor patients remotely using connected devices for blood pressure, glucose, weight, etc., enabling early intervention and closer medication management.
  • Pharmacists collaborate directly with primary care providers to improve medication adherence and disease control.
  • Documented outcomes include improved blood pressure and A1c control among enrolled patients.

Collaboration & Impact:

  • Expansion of pharmacist-led chronic disease management services across Virginia.
  • Strengthened partnerships between community pharmacies and primary care teams.
  • Supported by the Virginia Healthy Heart Ambassador Program and VDH’s Chronic Disease Prevention and Management Programs.
  • Community pharmacists monitor patients remotely using connected devices for blood pressure, glucose, weight, etc., enabling early intervention and closer medication management.
  • Patients receive ongoing monitoring, education, and follow-up through CPESN pharmacies and clinic teams, reducing gaps in care and improving adherence.
  • Focus on rural populations and historically underserved communities, aligning with state public-health priorities.

Transitions of Care:

Overview:

A dedicated transitions-of-care track: At discharge from hospital, patients were enrolled in the Bridge & Link program via Clinch Valley Medical Center. This program demonstrated a reduction in avoidable readmissions from 11.8% to 7.8% in its initial phase. American Hospital Association+1

Collaboration & Impact:

  • Strengthened hospital-community pharmacy linkage for chronic disease management and transitions of care.
  • Integration of pharmacists with transition workflows to ensure continuity post-discharge and proactive management of chronic conditions.
  • Medication issues (cost, complexity, access, transition from hospital to home) are among the highest risk factors for readmissions; having pharmacists embedded in the transition of care team allowed early interception of these issues.
  • Their role bridged hospital, home, and pharmacy settings — enabling coordination that might otherwise be fragmented in a rural setting.
  • By engaging on the ground (home visits) and collaborating with both community pharmacists and physicians, they helped ensure discharge instructions, medications, and home environment were aligned — improving continuity of care.
  • The tangible outcomes (reduced readmissions, decreased prescription drug costs for a patient) illustrate that the pharmacist interventions were not peripheral but instrumental.
  • Support from the VDH Chronic Disease Prevention & Management Programs and regional agency partnerships.

Chronic Care Management:

Evaluation of a Chronic Care Management Model for Improving Efficiency and Fiscal Sustainability by Margaret A. Kadree et al.

Study Overview

  • Objective: To test a care-team model for high-risk Medicare patients with uncontrolled type 2 diabetes or hypertension, assessing whether an expanded team (provider + nurse + community health worker + pharmacist) could improve clinical outcomes, reduce provider workload, and approach fiscal sustainability.
  • Design & Setting: Conducted January to October 2022 in an ambulatory (outpatient) setting; convenience sample of 134 Medicare patients with uncontrolled chronic conditions.
  • Intervention: Four-month enhanced chronic care management model where the multidisciplinary team provided proactive monitoring, care planning, medication/therapy oversight, and coordination.

 Key Findings

  • Significant improvements: Patients achieved statistically significant better control of type 2 diabetes (P < .01) and blood pressure (P < .001) during the intervention period.
  • Reduced provider workload: The model showed a decrease in direct provider (physician/NP) time burdens, suggesting task-shifting to team members may free up physician capacity.
  • Financial sustainability indicator: The Medicare reimbursement rate achieved was 85.5% (i.e., captured 85.5% of program cost via reimbursement) in the four-month period, indicating a stronger fiscal outlook for the model.

Implications

  • For practitioners: Implementing a team-based CCM model with pharmacists and health-workers can improve chronic disease outcomes and may approach fiscal viability under Medicare reimbursement.
  • For health systems: The model suggests shifting tasks from physicians to other team members can relieve provider burden and still deliver measurable clinical improvements.
  • For policy: Demonstrates that enhanced CCM models may be both clinically effective and financially promising, supporting further investment in team-based care management infrastructure.

Publications & Resources:

Last Updated: January 19, 2026