Community Nurse Home Care Case Study

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Community Nurse’s Telehealth and RPM Program Reduces Hospital Readmissions and Care Costs

Community Nurse Home Care (CNHC) is an independent, non-profit healthcare agency, serving communities across Southeastern Massachusetts. CNHC’s team of skilled nurses, therapists, home health aides, and social workers coordinate with patients, families, and physicians to ensure patients receive the compressive, quality care necessary to recovery in the comfort of home.


Across the country, medical costs related to chronic diseases will continue to soar over the next decade, as the number of Americans living with one or more chronic diseases rises exponentially. According to the Partnership to Fight Chronic Disease, in the state of Massachusetts, health care expenditures for chronic disease treatment are projected to cost the state an average of $41 million per year by 2030.

Reducing care costs requires both behavioral changes on the part of patients and treatment advancements on the part of providers, including:


Improved education offered to patients, explaining how to recognize and proactively address symptoms..

Patient Engagement

Increased patient engagement in their care plans and therapies to support long term behavior change.

Medical Phone Call

Enhanced communication between patients, family caregivers, and healthcare providers.


Early identification of exacerbations to prevent unnecessary ED visits and hospitalizations.


In April 2019, Community Nurse Home Care partnered with Health Recovery Solutions to launch a telehealth and remote patient monitoring (RPM) program, targeting high-acuity patient populations. To improve patient outcomes and decrease care costs, CNHC looked to enroll patients with one or more chronic diseases and a history of hospitalization or non-compliance. Patient populations identified for the telehealth program included CHF, COPD, diabetes, and hypertension.   

Placing communication and care coordination at the center of their telehealth and RPM program, CNHC deployed a centralized model of monitoring in which a telehealth coordinator monitors patient vitals signs and symptoms, performs virtual visits, reviews educational materials, and coordinates care plan and medication changes with patients’ physicians.

A Centralized Telehealth and RPM Model Enables CNHC to Improve Patient Care and Reduce Care Costs

  • Daily biometric monitoring and risk alerts enable CNHC to identify exacerbations and address them through an in-person or virtual visit to prevent potential hospitalizations.

  • Symptom surveys provide a complete picture of patient’s health status to the telehealth coordinator.

  • Condition-specific educational videos and teach-back quizzes help patients engage in their care plan, learn about their condition(s), and prepare them to live more independently in the future.

  • Medication reminders keep patients on track and increase compliance with complicated medication regimens.

  • Patient and population-level reporting enhance communication between CNHC and referring physicians to ensure every patient receives comprehensive, quality care.

Having the ability to monitor our patients virtually while providing clinical support has been instrumental in keeping patients with chronic diseases out of the hospital.

Heidi Gonsalves, LPN, Tele Med Nurse
Community Nurse Home Care

Average Biometric Adherence Rate

Average Patient Satisfaction Rate

Lower 30-day ACH among Telehealth Patients than Non-Telehealth Patients


Since launching the program in 2019, Community Nurse Home Care has treated over 400 patients through telehealth and RPM. To evaluate the success of the telehealth and RPM program, and its impact of reducing health care utilization and care costs, CNHC evaluates several key metrics: patient adherence, patient satisfaction, and hospital readmissions.

A core goal of the telehealth and RPM program is engage patients in their care plan and increase their understanding of their condition(s), symptoms, and treatments. The telehealth program has significantly increased patient engagement, boasting an average 84% adherence rate. In addition, 93.5% of telehealth patients agree they are more involved in their care after being enrolled in the telehealth program.

Not only are telehealth patients more engaged in their care on a day-to-day basis, but over 93% of patients feel more supported by their healthcare team due to the additional monitoring and support provided by telehealth and RPM. 

Finally, CNHC has substantially reduced hospital readmissions among telehealth patients, allowing these high-risk patients to recover in the comfort of home. To provide the most accurate outcomes data, CNHC partners with Strategic Healthcare Programs (SHP), a leading performance improvement software company supporting home health benchmarking. Through the partnership with SHP, CNHC has the ability to compare readmission rates between its high-acuity, telehealth patients and its global patient population.

The Acute Care Hospitalization Scale, developed by SHP and using over 163 different risk factors, assigns patients a risk score on a scale of one to nine. Since launching the program in 2019, CNHC has utilized telehealth and RPM to target high-acuity patients with vital signs and symptom monitoring, as well as custom education and care planning. This intensive care has resulted in a significant reduction in hospital readmissions, particularly among high-risk patients with multiple comorbidities and a history of hospitalization.

Across all risk levels, CNHC telehealth patients have an average 30-day ACH rate 49% lower than non-telehealth patients. Among CNHC’s highest acuity patients with an SHP risk score of five or six, CNHC recorded a 4% 30-day ACH rate for telehealth patients—75% lower than the 30-day ACH rate for CNHC patients of the same risk level not enrolled in telehealth.