FirstHealth of the Carolinas Case Study

FirstHealth Launches Care at Home Program with Telehealth and Remote Patient Monitoring



Serving communities across North Carolina, FirstHealth of the Carolinas is comprised of four hospitals, primary care clinics, specialist practices, convenient care clinics, home health, hospice and palliative care, and a philanthropic foundation.

In 2015, FirstHealth partnered with Health Recovery Solutions (HRS) to launch a telehealth and remote patient monitoring (RPM) pilot program for high-risk patients, reducing hospital readmissions by 53% over six months and saving payers $1.9 million

The health system developed its own Complex Care Management Model (CCM) and launched the pilot program within it’s own Medicare Advantage plan to address the rising costs of chronic care patients. The program included telehealth software to track patients, a home health visit within 48 hours of a hospital discharge, a clinical assessment and medication reconciliation.

Due to the success of the pilot program, FirstHealth continued to offer telehealth and RPM services for chronic care patients. 


In 2020, FirstHealth faced a new challenge. As COVID-19 cases rose across North Carolina—peaking in January 2021 with nearly 12,000 new cases recorded in one day—FirstHealth faced several challenges to staffing, resources, and community spread.

FirstHealth launched the COVID Care at Home (CCAH) program focused primarily on addressing the main challenges of bed availability and controlling ED surges. In addition, the CCAH program sought to:

  • Prevent community spread through the rapid identification of COVID-positive patients and provide monitoring free of charge.
  • Decrease length of stay and increase hospital bed capacity by evaluating patient risk based on PRIEST Score, O2 saturation, gestalt assessment, and breathing, among other factors.
  • Reduce ED visits through monitoring and early community intervention.
  • Protect healthcare providers by offering telehealth consultations, maximizing PPE.


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The COVID Care at Home program required comprehensive collaboration across FirstHealth providers, departments, and organizations. Prior to launching the CCAH program, FirstHealth developed and shared detailed educational materials to support clinician buy-in and patient engagement, including a COVID-19 Disposition Tool, Oxygen Tip Sheet, CCAH Nursing Workflow, and COVID-19 Plan of Care guidelines.

Telehealth and RPM Services Provided by FirstHealth Included:

Medical Phone Call

Telehealth consultations offered through virtual visits or phone calls to assess patient status and determine the need for additional services such as antibody infusion, oxygen, or home health.

Package Tracking

A partnership with an oxygen vendor to allow for rapid turnaround of oxygen deliveries and expand hours of availability. In turn, this partnership provided faster access to medical providers in case of changes in the patients condition that required expedient interventions.

Magnifying Glass with Chart

Biometric monitoring to identify exacerbations in patients’ health status and prevent potential ED visits and hospital readmissions.

Case Study

Daily survey and teach-back quizzes enabled FirstHealth clinicians to closely monitor symptoms and provided additional education regarding COVID-19 symptoms and vaccinations, when applicable.

Pill Bottle

Medication reconciliation, antibody infusions, oxygen support provided to patients identified through consultations and vital sign monitoring. Patient education and coaching provided to offer additional support.

Unplanned ED Visits

Daily Patient Adherence


The COVID Care at Home program proved critical to FirstHealth of the Carolina’s overarching response to the COVID-19 pandemic. The CCAH program allowed FirstHealth to discharge patients from emergency department—avoiding a hospital admission while providing a safe net throughout recovery—while increasing ED throughput.

In addition, FirstHealth was able to avoid canceling elective procedures during COVID-19 surges, an outcome many healthcare organization were unable to avoid, because of the hospital beds, PPE, and essential staffing resources made available due to the CCAH program.

Patients enrolled in the CCAH program, received telehealth and RPM services for an average of 10 days after being discharged from the hospital. While enrolled on the telehealth program, patients were asked to record their vital signs and respond to symptoms surveys. Across the nearly 200 patients monitored, the CCAH program achieved a daily adherence rate of 73%. In addition, the program successful reduced ED utilization, with only 5 unplanned ED visits occurring throughout the year-long program.

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