This article was originally published in AIS Health’s Radar on Medicare Advantage and was based on a panel held by The Bliss Group on February 27, 2025.
With the last of the baby boomer generation aging into Medicare by 2030, when an estimated one in five people will be over age 65, seniors will be a driving force in health care transformation. At a recent panel moderated by AIS Health, a division of MMIT, three New York-based providers discussed how technologies such as remote patient monitoring and telehealth are just the tip of iceberg when it comes to innovating patient care. Meeting the unique needs of vulnerable seniors and bypassing critical barriers to care will require a nimble and multifaceted approach, agreed the panelists during a discussion hosted by The Bliss Group, a marketing communications agency in New York City.
Deploying a blend of in-home and remote care, whether that is done telephonically or through software applications and other digital solutions, can help tackle health disparities that came to light during the COVID-19 pandemic, suggested Debra Corbett, vice president of care management solutions with VNS Health. The 130-year-old not-for-profit organization serves seniors and other vulnerable New Yorkers through behavioral health, home health, care management, hospice care and other specialized services.
Corbett leads VNS Health’s care management organization and home care practice, which contracts with Medicare Advantage insurers. VNS Health also has an insurance division, which serves more than 24,500 MA and Special Needs Plan (SNP) members, according to CMS’s recent enrollment data. In addition to delivering ongoing care management, the organization offers a short-term care management program as part of its home health agency contract that focuses on post-episodic care and avoiding rehospitalization.
During the public health emergency, VNS Health — like many other plans and providers — witnessed firsthand the impact that certain social factors such as loneliness and isolation were having on the health of older patients. Working with software developer Vitalic Health, VNS Health began offering a virtual solution to conduct proactive outreach and engage seniors in an evidence-based model of care to address their mental health needs.
The organization also deployed remote patient monitoring (RPM) to assess home health patients’ biometrics “so we can get a sense of what we’ll be doing at home, when we reach out and intervene,” said Corbett. On the health plan side, deploying RPM can also impact Star Ratings as it can be used to improve scores on the heavily weighted blood pressure control and blood glucose control measures, as well as keep readmission rates down, she added. (VNS Health’s MA plans have earned an overall Star Rating of 4.5.)
Rather than relying on one technology or another to augment care, Corbett recommended offering a “range of solutions” that recognizes seniors’ preferences and varying comfort levels. At the same time, plans and providers should make sure that applications are available in multiple languages and that the technology they’re offering can be easily accessed by either the patient or the caregiver.
Remote Monitoring Leads to Lower Readmissions
RPM can also be a critical tool in transitional care management, whether it’s helping a patient move from the hospital to a skilled nursing facility, or the SNF to the home, said Luis Cunha, who is chief strategy officer with Vis-À-Vis Health, a Brooklyn-based telehealth provider operating in 21 states. By contracting with fee-for-service Medicare, Vis-À-Vis frequently augments care for patients in SNFs when they need access to a clinician after 5 p.m., said Cunha, who participated in the panel. At the same time, telehealth enables patients to swiftly obtain any physicians’ orders they may need to connect with a home health organization or other provider once released. And compared with a typical readmission rate of 18%, the SNFs that work with Vis-À-Vis report a rate below 7%, he added.
To support at-home care, Vis-À-Vis partners with technology providers to set up RPM. But Cunha noted that such devices (e.g., blood pressure cuffs, blood glucose monitors) may not work for every patient. Questions to consider include: Will the patient be able to use the technology? And will they be able to use it the required number of times per week or month? Can it deliver actionable data? “You think that’s easy enough, but it’s really not that easy when they’re at home on their own and you’re not really watching them,” he said.
Additionally, RPM “is constantly changing and improving,” Cunha said. Things that are “state of the art” now may be obsolete in six months. About 1,800 patients currently being served by Vis-À-Vis are using some type of RPM, he added.
Virtual Care Can Fill Dementia Care Gap
In memory care, a shortage of specialists and long wait times often correlate to delayed diagnoses and care planning. Isaac Health aims to conquer those barriers by providing a virtual specialist clinic that is available in 22 states, and it partners with payers such as MA organizations and managed Medicaid, explained Julius Bruch, M.D., Ph.D., CEO of Isaac Health and another speaker on the panel. Isaac Health is also working with fee-for-service Medicare to provide care management and navigation through the new Guiding an Improved Dementia Experience (GUIDE) Model.
Through claims analysis, Isaac Health identifies plan members who may be at risk for Alzheimer’s disease and related dementias (ADRD) and conducts “proactive outreach” to get them diagnosed and established with a specialist and to provide care management to help them thrive at home. That can in turn keep them out of the hospitals and emergency departments, which can be a very scary place for dementia patients, he noted.
While technology has largely proven not to be a barrier to assisting patients, especially if they have a caregiver available to help facilitate a digital health visit, “we have had to make adaptations,” said Bruch. After initially assuming Zoom or another out-of-the-box platform would suffice for connecting with patients, Isaac Health ultimately had to build its own virtual platform to host appointments. “Now, you get a text message with a link, you click on the link, and we’re in,” said Bruch.
And in rural areas where Internet access may be a challenge, Isaac Health uses home health aides to go to patients’ homes and assess their care needs in person. “You have to make things very simple to in order to make it accessible to everyone. And it’s an ongoing process, but I think we’re making good progress.”
Bruch said Isaac Health doesn’t currently use RPM. “For us, the key is really to deploy technology for the purpose of breaking down those barriers to access while it’s not actually feeling like technology to the people receiving the care.” That means engaging providers to deliver the most effective level of care, such as “upskilling” nurse practitioners to the level of care a behavioral neurologist would deliver.
He said Isaac Health’s patients typically have a virtual provider visit once a month to stay on top of new symptoms, medical developments, issues with activities of daily living or potential issues with medication adherence. Regarding the latter, Bruch said patients can have up to 20 medications but may have no idea what they are for, not to mention they may be making cognitive function worse and can lead to readmissions. During a virtual visit, it’s not uncommon for a provider to discuss medications with the patient and make a medication change.
In addition to these more established technologies, panelists discussed the promise of predictive analytics to anticipate events like potential diagnoses and/or members’ changing needs (e.g., palliative care). They also noted that artificial intelligence can be used to communicate with members and support scheduling — with proper testing and adapting from learnings — and that AI-driven medication tracking systems and smart dispensing devices can help reduce medication errors.
By Lauren Flynn Kelly, Executive Editor of AIS Health
Photo by Kaboompics.com via Pexels
