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Boosting Equity and Engagement in Rural Texas with Remote Monitoring

Pressure was mounting at OmniPoint Health (f/k/a Chambers Health). Just 50 miles east of Houston, Texas, in the small rural town of Anahuac, the rural health system was making strides in improving its services and reach. But it still felt like it was worlds away from meeting government expectations for their patients’ hypertension scores.


“We were below most other health centers,” says Kaley Smith, the center’s Executive Director. “Around 50% of our patients were compliant. To meet our benchmarks, however, we needed to be closer to 60%.”


Smith knew that even the best-laid plans would fail to move the needle without adequate funding. So she applied for and won a grant from the Health Resources and Services Administration’s (HRSA’s) National Hypertension Control Initiative (NHCI). The NCHI was designed to connect vulnerable communities with healthcare professionals so they could co-develop plans for blood pressure control.


Today, the funds are helping the health system make that happen. But getting there has taken careful planning. First, Smith had to address the biggest challenge of all: How could she direct those dollars to build health equity and improve engagement for the underserved community that depends on OmniPoint Health?


She found the answer in remote patient monitoring (RPM).


Connecting with the Underserved

Federally Qualified Health Centers (FQHCs) like OmniPoint Health have one of the most important and difficult jobs in healthcare: bridging the many gaps that prevent underserved patients from accessing healthcare services in rural communities.


The pandemic has brought their challenge to the national stage. COVID-19 is killing rural Americans at twice the rate of urbanites, and access to care continues to shrink in underserved communities, where people tend to be older, sicker, poorer, and less likely to be vaccinated.


Traditional methods for connecting and engaging with these hard-to-reach communities were falling short at OmniPoint Health at a time when there was little room for error. Staffing was sparse throughout the nation, pandemic pressures were building, and expectations from federal funders were high as health equity earned much-needed time in the spotlight.


With a new CEO at the helm and a new name, the health system pushed for new ways to bring care to the community, including new facilities, improved technology, and deeper connections with patients.


“The transformation to OmniPoint Health is more than just a name change,” said William Kiefer, OmniPoint Health CEO. “We are providing care closer to home in rural communities so our patients can focus on treatment, not transportation. We make meaningful connections with our patients and provide personalized service to keep them coming back to get the treatments they need to stay healthy.”


Previously, the rural population in Anahuac was disengaged. Hypertension-lowering strategies failed to resonate. “We would send patients home with a log to record their blood pressure,” says Tonya Pagel, the center’s Director of Nursing. “Some people would record it, but it wasn’t reliable.”


Clinicians had a tough time making sense of the data in manual logs and it wasn’t clean enough to be included in metrics that determined the center’s quality scores.


Many other FQHCs and community health centers that received HRSA NCHI funding faced similar engagement hurdles. Some attempted to boost scores and engagement by sending patients home with devices, like blood pressure cuffs, which could simplify the mundane task of filling out logs. But the novelty of the devices wore off quickly, and the programs crumbled soon after.


Technology alone couldn’t solve the issue; the missing piece was meaningful engagement. Patients — especially diverse, rural patients who had been spurned by the healthcare system for so long — needed a dialogue with their clinicians. With many lacking adequate transportation and paid time off, patients needed to be able to share vital health information and correspond with their providers from the comfort of their homes.


OmniPoint Health needed a solution for its challenges, too. Leaders were working to implement changes that would help build better relationships with patients, provide the best possible care, improve staff efficiency, collect better insights, and become a leader in rural quality metrics.


“Our transformation includes finding efficiencies and having better tracking and systems in place to follow up with our patients to make sure they are getting the preventive treatment needed for long-term health issues,” William Kiefer, OmniPoint Health’s CEO said. “Seeking partners has played a key role in our incremental progress as a health system. OmniPoint Health leaders knew that remote patient monitoring (RPM) would bridge the gap of care, but they needed a partner who could customize and scale its service to their patient population’s unique needs. They found that partner in Carium.”


Implementing RPM and Realizing Its Results

OmniPoint Health went live with Carium in May of 2021 and quickly exceeded expectations by onboarding nearly 180 patients into the program in just over five months. Staff engaged patients during visits and Carium connected the center with prospective patients by using catered digital messaging campaigns, a process that continues to get results today.




Jennifer Webb, a registered nurse at OmniPoint Health who was hired to help run the hypertension-lowering program made possible by the HRSA funding, says care teams have already benefited from the program.


“The technology gives our clinicians a better understanding of the daily life of a patient, especially compared to what was going on before. It used to be a big mystery unless they showed up here, but now we can monitor patients regularly,” she explains.


A handful of patients have already “graduated” from the program, a phrase Webb uses with pride to describe people whose hypertension scores have improved thanks to more frequent and more meaningful interaction with their clinicians.


“It’s such a rewarding experience to see where their numbers started and where they are now. Watching them continually improve is extremely rewarding — down to levels that are deemed controlled,” Webb says.


Moving Toward Better Equity and Engagement

Without RPM technology, engaging as many patients and improving their hypertension scores would take more time than OmniPoint Health — or its patients — could afford. “If all these patients had to come into the clinic every time we wanted to talk to them, it just wouldn’t work,” Pagel says. “One of the most important features of the program is that the care team can recommend changes to a patient that can be quickly and easily implemented so they can move on with their lives.”


The hypertension program’s success has inspired the OmniPoint Health team to analyze other clinical applications of Carium’s technology.


“One of the primary focus areas of our health system is what we are calling the OmniPoint Experience,” Kiefer said. “It’s part of every service we provide whether it be in person or virtual and core to every interaction we have with our patients. When every patient feels like a VIP and feels cared for as though they are family, it makes them want to do better. We are excited to offer new and innovative ways to engage with them on a more personal level.”


Many of the patients at OmniPoint Health have comorbidities such as diabetes, obesity, congestive heart failure, or chronic obstructive pulmonary disease. Carium has shown efficacy in helping clinicians treat many of these conditions, and there is little doubt that it can do the same for the patients at OmniPoint Health.


“Our patients’ issues are not independent,” Webb says. “Everything ties together, so being able to look at more than one aspect of their health — being able to look at the patient as a whole — that’s going to lead to a lot better outcomes in the long run.”


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