Staying healthy encompasses more than just visiting your doctor – many factors play a role outside of the clinical context. Everything from transportation access to food security to financial stability can significantly affect how people maintain their well-being. And factors like these become even more important for patients who have to meticulously manage chronic or complex conditions that demand ongoing care routines and resources. 

So how can providers continue to support their most at-risk patients outside of hospital walls? 

Remote patient monitoring (RPM) can empower care teams to understand and engage specific patient groups, including individuals with chronic diseases, seniors, cancer patients, newborns, and more.  

Let’s explore its benefits for patients, providers, and payers, how it aligns with value-based care, and the ways in which remote monitoring can support population health management (PHM). 

What Is Population Health Management?

Population health management is a system of care designed to improve the health of specific patient segments. By breaking down the larger population into smaller subgroups, providers can more efficiently gather data, analyze trends, and treat patient segments with targeted services. The goal of doing so is to support better patient health outcomes. 

Data plays a critical role in managing population health. Healthcare organizations collect information from multiple sources — from the medical chart and laboratory results to claims data and beyond — to paint a bigger picture of a subpopulation. They then analyze this data to understand the greatest care needs of specific segments. Data can also fuel predictive modeling to stratify risk and identify patterns of change in risk distribution across each subsection. 

Ultimately, this information gives providers more insight into the highest priority needs of their patients, the most appropriate type of care to provide them, and even the points at which they may need to intervene to address illness or help prevent future conditions. 

The Benefits of Population Health Management 

PHM’s focus on identifying and optimizing the treatment of specific patient segments has a variety of benefits for everyone involved in the care continuum, from patients to providers and payers. 


PHM is designed to deliver the right care to the right patient at the right time, and when a patient falls within a detailed dataset of a subpopulation, providers can arrive at the right treatment options faster and better tailor the treatment plan to the individual patient’s needs. For patients, this results in a highly personalized care journey. 


When working with improved insights into patient trends, providers can make more informed care decisions. This can lead to improved outcomes and strengthen the patient-provider relationship. Patients may feel more ownership over — and more committed to — their treatment goals as a result, driving better engagement and overall care effectiveness. 


With predictive risk models and more data on each subpopulation, unnecessary care interventions can be avoided, readmissions can be reduced, and the possibility of developing comorbidities or exacerbating illnesses can be lowered. These factors can drive lower per capita costs and reduce overall expenses while improving reimbursement from institutions like the Centers for Medicare and Medicaid Services (CMS). 

How It’s Tied to Value-Based Care 

PHM is an extension of value-based care, a care model wherein providers are reimbursed based on the health outcomes of their patients rather than the number of services they deliver, as in the fee-for-service model. 

As defined by the CMS, value-based care aims to support better care for individuals, better health for populations, and lower costs. It helps incentivize providers to focus on the quality of care — rather than the quantity of services delivered — and puts the patient at the center. 

According to a case study in Academic Medicine, this framework was introduced in 2008. After a slow start, it’s gaining adoption across care models, with population health improvement as a central tenet. PHM is helping support this novel payment model and has grown sharply in utilization. 

One factor fueling the adoption of PHM is its flexibility. PHM solutions can be as extensive or as minimal as needed, allowing it to adapt to various budgets and workflows, no matter how complex. This allows PHM to be an effective and powerful tool in elevating health outcomes across specific segments — raising the overall health of all populations and reinforcing value-based care goals.

The Role of Remote Patient Monitoring in PHM

PHM requires extensive data to be successful. This is where remote monitoring of patients comes in. RPM comprises a system of tools and technologies to track and record patient conditions. Remote monitoring devices can provide detailed patient data in real time, as well as the analytic tools providers need to drive strategic considerations and better-informed decisions. 

Here’s how remote monitoring can support five notable subpopulations: 

  • Patients with chronic diseases: To qualify for chronic care management, a patient must have at least two chronic conditions, which can greatly complicate treatment. Chronic diseases can present elusive symptoms, but with RPM, providers can continuously monitor patient vital signs and other physiological data outside of an office setting. This can help patients better treat their illnesses and address their symptoms, leading to more effective chronic care management and fewer escalations. 

  • Seniors: Aging adults are at a higher risk of being affected by chronic disease, post-acute infection syndrome, and injuries, so the ability to monitor their vital signs continuously is key to senior care management. RPM can enable senior patients to return to the comfort of their homes or heal in alternative care settings while still allowing providers to track their conditions. This can help patients feel at ease and give them a fast and simple way to communicate with their physicians at a moment’s notice. In turn, providers can monitor these patients while simultaneously completing additional tasks, and lower key operational costs without diminishing senior care quality. 

Providers can monitor these patients while simultaneously completing additional tasks, and lower key operational costs without diminishing senior care quality. 

  • Newborns: Like seniors, newborns have a higher risk of infection in hospital settings, including in neonatal intensive care units. RPM can empower neonatal specialists to better monitor patients, communicate with families, and provide specialized care remotely, both increasing patient safety and extending specialized staff resources. 
  • Rural residents and marginalized communities: RPM is a crucial tool for providing equitable access to care in populations where multiple barriers exist, such as lack of onsite clinical options, transportation, and/or connection to technology. It further provides time and cost savings for both patients and providers and helps improve health outcomes in these populations.  

In short, remote monitoring solutions can offer simple, scalable, and affordable ways to support both population health management and value-based care models with their focus on delivering powerful data capabilities and ability to seamlessly integrate with a variety of care programs. 

Looking to learn more about or get started using RPM as a tool for population health management? Contact CareSimple today and discover how we can help.