How Hackensack Meridian Health is building chronic care that reaches patients between visits

Hackensack Meridian Health’s employed medical group delivers roughly 2.5 million visits a year across 450 care sites. Now the New Jersey-based system is setting a bold new standard for patient access and redesigning how it delivers care to meet it.

At the Health Management Academy Leadership Summit earlier this October, Dr. Daniel Varga, President of the Physician Services Division and Chief Physician Executive at Hackensack Meridian Health, joined Cadence Founder and CEO Chris Altchek to discuss how the system innovated its chronic care model to meet the access standards the system has set.

Through its partnership with Cadence, Hackensack is extending care into the homes of more than 6,000 enrolled patients, where connected devices and a clinical team help manage chronic conditions under the system’s own protocols.

Read on to see how Hackensack partnered with Cadence to reach its access goals, and what other health systems can learn from its approach to caring for patients between visits.

Extending their statewide platform

Hackensack is a rapidly growing health system, expanding from roughly 1,000 physicians in 2018 to nearly 3,000 clinicians today, with more than 450 sites of care across New Jersey.

With over half of Hackensack’s 450 sites having five or fewer exam rooms, their existing demand kept their rooms full. To figure out how to increase capacity to better meet patients, Hackensack chose Cadence to extend the capacity of the system to deliver chronic care between visits.

“Logistically, we just can’t do this on our own,” Dr. Varga said.

Remote patient monitoring, chronic care management, and tech-enabled CMS models were new territory for the system, and Cadence offered a way to build them. Dr. Varga described the Cadence program as “a new way to extend care,” and one that brought new funds rather than new cost.

Remote monitoring can handle much of the routine management of diabetes, heart failure, and hypertension; freeing up space and time for Hackensack’s clinicians to focus on seeing new patients and complex cases, while ensuring the full patient population is still receiving the highest quality care.

What builds adoption

Offering a new tool did not ensure that Hackensack’s clinicians utilized it. For Dr. Varga, adoption comes down to whether a program solves a problem for physicians – and what won physicians over was relief from the inbox. A patient message about swinging blood sugars or rising weight often ended with “why don’t you come in?” Now a Cadence clinician adjusts insulin or a diuretic under protocol, and the physician hears about the result. As Dr. Varga put it, “Not having somebody come in or call or fill their inbox solved a big problem.”

And he’s seen that smaller practices benefit too. “We actually have one-and-two-doctor practices who are big fans,” Dr. Varga said. For a practice with two providers and four exam rooms, cutting a few unnecessary walk-ins and moving a patient from four follow-ups a year to three can open room for new patients. It’s also more convenient for patients who can receive more care from home.

Results from the program in practice

At 6,000 patients, initial clinical data is promising with a 76% relative increase in patients at <130/80 goal blood pressure after 6 months, and anecdotal stories about patients staying out of the ED. Altchek shared peer-reviewed data from Mayo Clinic Proceedings: Innovations, Quality & Outcomes, showing a 27% reduction in hospital admissions, concentrated in stroke, sepsis, cardiac dysrhythmia, and heart failure, conditions with long stays. He also highlighted that patients who are admitted have shorter stays on average.

Altchek illustrated the results of the program with a recent example from a Texas health system. On a Saturday night, a patient entered a blood pressure reading of 190. Within three minutes, an AI voice agent and then a Cadence clinician called, coached the patient through taking additional medication, and asked for a recheck an hour later. When the reading came down, the patient was texted that no ED visit was needed, and a heart failure cardiology appointment was booked for Tuesday. He noted that sometimes the same monitoring might send a patient to the ED, but the real value is having a clinical team ready to assess and coordinate the right next step.

The signal from physicians

The strongest endorsement, Altchek shared, has come from physicians themselves. Three health systems signed on after their physicians joined a different system and asked how they’d been practicing without it. While anecdotal, it points to where he views the industry heading: white-label partners delivering meaningful care under shared clinical protocols and payment arrangements with payers.

The goal is “hopefully not a 20% increase in capacity, but a 100% increase in capacity.”