Telehealth, Rapid Case Management Help Essex County Home Care Reduce Hospital Admissions by 60%, Bridge Geographic Divides

Jennifer Newberry, RN, BSN, Essex County Dept. of Health (Photo credit: Kim Dedam)


The home care services provided by Essex County’s Department of Health are vital to a rural community with an increasingly aging population living in geographically isolated areas.

For this population – and others served by Essex county’s home care unit – accessibility to care options is vital. Traditional skilled nursing, therapies and aide services are a lifeline. Since 2017, Essex County has added an innovative and award-winning home telehealth program to further strengthen its connectivity to patients.

This cutting-edge software supplies home care agencies with advanced remote-monitoring platforms focused on changing patient behavior to reduce readmissions and improve clinical outcomes. Loaded onto 4G tablets, the software connects to Bluetooth biometric devices – such as weight scales, pulse oximeters, blood pressure machines, stethoscopes and more – within the patient’s home.

Using this technology, patients take and track their vitals on a daily basis and respond to condition-specific survey questions. These responses are then made immediately available to Essex County’s home care clinicians and case managers who communicate with patients in real-time – via text, phone and video – to appropriately assess what kind of service is most appropriately needed, whether it’s RN support, an RN visit, or a notification to the patient’s physician. Clinicians are able to provide the kind of quick response that helps overcome travel limitations or other restrictions due to a patient’s health condition or geographic location.

“This program is necessary to stretch our health provider resources and to appropriately use them as efficiently as possible,” says Jennifer Newberry, RN, BSN, Director of Patient Services for the Essex County home care unit. “We are able to reach clients in real time and respond to patients at high-risk of ER visits or hospitalization.”

The program focuses on a diverse population of patients at high-risk who suffer from a wide-range of health conditions, sometimes many in combination, such as: atrial fibrillation, pneumonia, falls recovery and prevention, cardiac post-surgery, organ transplants, kidney disease, cirrhosis, heart attack, hypertension, bariatric care, palliative care, joint surgery, sepsis, oncology, obesity, behavioral health, and others.

Patients who suffer from multiple chronic conditions face challenges managing them independently. The telehealth case managers from Essex County provide them with support and reassurance as their health continues to improve – an ongoing level of involvement that encourages patients to become more engaged in their care and eventually learn to identify early indicators of symptoms before a condition becomes more serious.

With over 85 units placed, the program has seen a 35 percent increase in patient engagement in daily monitoring of vital signs and survey questions. Hospital admissions have fallen by 60 percent, saving approximately $200,000 through avoidance of higher-cost services; but the program has also driven cost or resource savings in other areas, including 1,000 fewer nursing visits.

Since home telehealth was adopted, Essex County is able to cost-effectively provide services to more residents in a shorter period of time, while improving quality of care and patient satisfaction. Indeed, Essex County’s home care unit has earned 5 stars out of 5 under the federal rating system for patient satisfaction on Home Health Compare, putting it in a class of only 800 agencies nationally that have achieved this benchmark.

To learn more, visit or call (518) 873-3506.

A testimonial 

Liz Rowe, a community telehealth recipient, provides the following testimonial about Essex County’s program. As someone who was previously uninsured, she was able to obtain critical health monitoring services through telehealth equipment provided at no cost by Essex County’s program.

“I remember a year ago laying on my sofa knowing I can’t go to the hospital in the middle of the night while I thought I was having a heart attack.  The ambulance and ER would be $1,000 an hour and I can’t afford that – I have no insurance.  I just stayed there petting my cat … they say petting your cat helps lower your blood pressure!

Then, I received free telehealth equipment to help me monitor my vital signs, blood sugar and weight. I lost excessive weight and was able to stop 10 medications including blood pressure and blood sugar medications.  The only medication I take now is one-half of a cholesterol pill every other day. 

I depend on telehealth now.  Sometimes I get up in the middle of the night and test my vital signs and still can’t believe how well I am doing.  I’m not going to die tonight, I tell myself!  Telehealth made everything come together and yesterday I finished signing up for insurance for the first time.  I was sobbing all the way through the process.

If you think I was riding my horse fast last summer – watch me now that I have health insurance!  I fly like the wind.”

-Liz Rowe, Community Telehealth User