Health Care Coordination and Remote Patient Monitoring Using Artificial Intelligence System

The Vendor is required to provide support Artificial Intelligence (AI)-enabled remote patient monitoring and virtual care models that extend care into home and community settings.
- These models are designed to improve health outcomes, reduce avoidable hospital utilization, and expand access to care in rural communities, while addressing workforce shortages and supporting safe, sustainable care delivery.
- Eligible organizations to implement AI-enabled remote patient monitoring (RPM) and care management models that improve access, strengthen care quality, and reduce costs for rural residents.
- Program Goals and Expected Outcomes
• Improve health outcomes for rural residents with or at risk of chronic and complex conditions, including hypertension, diabetes, depression, substance use disorders, and Chronic Obstructive Pulmonary Disease (COPD).
• Expand access to care through technology-enabled delivery models, including AI-powered RPM, virtual care, and home- and community-based services that help address rural workforce shortages.
• Reduce avoidable utilization, including preventable emergency department (ED) visits, avoidable hospitalizations, and 30-day readmissions.
• Strengthen care coordination and continuity of care through integrated clinical triage workflows, automated patient navigation, early-warning AI alerts, and seamless incorporation of RPM data into EHR workflows.
• Advance statewide interoperability by ensuring bidirectional exchange of data with state HIE.
• Support patient independence, safety, and engagement through the use of assistive and enabling technologies, where appropriate.
• Promote long-term sustainability by supporting adoption of Medicaid and commercial reimbursement pathways and strengthening the financial stability of rural providers through strategic technology investments.
- Care Models Supporting Ongoing Monitoring and Clinical Decision-Making
• Tracking key health indicators (e.g., blood pressure, weight, oxygen levels, glucose) to inform clinical decisions
• Using AI to identify meaningful changes in patient status and support prioritization of care
• Enabling timely follow-up through outreach, care plan adjustments, or virtual care
- Care Models for High-Need and Complex Populations
• Individuals with chronic conditions requiring ongoing management
• Patients at elevated risk of hospitalization or complications
• Individuals with developmental disabilities or other needs requiring additional support for daily living, communication, or care access
- Care Models that Strengthen Patient Engagement and Home-Based Care
• Supporting patients in following care plans and managing conditions at home
• Providing tools and resources that encourage engagement and communication with care teams
• Enabling caregivers to play a more active role in coordination and support
- Integration into Clinical Workflows
• Patient information is incorporated into EHRs to support continuity of care
• Insights are presented in a way that is actionable and aligned with provider workflows
• Care teams are supported in prioritizing and responding to patient needs efficiently
- Deploying sustainable, AI-enabled technology solutions in rural care settings.