Examining a Remote Patient Monitoring Program with Medicaid Patients Managing Diabetes and Hypertension: A Qualitative Study

Abstract

Consistent and effective self-management of Diabetes Mellitus (DM) and hypertension (HTN) remains a challenge for many patients, who face barriers such as limited healthcare access, poor diet, and insufficient exercise. Remote patient monitoring (RPM) allows patients with specific chronic conditions to monitor and report their healthcare data through a digital platform. However, there is limited research on Medicaid patients’ experiences using RPM. The purpose of this study was to describe patients’ experiences managing their DM and HTN using RPM. Semi-structured longitudinal interviews were conducted with seventeen participants enrolled in a RPM program. Thematic analysis of interviews revealed three main themes: program enrollment experiences, utilizing RPM, and factors impacting disease management. Patients reported that their overall experience utilizing RPM was positive, and RPM helped to overcome challenges such as unhealthy eating and infrequent monitoring of their blood sugars and/or blood pressures. Results suggest that RPM programs could be an effective strategy for supporting the management of DM and HTN. Limitations include small sample size and variability in Medicaid program design by states in U.S.

Clinical Trials.gov

NCT: NCT05555095

https://clinicaltrials.gov/study/NCT05555095

Introduction

The prevalence of diabetes mellitus (DM) and hypertension (HTN), which often co-occur, is on the rise. ¹ In the United States, 69% of Americans diagnosed with diabetes also have a diagnosis of hypertension. ² Research has shown that self-management is vital to care; however, adhering to complex treatment regimens, monitoring schedules, and dietary restrictions can be burdensome. ³ These challenges may be even more pronounced for individuals enrolled in Medicaid, who often encounter additional barriers (eg, financial, transportation, and inconsistent health insurance coverage) to accessing care and managing their health. ⁴

Multiple studies have demonstrated that remote patient monitoring (RPM) programs, a form of telehealth that collects and transmits patient data via connected devices, can effectively reduce blood pressure ⁵ and hemoglobin A1c levels. ⁶ Additionally, telehealth more generally can increase access to care^7,8 and potentially alleviate barriers such as limited transportation, especially for vulnerable and low socioeconomic and rural patient populations. ⁹ However, research on patient use and experience of telehealth programs has primarily focused on those with private insurance, Medicare, and international patients.^3,10,11 Thus, limited information is available about the telehealth experiences of Medicaid patients, ¹² who typically have lower incomes and different health profiles than those with private insurance. ¹³ Therefore, it is essential to understand Medicaid patients’ experiences, as they may utilize and perceive telehealth services differently than other populations, potentially impacting the effectiveness of these programs.

Methods

This descriptive qualitative study aimed to better understand Medicaid patients’ experiences managing their Diabetes Mellitus (DM) and hypertension (HTN using a remote patient monitoring (RPM) program by interviewing them shortly after enrollment, at 3 months, and then again at 6–9 months to gather information on participants’ short-, medium-, and long-term experiences managing their conditions through the program.

Setting

In June 2022, a not-for-profit healthcare system in Illinois launched an RPM program designed for Medicaid patients with chronic diseases (eg, DM/HTN). Communication primarily occurs via automated standard message service (SMS) texts and voice calls, tailored to patient preferences. Patients have 24/7 access to nurses and advanced practice providers through a centralized call center for symptom-related concerns. The vendor software facilitates interaction, allowing patients to report health data for their specific condition. Upon enrollment, patients receive blood pressure cuffs (if needed) and are prompted to report their blood pressure and blood sugar at least twice weekly via text message. The software triggers alerts for nurses to evaluate concerns and provide further assessments as needed. During the initial and scheduled visits, nurses assist patients by reviewing their medications and adherence to the treatment plan. They also help establish patient goals and provide education tailored to the program and specific patient needs. For a more detailed description of the program and its development see Cooling et al. ¹⁴

Participant Recruitment

Participants had to be at least 18 years old, diagnosed with DM or HTN, insured by Medicaid, and enrolled in the RPM program, participants who were non-English speaking were not included in the study. Patients were selected through purposeful sampling from those enrolled in the RPM program, received recruitment text messages on their phones, and those interested were invited to participate in three interviews over nine months. Oral consent was obtained prior to the first interview, and participants received $20 for each interview. This research study was approved by the University of Illinois College of Medicine Peoria IRB-1.

Data Collection

Based on the literature review and programmatic needs, unique semi-structured interview guides were created for the three interviews and refined as new themes emerged. (Supplemental Table 1) Three research team members (MD, SJ, CK) conducted interviews via phone or Microsoft Teams from January 2024 through May 2025. The same researcher conducted all interviews with each participant across baseline, 3-month, and 6–9 month time points to ensure consistency. The interviews lasted between 20 and 60 min.

Analysis

Interviews were recorded, transcribed, and uploaded to NVivo 14, a qualitative data analysis program. Data analysis was guided by a constructivist approach, recognizing that participants’ experiences are socially constructed and co-interpreted with researchers. Interviews were analyzed for overall themes, without comparison longitudinally using Braun and Clarke's ¹⁵ reflective thematic analysis approach. To enhance reliability, the research team met in person to code the first five transcripts and to develop the initial code set. The team (anthropology and nursing backgrounds) discussed how their perspectives shaped interpretations. MD and SJ then coded the remaining transcripts. Afterwards, team members reviewed all codes and themes until consensus was achieved, engaging in reflexive dialogue to ensure that analytic decisions were transparent and grounded in participant data.

Results

In total, 187 participants were sent recruitment texts. Thirty-nine participants responded, and 17 answered the follow-up call and participated in at least one interview (Table 1). The analysis of the transcripts uncovered three main themes: 1) experiences related to program enrollment (positive and negative); 2) use of remote patient monitoring. eg, text messaging, monitoring practices, and technology usage; and 3) factors affecting disease management, such as mental health and prescription access. This section highlights the most illustrative quotes, while Table 2 presents more detailed participant perspectives.

Table 1.

Descriptive Characteristics of Remote Patient Population.

Characteristics		Number	Percent
Insurance
	Medicaid	17	100%
Subprogram
	Hypertension	9	52.94%
	Diabetes	8	47.06%
Number of interviews completeda
	1 interview	17
	2 interviews	6
	3 interviews	3
Demographics
Age
	≤ 40	2	11.76%
	41–50	7	41.18%
	51-60	3	17.65%
	61-70	2	11.76%
	≥ 70	3	17.65%
Gender
	Male	4	23.53%
	Female	12	70.59%
	Other	1	5.88%
RUCA Category b
	Metropolitan	12	70.59%
	Non-Metropolitan	5	29.41%

Note. ^aOverall, patients remained enrolled in the RPM program for an average of 6-7 months. Participants who did not complete interviews 2 or 3 either did not answer the phone or stopped participating in the program.

^bRUCA = rural-urban commuting area codes.

Table 2.

Qualitative Findings of Patient Experience Managing Their Diabetes/Hypertension Using Remote Patient Monitoring.

Theme	Codes	Exemplar Quote
Enrollment	Enrollment experience	“I think somebody called me. I think they called me, and they were just like, hey, do you want to do this? I'm like, Yeah, sure, why not” (P1, Interview 1)
	Enrollment rationale	“Basically, I think for peace of mind and to be able to send in my vitals and stuff and know that if there was something wrong, you know, there's somebody right there that could help” (P2, Interview 1)
Factors impacting disease management	Behavior	“I've altered the way I eat a lot. I'm eating much healthier and smaller meals more regularly. And I've been doing really well because of it” (P3, Interview 1)
	Health literacy/knowledge	“I don't really think about it [monitoring] because I don't even know I got hypertension. They just said I did, and I take the pills. I don't even know what it feels like to be sick from hypertension” (P4, Interview 1)
	Mental health	“With my mental health. I need people to monitor me. Otherwise, I will languish. I'm not productive if I don't have anybody to tell my accomplishments” (P5, Interview 2)
	Social determinants of health	“I didn't go to a doctor for many years because I couldn't afford too” (P6, Interview 2) “Just everyday living- cuz’ with all the different insurance stuff and things like that. It's very hard to, uh, sometimes get certain medications that I need” (P7, Interview 1) “My ex-wife caused my diabetes and high blood pressure, and I got my 15-year-old son. I got him full-time right now” (P8, Interview 1)
	Patient goals	“Better health, better vitals whether it be, you know, eating better, eating less, you know, more exercise and stuff like that” (P9, Interview 1)
	Monitoring	“I don't check my blood sugar very often. I know I should. I don't. I just forget first thing in the morning and A lot of times I get home in the afternoon; I'm just wore out and I don't feel like climbing the stairs just to check my blood sugar. But having that support and someone reminding me to take my blood sugar would be okay I guess” (P10, Interview 1)
Using remote patient monitoring	Patient-reported health outcomes	“I went from went from 300 [weight], I think I was about 350 and I'm down to 240 right now. So, I still got a way to go, but a lot better than what I was” (P11, Interview 2)
	Perceptions of the program	“I feel that it [the program] actually makes me want to take [my blood sugar] and keep track better. Because for a while there I was just like, okay, my blood sugars, okay. I'm good. I'm not feeling the effects. Now…. I’m saying, okay, I'm checking my blood sugar. I'm a little bit high. I got to take a little bit of insulin before I eat my meal. And it makes me want to go on to do it [take insulin]. I should say it reminds me to go and make sure that I've got my insulin taken every morning. And I'm checking and making sure that I go and take my insulin. Fast-acting insulin before meals. Bring some numbers down before I go and have the meal” (P12, Interview 2)
	Communication with program staff	“I really appreciate that it was the [blinded] team that had called me and recommended the change for the blood pressure medication” (P13, Interview 3)
	Suggestions for improvement	“There were times where I wish it [reminders] was every other day like Monday, Wednesday, Friday. Instead of just the two days a week” (P14, Interview 3)

Note. P = patient.

Program Enrollment

Most participants indicated that the enrollment process was easy. However, some did not know why they were asked to enroll or were unaware they had opted to join the program. One participant noted, “I don't remember doing it. I must have just seen it and thought, oh, that might be handy.” (P15). Some participants stated that they enrolled in the program because they needed extra support in managing their diabetes and/or hypertension. Others thought that having someone to report their blood sugar and blood pressure readings to would improve their understanding of their conditions.

Utilizing RPM

Many participants enjoyed the RPM program and appreciated its reminders to check their blood sugar and blood pressure levels. They felt that without these reminders they would be less likely to complete these important tasks or maintain their self-care routines. One participant mentioned, “I fell off the boat for a while and stopped testing for a while. And, um, basically, this program made me start testing again. It's all been going pretty smooth.” (P16). However, some also wanted more interaction with program staff, more frequent monitoring reminders, improved care coordination with their primary care provider, and the ability to provide detailed responses instead of just “yes” or “no” for blood sugar or blood pressure entries.

Participants also noted that they increased the frequency of self-monitoring, felt more in control of their health, reported weight loss, and improved blood pressure and blood glucose levels. All the participants reported positive interactions with the program staff during virtual visits. Some participants indicated that in the future, the program should offer different resources tailored to other health conditions, such as mental health issues, or patient referrals to external resources.

Factors of Disease Management

Participants discussed challenges that they faced, such as access to healthcare, mental health issues, finances, and family dynamics, which made managing their DM and HTN more difficult. For instance, some participants mentioned their struggles with maintaining consistent insurance coverage and accessing medical supplies and healthy food. As one participant explained, “I should probably do it [test] a little more, but I’m conserving supplies right now because I don't have any insurance till next month.” (P17). Still others discussed how divorces, work schedules, and other responsibilities made it hard to do all the things necessary to manage their care. These challenges were amplified in some cases due to a lack of understanding about their disease, treatment, or management strategies.

Discussion

Similar to other synchronous and asynchronous telehealth programs with different patient populations,^10,16,17 participants liked the RPM program and felt it helped them manage their disease. Experiences with program enrollment varied, with most participants describing it as easy, and others were uncertain about why they were initially contacted. Other researchers ¹⁸ have indicated that effective communication is essential for digital health to enhance patient engagement and adherence to treatment plans. Thus, more transparent communication regarding the reason for enrollment calls could improve the initial experience, particularly during the enrollment process, since most communication is text-based. Nevertheless, participants reported that text reminders increased the frequency of checking their blood pressure and sugars, which has also been reported in other studies. ¹⁹

What sets these patients’ experiences apart from other, more affluent patient groups is that they use telehealth to help manage their disease within the context of the well-documented challenges many Medicaid enrollees face. Barriers such as limited food access and insurance gaps highlight how social drivers of health complicate DM/HTN management, unlike affluent groups where lifestyle and population density are greater challenges. ²⁰ Interestingly, despite concerns that internet connectivity may pose a risk to rural populations, ²¹ reliable internet was not a requirement for this program, because it used text and phone based reporting unlike other telehealth program that use continuous monitoring methods thus eliminating the internet as a potential barrier in this study. Moreover, participants highlighted how the program's reminders helped them manage their DM and HTN better.

As others have suggested, ²² our study shows that patients reported the benefits of telehealth for managing their chronic conditions, with greater flexibility, consistent reminders, and convenience, all of which enhance their experience and engagement in self-monitoring their blood sugars and/or blood pressures. These findings illustrate that RPM can be a strategy to provide care for patients with limited healthcare access and financial challenges, such as those on Medicaid. However, special attention should be given to ensuring that telehealth programs are designed to address SDoH needs and provide additional support for services that address other health issues, such as mental health, access to food, and medical supplies. One strategy would be to align RPM with value-based care initiatives and Medicaid payment reforms which could provide a sustainable pathway for expanding and implementation programs by rewarding improvements in outcomes and patient engagement. RPM programs can also be adapted to support other vulnerable populations by tailoring technology and delivery models to their specific barriers. For example, using text- or phone-based reporting can expand access in rural areas where internet access is limited, while embedding RPM in Federally Qualified Health Centers (FQHCs) may improve continuity of care for uninsured patients. In addition, partnering with local organizations to provide food, medication, and supplies alongside digital monitoring could further strengthen engagement and disease management. ²³

Limitations

Findings are limited by the small sample of Medicaid patients from one state, female overrepresentation, and potential response bias. Non-participation is also notable, as 22 of 39 who expressed interest did not complete interviews. Given variation in Medicaid programs and the complexity of chronic disease management, these findings may not represent experiences in Illinois or other states. Nevertheless, the study offers insights into an underrepresented group and highlights how RPM programs may be adapted to better meet Medicaid and other vulnerable populations’ needs.

Conclusions

This study suggests that RPM could be an effective strategy for helping Medicaid patients manage diabetes and hypertension. Moreover, these findings highlight the importance of strengthening onboarding to ensure patients understand program goals and rationale, providing opportunities for communication with program staff, and designing literacy-sensitive communication strategies. Embedding RPM in safety-net settings and aligning community resources along with value-based care reforms could enhance effectiveness and sustainability. Additionally, integrating program development with Medicaid payment reforms could support sustainability and incentivize programs to address the social drivers of health. Future research should examine the impact of different RPM programs on patients’ experiences with Medicaid insurance across different cultural groups and geographic regions.