June 26, 2025
Part of our 25th anniversary blog series celebrating 25 years of member-led transformation in community care
As we mark a quarter century of progress with our national member network and partners, we are thrilled to highlight our members’ inspiring stories. Together, they have achieved operational and financial wellness, supported clinician well-being, and enhanced clinical quality through OCHIN’s integrated knowledge solutions, fueled by the insights and imagination of our national member network.
We invite you to join us in recognizing their collective impact, extraordinary leadership, and groundbreaking efforts to transform the health and well-being of their patients, providers, and communities.
Asian Health Services in Oakland, California, enhanced clinical quality by finding a way to keep patients with hypertension connected to care—especially when visiting the clinic was a challenge during the COVID-19 pandemic.
As a member of the OCHIN network for six years, they implemented an innovative, physician-led telehealth and remote monitoring program, providing iPhones and Bluetooth-enabled blood pressure cuffs to over 1,300 patients. The result: 78% patient re-engagement, improved health outcomes and significantly expanded access to care.
Julia Liou, chief executive officer at Asian Health Services, shared insights into this pioneering program, discussing how they broke down barriers to consistent monitoring and set a new standard of care using OCHIN’s integrated knowledge solutions.
How did you select the focus of your program to enhance clinical quality, and why was transformation in this area so important?
It goes back to when we were at the height of the pandemic. Our staff were all exhausted, and our patients were really scared to come in. On top of that, our community and patients were being targeted and blamed for COVID.
But even in those really hard times, our staff was thinking about how we could better care for our patients, especially those who were not coming into the clinic. This led to the creation of our remote patient monitoring program.
We focused on hypertension because a lot of our patients who were high utilizers of our clinic had high blood pressure. Giving our patients a blood pressure monitor enabled them to take down the stats so we could get the information to the care team. That way, we could make sure we were still caring for and supporting them in between visits.
We selected a cohort, which mostly consisted of older patients with complex health conditions as well as limited English proficiency and technology use. This was a challenging population to work with, but we were amazed by the outcomes.
What OCHIN network resources did you use to support your initiative and why?
In 2020, we received funding from OCHIN to buy 50 cellular-enabled blood pressure cuffs and 50 iPhones, which helped us build the program. Many of our patients didn’t have internet access and faced challenges with digital literacy. The cellular-enabled devices allowed patients to check their blood pressure without needing internet access, breaking down barriers to consistent monitoring.
We then used the funding from OCHIN to get two more foundation grants, which allowed us to hire digital health advocates who were crucial in helping our patients navigate the technology. Our providers were initially spending a lot of time helping patients log on and use the equipment. With the digital health advocates, patients received the support they needed without using up their clinic visit time.
We also partnered with OCHIN to create an interface so that we could bring the remote patient monitoring data into our EHR. This interface dashboard allowed us to keep track of our patients and do follow-ups, especially for those who might need a little extra help.
What were the outcomes of your program, and how did they enhance patient well-being?
The program saw amazing results:
We’ve been able to serve 1,600 patients, and within a couple of months, we saw that 80% of them had controlled or improved their blood pressure.
This was a significant achievement, especially considering the challenging population we were working with. But I feel that this work goes even beyond the numbers.
We had patients who came to us and said, “I feel like I’m more connected to our doctors and nurses through this program.” And our providers said, “I feel like I actually have some tools to be able to impact the critical part of someone’s health between visits.”
We found that this idea, about continuous care extending beyond our four clinical walls, was working. Because we all know that a 15-minute exam room visit is really very rare to change a life in such a short amount of time.
I also want to share a patient story. There’s a woman who told us, “Before this, I didn’t really understand what was happening inside my body. Now, I see the numbers, I know what helps and what hurts, and I feel like someone is paying attention.” And I think that’s what it’s all about. It’s about empowering our patients and community members to take control of their health, helping to break down the barriers they’re facing, and ensuring they don’t feel alone in this process.
How will you build on this progress? Where are you headed next?
We’re really excited because we’ve seen such amazing results that we’re expanding the program to support patients with congestive heart failure and continuous glucose monitoring. We have also figured out how to sustain the program without grants through reimbursements.
But it’s not just about the numbers; it’s also about how our patients can be empowered to take control of their own health, and how innovation can be deeply human.
This work couldn’t have happened without the leadership and tireless work of our chief innovation officer, Dr. George Lee, and his team.
OCHIN has also been an incredible partner to us. Their investment and grant for our remote patient monitoring program were transformational. They also believe in health centers and support us in pushing forward on a trajectory of transformation.
It really is through partnership that we can build something impactful and meaningful, together.
Visit OCHIN’s website to explore more member stories and learn about the transformative impact of the OCHIN network over the past 25 years.
