Leading preventative care platform CircleLink Health is delighted to share the positive clinical results that RWJBarnabas achieved through our Medicare Chronic Care Management program, using 100% RNs.

By transitioning to CircleLink’s best-in-class preventive care platform, RWJBarnabas not only significantly expanded their in-house program with zero additional staff, but also achieved the below clinical results.

To date, the partnership has increased the number of patients serviced over 20X since launching in late January 2019.

On the clinical side, RWJBarnabas’s data analysis team compiled the below results showing significant improvements in outcomes and healthcare cost avoidance. Note: High utilizers (3+ hospital admissions or 6+ ER visits during 12-month baseline period) saw an 81% reduction in ER visits and a 100% reduction in 30-day readmissions.

Note: Data covers the 12 month period during which 220+ patients were on Chronic Care Management with CircleLink (for 6+ months) vs. same patients’ prior 12 month period. All data collection ceased in March 2020 to avoid any COVID-19 related effects.

An excerpt from their analysis reads:

Two internal studies were performed to evaluate healthcare utilization for… members  [patients on CircleLink Health’s Chronic Care Management program]. One study considered a cohort of 228 engaged members and compared the 12 months prior to enrollment to the 8-15 months after enrollment. The second study compared outcomes from engaged… members to eligible patients (Medicare beneficiaries with ≥ 2 chronic illnesses) not enrolled in the… program. Safety stories from the 3rd party vendor [CircleLink Health] have also been included.

Note: Both study review periods end March 2020.


Highlights from the studies:

– Lower healthcare expenditures1, 2
– Less inpatient visits and shorter hospital stays1, 2, including an 83% reduction from high utilizers1
– Less unplanned 30-day readmissions1, 2, including a 100% reduction from high utilizers1
– Generates monthly revenue stream1, 2
– Increased Annual Wellness visits1, 2
– Less Emergency Room visits1*, including an 81% reduction from high utilizers1
– Increased Clinic appointments2*

1 Cohort study of 228 engaged Care members
2 Population study: members compared with Medicare beneficiaries with 2 or more chronic illnesses
* indicates statistical significance


Highlights from CircleLink Health care coach interventions:

  • In July 2020, a patient set a SMART goal to reduce smoking 10 cigarettes/day to 10 cigarettes over 2 days. The care coach worked with the patient and provided smoking cessation resources from the CDC and NIH. In Dec 2020, the patient met and exceeded goal, reducing cigarette intake by 60%, smoking 4 cigarettes/day.
  • A patient with Hypertension did not have the means to monitor blood pressure. The care coach helped the patient acquire a blood pressure cuff, allowing the patient to check her blood pressure weekly. The patient also recently quit smoking and is working towards a goal of weight loss – Oct 2020
  • A patient stopped taking Eliquis as prescribed as they had issues paying the $45-$95 copay. The care coach helped the patient receive an Eliquis discount card to reduce the copay to $10 (78%+ savings) – Jun 2020
  • During a care call, a patient complained of chest tightness. The care coach facilitated a next-day telehealth visit with Dr. [redacted], who then prescribed Pepcid to treat the symptoms – May 2020

Healthcare Expenditure Avoidance:

  • $106,000+ savings impact for member cohort1, including:
    • $32,000 savings impact from 37 avoided Emergency Room visits1
    • $46,000 savings impact from 2 avoided 30-Day Readmissions1
  • $281,000+ savings impact for Care members2, including:
    • $133,000+ savings impact from 6 avoided 30-Day Readmissions2