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Charleston Area Medical Center’s Patient Education-Fueled Readmissions Breakthrough

July 15, 2017
by Mark Hagland
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CAMC’s Beverly Thornton, R.N. explains her health system’s success in leveraging patient education to reduce readmissions

Charleston Area Medical Center (CAMC), a 956-bed academic medical center in Charleston, West Virginia, has been able to leverage interactive patient engagement and education technology to improve patient outcomes—specifically to reduce readmissions for causes related to chronic illnesses. The four-hospital system in West Virginia reversed a trend of rising readmissions. CAMC leaders have reduced their readmissions for congestive heart failure (CHF) by more than 22 percent, and for chronic obstructive pulmonary disease (COPD) by almost 30 percent in early 2016 compared to the previous year. Readmissions have also been reduced for pneumonia. CAMC has one of the largest heart programs in the U.S., and the only kidney transplant center in West Virginia, according to hospital executives.

In this initiative, the CAMC leaders have partnered with this success is a comprehensive strategy supported by the TIGR interactive patient engagement and education system from the Raleigh, N.C.-based TeleHealth Services.

Recently, Beverly Thornton, R.N., education division director in the Education and Research Institute at Charleston Area Medical Center, spoke with Healthcare Informatics Editor-in-Chief Mark Hagland, regarding this patient education and patient engagement initiative. Below are excerpts from that interview.

How long have you been in your current position?

I’ve been a nurse for a number of years, but I have a love and appreciation for patient and family education. That’s what drew me into this area. And so I am an advocate for this. I landed in the Education and Research Institute, working with patients and community health activities, and also with our continuing education staff and medical professionals. I’ve been doing this portion since 1995; I’ve been in nursing for 42 years.

How big a staff do you have at the Education and Research Institute?

We have a continuing education department for CME, and I have two people who do that. And I have a media department and TV studio, and graphic designers and TV producers and those kinds of folks; so  that’s about four or five staff members altogether; but they all have a wide variety of responsibilities, including running our learning management system for employees’ routine and required education for working in the hospital. Altogether, about a dozen people have some involvement in our continuing education, learning and management, processes. And we do education and training around the EMR as well.


BeverlyThornton, R.N.

And who on the team focuses on patient and family education?

That would be me. We don’t have a department, per se; we have a multidisciplinary council. Patient and family education is everyone and everywhere—it’s the responsibility of all the clinicians and everyone who touches the patient and family. We have a multidisciplinary council from all four hospitals and from all disciplines that I chair, to develop policies and procedures. There are about 35 on the council. We meet once a month. We also have ad hoc members; a lot of our physician membership is ad hoc; we will bring physicians in to speak on specific topics; it’s a two-hour meeting every month, and some online meetings as well.

How would you articulate your overall approach or strategy towards patient and family education?

I would say it’s around patient and family engagement around that education process. We can just be giving them things and hold them accountable for behavioral change. It’s a cultural thing, too, in our Appalachian state; it’s very cultural. So we have to engage the primary care provider, because our folks still listen to their primary care providers, they do what they tell them to do. So we have to engage them as a component to their care process.

And all of this is particularly important in the context of the low health status of the population, poverty and unemployment, in West Virginia, correct?

Yes, and there are additional social factors, too, including the aging of the population, and smoking.

What are the biggest gaps or areas you work on?

Access to follow-up care, making sure that that happens; and that they have the ability to get there; that they have the resources, so for example, a set of scales in their house to weigh themselves, with CHF, as well as to medications, and those kinds of things; and then the medication compliance issue. I don’t think it’s anything new or that anyone else isn’t experiencing. And then it’s the general engagement, so that they are central to making the difference—getting them to realize that they can make a difference in the outcome of their health by making lifestyle changes.

How did you achieve those strong readmission reductions for CHF and COPD in a year?

Starting at the beginning, we are a hospital that’s been working for several years on the Baldrige Awards application process. And Working in Baldrige, you are really, really challenged by process. So that means coming together in an interdisciplinary way and working on issues. So we had a multidisciplinary planning group that said, how do we work on these chronic illnesses? So we began to look at strategies. It’s not one, it’s not two, it’s five or six strong strategies that we were putting in place. And once we began to use the TIGER system, the TV telehealth system… Our culture is that we don’t just go in and tell people; TV is an important part of their lives. They use it daily and aren’t afraid of it. So that was a natural way for us to engage the patient that this a part of your care plan. You’ll watch these videos, we’ll talk about them. And you can assess how good a teacher were we in teaching them? So we evaluated what they learned, though we didn’t call it a test. So the TIGER system, as we call it, provided us that avenue for getting into the patient/family room, and letting engage.

Do CHF patients and their families readily understand the extent of the dietary and lifestyle changes they need to make?

No, they don’t get it readily. If you’re diagnosed, your brain kind of turns off, and you have to go through those stages of denial and acceptance—that’s why the follow-up is so important. When they go to our clinics, we continue to provide video education. And if they go home, can they continue to access the same programs, so they can be reinforced? And 20 years ago when I started doing some of this, I found that to own the information, you have to express it something like six different ways at six different times. So people don’t get it right away; it has to dawn on them. And I have countless stories of how that happens, and you see the lightbulb go on. And as an educator for patient advocacy, it’s great when you make the breakthrough. And they don’t’ get it every time—it’s like an 80/20 kind of thing. But our challenge was to find out what was impactful. That’s when we discovered that video and the TIGR system became one of the top five things that turned the corner for us.

How was the readmissions reduction accomplished over time?

That’s where our quality folks, our data collectors came in. We had a process by which we piloted on one unit that had 40-50 patients whom we followed. We followed them through inpatient stay and diagnosis; they were provided five strategies; they were given an education plan; they were given what’s called “teach-back.” In that methodology, you talk with the patient and evaluate their learning. Once we identified those patients and followed them to see what the 30-day and 60-day readmission rate was, and which patients were readmitted. So we developed prescriptions around a standard of care, so that every patient coming in with heart failure must receive certain types of education, including video and paper handouts. And it’s required; it’s a standardized education plan. Because hospitalization is all about consistency of process, that every patient gets something every time. So we developed that. And that’s where the difference came, and we made a movement on the HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems] scores, where patients felt they were taken care of; and those scores also went up by 10 percent.

With regard to the 22-percent reduction in CHF reductions and the nearly-30-percent COPD reductions, were those across your entire health system?

Yes, that was the entire system. And that was 2015-2016. This all happened prior to November 2017.

What should CIOs and CMIOs know about this kind of work?

I think it’s important for CIOs to know the importance of technology in the personal growth and development of healthcare education and of quality of care; and it’s not they don’t know that. I know they do. But the integration of the care components is so important, to not just get the technical piece, but how do you relate the personal connection, while still using technology?

Are you working with the physician practices directly to avert readmissions?

Oh yes, we have to; it impacts us so much. That’s the whole focus around readmissions. And we employ more and more physicians, and those physicians we  can really pull into the process, and we can make sure that the CHF patient sees their cardiologist within seven days. We’ve found that if they’re not seen by a cardiologist within seven days, their rates of readmission skyrocket. And how do we do that with non-employed physicians? So we send them to our congestive heart failure patient, to make sure they’re on track to make sure they’re seen by their cardiologist. You have to find those gaps. And that gets back to access to their physicians. Because you know, in the mountains of West Virginia, we have patients who may live 100 miles from their cardiologists. So we’re looking at telemedicine and other options, because we’re trying to make sure to make the connections.

What mechanism is involved to trigger or prompt those actions?

We make their appointments prior to their discharge. We make sure that they have an appointment prior to discharge. If they’re unable to get in within a week, they go to our clinic, and then go to their cardiologist. So that’s an important piece—you have to make sure they have that connection before they ever leave us.

And you believe that your initiative is widely replicable, correct?

Yes, it is replicable. One thing I will say that we do use is nurse navigators. These are LPNs, and we only have two of them for the whole system. What they do is that they get a report—there’s a risk stratification formula that’s used. So they’re given that list, and they have a one-on-one session with those patients while they’re still inpatient. And this isn’t new, either. It was actually brought back by one of our vice presidents from a conference he attended. Another hospital had been using RNs, but really, an LPN can do that. And they make sure the high-risk patients get the education, and they reengage with them as needed. So I wanted to mention that nurse navigator program; that’s been a key piece in that personal touch.

So it really is everything, all together—people, process, and technology—then, yes?

Absolutely. You can’t just depend on one. It’s like we have our five senses; you have to touch each one, to make it stick.


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Top Ten Tech Trends 2018: A Patient-Generated Health Data Future is Becoming a Reality

September 5, 2018
by Rajiv Leventhal, Managing Editor
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Providers are becoming more open to integrating patient-generated health data into clinical processes, but core challenges still remain

Editor’s Note: Throughout the next week, in our annual Top Ten Tech Trends package, we will share with you, our readers, stories on how we gauge the U.S. healthcare system’s forward evolution into the future.

Last fall, the Boston-based Partners HealthCare system launched a project with the aim to provide its clinicians and researchers with access to patient-generated health data (PGHD) from more than 420 consumer and clinical health devices. Working with Durham, N.C.-based vendor Validic, Partners Connected Health announced its plan to integrate PGHD into care plans and the electronic health record (EHR) throughout the Partners HealthCare network this year.

Of course, Partners HealthCare is far from the only organization working on PGHD projects across the U.S., but the initiative, along with many others, proves that patient care systems are turning more toward collecting and integrating key data from consumers that is accumulated outside of a facility’s four walls. Indeed, during the second quarter of 2018, wearables were one of the top-funded categories for digital health VC funding, according to a Mercom Capital Group report.

That said, plenty of fundamental challenges remain, even as the motivation to integrate PGHD into clinical processes increases. For one, patients must be willing to use the devices and be engaged in collecting their own data. In the Partners HealthCare/Validic project, the devices used were either ones that patients already owned and were comfortable with, or were purchased from Amazon or someplace similar. In previous PGHD initiatives, Partners HealthCare tried to get most patients to use a single device, but the results were less than ideal, recalls Kelly Santomas, R.N., senior director, Partners Connected Health, an arm of Partners HealthCare.

For this initiative, Santomas’ team particularly wanted to collect data on patients’ blood pressure and glucose levels, activity and weight. She notes that the data is being integrated into providers’ EHRs, and that incorporation has not been difficult. The challenge with this project, so far, she says, has been fighting the perception that the patient data is not valid.

For instance, Santomas offers, if a patient is taking his or her blood pressure at home, and then that recordation is sent to the EHR, some providers might see that number as invalid. “But that’s a misconception,” she asserts. “It’s interesting, because we send patients home right now, tell them to buy a blood pressure cuff, write down their levels, and email it to us. So how do we know that is valid? You are assuming patients will do the right thing and give the right information, and working within [providers’] perceptions [on that] is the biggest challenge,” she contends.

Kelly Santomas, R.N.

Brian Modena, a clinical researcher at the Scripps Translational Science Institute who has researched the effectiveness of mobile health data gathered outside the doctor’s office, also believes that integrating this information into EHRs “is easily doable.” But Modena doesn’t see this being done industry-wide and he says that’s because “healthcare is always so slow to adapt, and people are used to the old way.” The “old way,” he says, involves a nurse taking a patient’s blood pressure and handing that off to the doctor, who then gives the patient advice. “The question becomes, are doctors going to look at PGHD? And if so, how often will they use it? What type of format should you put it into so doctors can easily process it?”

To this end, Santomas believes that physicians genuinely do want to incorporate patient-generated data, but it needs to be presented in a way that makes sense and is actionable to them. “They don’t have the time to sift through [non-valuable] information. So we need to make sure we are providing the data in a format that makes sense, is actionable, and benefits the patient in the long run,” she says.

UPMC Innovating Toward a Patient-Centered Future

In 2017, the University of Pittsburgh Medical Center (UPMC) said it would be investing in Xealth, a digital health startup that offers a digital prescribing platform, allowing clinicians to prescribe patients digital educational content, disease management apps and monitoring devices.

Rasu Shrestha, M.D., chief innovation officer and executive vice president at UPMC Enterprises—the health system’s innovation hub that funds promising health tech ventures—says that one of the primary reasons for the investment was to solve what he believes is a major barrier in advancing forward with patient-generated health data: an EHR divide that exists between providers and patients.

As Shrestha sees it, on one end, clinicians spend a great deal of time in their EHRs, as that’s where they document and how they bill. “Essentially, it’s how they provide care, and these care pathways and decisions they make are all documented and contained in the EHR,” he says. But at the other end, patients don’t live in the EHR. “At best, they maybe live on their phones, and they might use apps that might be connected to mobile devices. But these apps and devices are separate and are different from the EHR, and they don’t communicate well with each other. So you have these two divides, these two worlds, that are coexisting in these two different spheres,” Shrestha says.

Rasu Shrestha, M.D.

What’s more, if patients do download a health data app, it’s likely they won’t use it very frequently, and even if they do, they might also be fitness fanatics and own Fitbits and Apple Watches, meaning there is a lot of data that is remaining in the confines of the patients, apps, and devices, and in no meaningful way is being made back to the physician’s eyeballs, explains Shrestha. “Patients might make mention of this [data] during an annual visit and maybe they even take printouts. But that’s the extent of the interaction we see today,” he adds.

Bridging that divide was a big factor in the work UPMC is doing with Xealth. Shrestha says that the two organizations are co-creating a set of capabilities that will allow for clinicians who live in their EHRs to directly prescribe apps to their patients, much like how they are prescribing medications in the EHR today.

The prescribed apps then appear on patients’ phones, and with patients’ permission, a bi-directional interface can be created between apps and devices—through the patients’ phones, to the EHR. “Data would then be consumed in a matter that the EHR could understand,” Shrestha says.  “All of the readings and the data elements would then be available to the clinical decision support systems within the EHR, or through various means into the database of the EHR itself. That is something that is noble and unique, and this needs to be a standard of care and best practice across the board,” Shrestha asserts.

And UPMC physicians are embracing the validity and quality of the data, too, he adds.  Up until as recently as a year ago, he notes, physicians were resistant to engaging patients and consumers. But what were once disconnected experiences and data that simply was overbearing for clinicians in the little amount of time they had has now become data that is easily consumable and digestible for them, Shrestha says. “I am seeing that change happen in front of my very eyes.”

What Could Apple’s Role Be?

In June, Apple introduced a Health Records API (application programming interface) for developers and researchers with the goal “to create an ecosystem of apps that use health record data to better manage medications, nutrition plans, diagnosed diseases and more.”

The Health Records feature allows patients of hundreds of hospitals and clinics to access medical information from various institutions organized into one view on their iPhone. “For the first time, consumers will be able to share medical records from multiple hospitals with their favorite trusted apps, helping them improve their overall health,” Apple officials stated at the time. And starting this fall, Apple officials say that developers building health apps can individualize experiences based on the user’s unique health history.

Shrestha, for one, says he’s excited about the way Apple is approaching things. “It’s a really good thing that there is now one place on patients’ iPhones where they can collect information that belongs to them from any health institution that they have their data in, and that they can also send data back to the hospital. That’s a big deal for patients,” he says.

But, he adds that it shouldn’t be just about the Apple ecosystem and iPhones, because “There is also a whole ecosystem of patients and consumers on Android devices and others.” So, Shrestha asks, “How do we make sure we enable a much broader view to apps that may reside across other ecosystems and allow for that bi-directional interface to happen?”

In the end, Partners Connected Health’s Santomas believes that it’s realistic to think PGHD can soon be used to improve clinical outcomes. “Ideally, I’d love to see a world where the patient can access the healthcare system virtually, on their phones and computers, and as a provider I can sit there and talk to patients, pull up their record, and pull up their PGHD so I can have a sense of what’s going on while they’re at home,” she says. “All of that works together and gives us a much more holistic view of what’s going on with the patient versus just these small episodes of when I see them only in the office. That’s my vision.”


More From Healthcare Informatics

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Connecting Expectant Moms and Others with Trusted Content—and Gaining Patient Engagement

August 31, 2018
by Mark Hagland
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Leaders at South Shore Health System in Massachusetts invest in mobile app infrastructure to increase patient engagement

Can the implementation of mobile health applications improve patient outcomes and enhance patient engagement? The leaders at South Shore Health System (SSHS) have invested in the proposition that it can. That three-hospital integrated health system, located in South Weymouth, Massachusetts, had been facing the same types of challenges that other integrated health systems have long faced, in terms of consumer health content that was not optimally presented or shared with patients and families.

So, partnering with the Raleigh, N.C.-based MobileSmith, an “app-as-a-Service” company, South Shore leaders have been able to achieve more targeted, consistent messaging and care to all obstetrical patients, regardless of practice.

Now, instead of frustrating users with irrelevant notifications or pages of unnecessary content, expectant mothers can use the app to quickly connect to everything they need to know at each stage throughout their pregnancy.

Among the results SSHS leaders have documented include the following:

  • OB-Maternity HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey scores have risen by 68 percent -- jumping SSHS from the 53rd percentile to 89th
  • The hospital’s Care Transitions ranking also improved by 40 percent (from 43rd percentile to 60th)
  • Nearly 50 percent of new moms have opted for the app over printed handouts
  • Beyond new referrals, SSHS saved $10,000-15,000 in printing costs alone last year, reducing wasted paper-based booklets still used by many OB/GYN practices
  • SSHS is about to roll out a new bariatrics app that will be used as part of their certification program

Recently, three leaders from South Shore Health System spoke with Healthcare Informatics Editor-in-Chief Mark Hagland about their initiative, and its results. Kim Dever, M.D. is the health system’s chair of obstetrics and gynecology, and president of its medical staff; Luke Poppish is executive director of obstetrical and gynecological services; and Faye Weir, Ph.D., is director of parent/child services for the organization. Below are excerpts from that interview.

Tell me about the origins of this initiative?

Kim Dever, M.D.: At South Shore Health System, patients were getting the bulk of their information through smartphones, and we thought, what better place for our information to go to them, than through the tool they use every day? So, Luke Poppish said, let’s develop an app for our pregnant patients. We wanted to get them information. So we created the South Shore Hospital Babies app… Paper information wasn’t being used or saved. And we also could save money on printing all those brochures, etc. They can time their contractions, they can register for classes. It’s really been a nice way to reach our target audience.

Luke Poppish: We also had a lot of moms coming from a variety of different private practices—five at that time—whose doctors delivered at South Shore. So, we were faced with five different ways of communicating, and sharing feedback. We were getting a lot of input that there was a lot of fragmented communication at the practices, about processes and procedures at the hospital when they would check in. So we wanted to achieve standardization of messages, of focused content, of referrals, etc.

Faye Weir, Ph.D.: It wasn’t a one-and-done. Given the vast amount of work that nurses do in terms of preparation for childbirth and delivery, breastfeeding, post-partum, etc., as Luke partnered to develop the app, we linked him into the shared governance professional practice model here at South Shore, which means that nurses are actively involved in decision-making; so Luke was able to partner with a number of the nurses doing the patient care, and collaborate. It’s been a very iterative process; the staff has been able to identify even other areas to work on, including first-year, second-year areas. So it’s been a very collaborative process.

What has the timeline been like around this initiative?

Weir: In the spring of 2016, we started investigating apps, evaluated them through the early summer, by mid-summer of 2016, we decided to go with MobileSmith—the longest period of time actually was developing and signing the contract—it was a new process for us. That was a two- or three-month process. By late October of 2016, we had a skeleton developed—with feedback from nurses, midwives, and obstetricians. And by the beginning of December, we had our first test app. We launched into the app stores by the end of December of 2016, started marketing it in February 2017. That’s when we started measuring our metrics. We circulated it once it got to the stores, to make sure we didn’t miss anything. Since March of 2017, we’ve probably gone through seven or eight iterations of the app. We’ve added content around transitions of care, breastfeeding and support for breastfeeding, modified some elements. And we’re planning to continue to produce a quarterly to biennial revision of the content, over time.

What have been the biggest challenges and learnings so far in this initiative?

Devers: The biggest has been getting the information to the providers so they could share it with their patients; that’s always a challenge. Next challenge, to get patients to sign up for it. And helping providers help get patients signed up. And then there’s the sustainability needs, once you get the initial group going.

Poppish: And I would say, feedback from the private practices. It was a little bit weird for some of the nurses who had been in practice for a long time not to have lots of pieces of paper—15 to 20 leaflets—to hand out to patients. At first, the practice managers were a little bit reticent. We haven’t yet gone 100-percent app yet. Patients who need any paper can be offered that.

Weir: It was communication, making sure the patients were aware at every contact point in the organization and in the offices, so that we could maximize communication. Having the nurses value this instead of handing out paper. And from time to time, we have to invigorate this. That involves shifting the culture from paper, to a new concept of mobile health.

Poppish: Because it’s free and there’s no protected health information—you simply enter a due date—family members would join in, extended family members would follow the pregnancy, after putting in the due date. And, around the process of taking the education out of the EHR [electronic health record] paperwork and putting it into the app, getting used to that shift—we’ve seen really good progress in that, too.

Weir: I underestimated the involvement that my entire division would want to have—pre-natal, post-natal, and then NICU, and then child development. I underestimated the scope that this particular app would take, well beyond the pregnancy period. That’s part of that ongoing adjustment that we’re making.

Devers: It is dynamic. In the past, if you printed something, you would have to change it entirely. And we found that mental health issues, substance abuse, in the post-delivery phase, those were areas we could add more information into.

And the informational content is private and it’s reliable, because it’s coming from your health system.

Weir: Yes. And as the app’s been built, these places in the app have direct links into it, and we can link them to ACOG [the American College of Obstetrics and Gynecology], or do evidence-based breastfeeding information, and so on and so forth—so the patients are landing in the right place and accessing the right sources.

Devers: And we’re tracking we’re they’re going.

Poppish: Yes, with every internal page they hit on the app, we get a monthly report from MobileSmith. And we have a lot of… And we can determine how much and what type of information to add to pages. We get monthly usage data, page viewing data, MobileSmith does the development, and we agreed we would track metrics, for improvement on a quarterly basis. We’ve been tracking HCAHPS around transitions of care and post-partum, and likelihood to recommend. We thought this would have positive impact on.

Has it had a positive impact?

Poppish: Yes.

Devers: We definitely can attribute a drop in printing to this.

What would you say to health IT leaders, to clinicians, and to other hospital and health system leaders, about all of this?

Kim: You have to look at your patient and consider them your consiumer and consider where they get their information. I love that the information they’re accessing is information that we know is evidence-based. From the clinical side, the discussion is easy; we just need IT support for this, because there are costs.

Poppish: From an IT standpoint, we’ve learned to keep it as simple as possible. Having a dynamic development platform is important; we’ve changed it many times. It’s important for it to be easy to work with. We also were getting ready to implement Epic at the same time as we were launching this. IT asked whether we needed additional resources, and we said no, we can do this. And it doesn’t have any PHI or HIPAA in it; that would have added a year or longer to its development and implement. So I think IT leaders need to balance how much information they want from patients, what they need, and what is their true goal, and then figure out how many resources you need to support your goal. It helped a lot that we were pretty hands off with them, and that was very helpful.

Is there anything you’d like to add?

Poppish: We’ve had such a great success with SSH Babies that this April, we launched an SSH Bariatrics app with a few surgeons—it helps to prep people ot qualify for bariatric surgery. And we’ve had good results with that as well. Possibly soon a post-partum depression and mental health app. Possibly a NICU app. Everybody wants to get their information in; so when do we launch a new app?

Weir: It does provide dynamic and interactive connection to content and to providers.

Devers: And people like to see the doctors, and they like to interact, too, via video tools.

 

 


Related Insights For: Patient Engagement

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PCCI Combines Predictive Modeling, Patient Engagement to Address Pediatric Asthma

August 16, 2018
by David Raths
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Over three years, effort leads to 31 percent drop in ED visits and 42 percent drop in admissions for pediatric asthma cohort
Steve Miff

The Parkland Center for Clinical Innovation (PCCI) in Dallas has spent the past three years developing and testing predictive models to identify children at risk for asthma exacerbations. Combining those models with clinical and population health interventions has led to improved outcomes, says PCCI, which is now turning its efforts to pre-term births.

This targeted population health effort was funded by Parkland Community Health Plan, the largest Medicaid plan in the Dallas area. PCCI has eight clinicians on staff, including two pediatricians by training. “They intuitively knew that for the population we are serving pediatric asthma is typically not well managed and is a high-cost condition,” said Steve Miff, president and CEO of PCCI.

A deep-dive analysis of the data for the health plan identified areas that had the largest expenditures and where there was the most variation in care and potential overutilization for services, such as emergency room visits for asthma, he said.

“We had to understand the disease itself and where these children receive care in the community.”

PCCI has built a predictive model to risk-stratify the children into different cohorts based on the likelihood that their asthma condition would exasperate over the next three months and likely require emergency department visits or hospitalizations. The model itself uses claims data, EHR data, social determinants of health information, which might include gaps in insurance coverage. “We also ingested and used data from EPA sensors in the community about air quality,” Miff said. That has been only marginally useful so far because the sensors are not specific enough to be able to attribute to an individual,” he said, “so we are working with local universities and some companies that are deploying sensors to get data on air quality that is more real-time and more specific.”

Part of the project involves being more proactive with clinicians and patients.  It sends alerts to the 21 physician practices involved before visits with these patients. Because the payer is involved, the case manager at the health plan gets a risk-stratified list of patients. The risk manager use that to focus on the very high-risk cohort, Miff said.

“We also engage directly with the children and families themselves in their home,” he said. “We enroll the very high-risk cohort into a texting program.” They receive texts multiple times per week with reminders about upcoming appointments, reminders about the need to take their medication, and ongoing education about their condition so it stays top of mind. “What is cool is that they 70 percent rated it very useful in a survey, and over a 12-month period, we saw only 15 percent attrition, which is pretty fantastic when you think about the frequency of engagements.”

Miff said that over the last three years, this has proven to be an effective way to engage individuals. “We have expanded the number of clinics and individuals involved and we have continued to refine the model.

He pointed to some key improvements: The program is saving the health plan around $6 million per year in costs for this population. “Contributing to that is that we have seen a 31 percent drop in ED visits and we have seen a 42 percent drop in in-patient admissions for the population,” he said.  Alerts embedded in clinicians’ EHRs and monthly progress reports have led to up to 50 percent improvement in asthma controller medication prescriptions and a 5 percent improvement in the asthma medication ratio.

PCCI also did a cross-market analysis to compare apples to apples with other Medicaid insurers. The overall Dallas-Fort Worth Medicaid managed care market saw ED visits decline 5 percent over the past three years in a similar population. The overall market is making progress, Miff said, but a similar cohort within Parkland Community Health Plan had a 31 percent drop.

PCCI also found that the children most actively engaged with texting had even better outcomes in terms of reduced ED utilizations.

PCCI did have a cohort of high-risk children they could not get engaged via the texting program. They designed a pilot to use Amazon Echo Alexa as a personal assistant and a group interaction to gamify this process for those individuals. The Echo is programmed to ask questions about their asthma. The children win together as a group if they participate on a regular basis and their knowledge about their condition improves. “The results are not in on that pilot in terms of how long they stay engaged,” Miff said, “but it is an interesting way to engage them in the home.”

Looking at other cohorts that are costly, have high utilization and are not favorable for patients, they chose pre-term birth as a next target. “Nine months ago, we launched a pilot to look at that population,” Miff said, “and we are rolling out a subgroup of that population looking at gestational diabetes using a similar approach and model.”

“For the sub-cohort on gestational diabetes, we need additional information if we are going to engage with them at home. It is not enough to build these models based on the most recent clinical or claims data or social determinants,” Miff said. “We need more real-time information about their condition, so we have included remote monitoring devices to extract real-time data about three things: blood pressure, blood glucose and weight so we can monitor those.” PCI is designing the predictive models that take those into account. For the general diabetic population, they are focusing on the diabetic foot ulcer population.

PCCI’s impressive results with predictive modeling and patient outreach have drawn interest from other Medicaid plans.

“We are at a point where this is ready to be tested in other environments,” Miff said. “We are in advanced discussions with two other Medicaid plans in other parts of the country, and in advanced discussions with one commercial payer with an employer population to test these models. They will have to figure out to adjust the predictive models and the work flows and the in-home outreach from a technology perspective.”

 


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