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Lessons Learned from the Mississippi Delta, Tackling Chronic Disease Through Remote Monitoring Technology

June 6, 2016
by Heather Landi
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Michael Adcock, administrator for UMMC's Center for Telehealth, discusses UMMC's successful telehealth and RPM model to enhance care coordination and improve health outcomes for chronically ill patients.
The University of Mississippi Medical Center in Jackson, Miss.

Two years ago, Jackson, Miss.-based University of Mississippi Medical Center (UMMC) deployed an innovation remote patient monitoring pilot project, as part of a public-private partnership, to address the growing diabetes crisis in the state, specifically focusing on the rural, underserved population in the Mississippi Delta region. The strong results from that pilot project, called the Diabetes Telehealth Network, prompted UMMC to expand the program to serve thousands of chronically ill and underserved patients across the Southeast.

Mississippi health leaders have been faced some with grim statistics. Mississippi has the third highest diabetes prevalence in the country, with 12.9 percent of Mississippi adults living with diabetes, according to 2013 statistics. In 2012, diabetic medical expenses in Mississippi totaled $2.74 billion, according to the American Diabetes Association. And, 12.1 percent of adults In the Mississippi Delta, among the more underserved and impoverished regions in the nation, reported being diagnosed with type 2 diabetes and 293 died from complications related to the disease. As previously reported by Healthcare Informatics, at the time of the pilot project, the tiny city of Ruleville (pop. around 3,000) had one of the highest rates of diabetes in the country at 13.2 percent.

To launch the Diabetes Telehealth Network back in 2014, UMMC worked with the State of Mississippi, rural-based North Sunflower Medical Center, health IT vendor Intel-GE Care Innovations and telecommunications provider C Spire to coordinate the deployment of remote patient monitoring technology with the aim of improving health outcomes and reducing the cost of care. The pilot project enrolled 100-plus Mississippians living with diabetes and enabled those patients to have timely and consistent access to clinicians through technology in their homes. In the first six months of the project, there was a 1.7 percent average A1C reduction among the enrolled patients and also within that first six months there were zero hospitalizations and no ER visits. While the health outcome improvements are impressive, the program also resulted in cost savings of $339,000 in the first six months due to the reduction in hospital readmissions.

The only academic medical center in the state of Mississippi, UMMC has a history of creating sustainable telehealth models. The organization has been providing telehealth services, via clinician to clinician, since 2003, beginning with a tele-emergency program that connected UMMC Level 1 trauma center physicians with rural emergency rooms. UMMC established the Center for Telehealth in 2013, providing telemedicine services in 35 different specialties in 213 clinical sites across the state, according to Michael Adcock, R.N., administrator for the Center for Telehealth at UMMC. However, the Diabetes Telehealth Network was UMMC’s first program to use remote patient monitoring (RPM) technology to engage patients in their own homes with the aim of connecting the care continuum.

UMMC has extended its collaboration with lntel-GE Care Innovations and will use the vendor’s Health Harmony telehealth solutions platform to serve patients across the Southeast living with chronic conditions, such as diabetes, heart failure, COPD, asthma and hypertension. UMMC’s goal is to enroll 1,000 patients each month both in and out of state by the end of 2016. UMMC officials are anticipating that the remote management programs will save $189 million in Medicaid each year just with the diabetic population.

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Healthcare Informatics Assistant Editor Heather Landi spoke with Adcock about UMMC’s successful use of remote patient monitoring technology to improve health outcomes for patients living with chronic disease and the lessons learned from the pilot project as the organization works to expand the program.

The remote management pilot project resulted in impressive health outcome improvements and cost savings. To what would you credit the success of the initial program?

One is obviously having technology that works in places like the Mississippi Delta with patients who don’t have a lot of technical experience, so technology that’s easy to use is certainly a huge piece of how the program works successfully. The patients are given a mini iPad or tablet and peripheral devices, such as glucometer, and they have daily healthy sessions. They are asked a series of questions and they take their biometrics and its uploaded automatically, so the patients don’t have to enter data, and it’s sent to clinicians at the Center for Telehealth. The patients enrolled in the program get small daily doses of education about their disease state that allows them to absorb that knowledge and practice it and use it. The patient can also talk to a clinician or do video visits if there is something they want the clinician to see, for example, there was a patient that had a foot ulcer and, through a video visit, they were able to avoid an ER visit.

Michael Adcock, R.N.

Another factor that sets our program apart from some of the other monitoring programs that are out there is that we are not just monitoring. The purpose of our program is to engage the patient, to empower them to take care of themselves and educate them on their disease process. I’m a nurse by training and when we used to discharge patients, we would go in with a stack of papers and walk the patients through the educational information about their disease. We would then ask them if it makes sense, and the patients would nod their heads ‘yes’ and we moved on. That’s not the most effective way to educate someone. This program actually gives them education in bite-sized pieces that’s repetitive and on a level that they understand; so they learn about their disease and, most importantly, learn to manage their disease themselves. The whole goal of this program is education, engagement and empowerment to create behavioral changes. We want them to, eventually, manage their disease process without the use of technology. Evidence shows that with this type of program, the majority of the behavioral changes will happen within the first four to six months. So it’s education and immediate intervention to help empower change.

So, patient engagement, and enabling self-management, are key pieces of this program, is that correct?

I don’t want to downplay the importance of the clinicians. Their immediate intervention is huge. You can’t control chronic disease through an order, you have to work with patients and help them to understand why they need to do certain things and how it impacts them, and that’s what this program has helped to do. In Mississippi, in general, and in the Mississippi Delta specifically, there is limited access to specialists, as these are patients that don’t have the means to drive an hour or two hours to Memphis or to Jackson. With the first 100 patients within the first six months, we found nine diabetic retinopathies that wouldn’t have been found otherwise because we were able to do ophthalmology through telehealth. The technology is important, the intervention is important, the education is important; it’s everything coming together in a way that makes sense to patients and that we can understand as clinicians.

Care Innovation's Health Harmony kit for patients

What is the feedback you’ve gotten from physicians about the program?

Primary care physicians are now getting trended information. They have access to the raw data and can look at it whenever they want to, but what we send them on a routine basis is actually trended information, which is what they really want as it helps them make decisions. That information goes directly into the electronic health record so they get trend data on blood sugar levels and medication compliance, on a daily basis. We immediately contact the primary care physicians if something goes outside protocols. The feedback we’ve received so far is that the data they receive is exactly what they need. And we’re trying our best not to overload them with data, and that’s why there are protocols.

The pilot project was a public-private partnership and you are continuing to partner with Care Innovations as you expand the program. So, how did working with a technology vendor impact the implementation of the program?

I think having that expertise was very helpful, as [Care Innovations] obviously already had the platform and were involved in remote patient monitoring. We have the ability to build content from a clinical standpoint and we certainly have connectivity expertise from connecting to all these different places, but actually being able to have a format and a platform that works outside of a healthcare setting in patient’s homes is something that is extremely unique. If we didn’t have this partnership with a vendor like Care Innovations, I think, if we tried to do this ourselves, we’d still be trying to figure out how to get this technology into patients’ homes.

Is that a big challenge for healthcare providers, getting the technology into patients’ homes?

It’s certainly a challenge. There are connectivity issues, and that’s how C Spire helped. As you can imagine, Mississippi is a very rural state, and the Mississippi Delta is as rural as it gets—it’s low, flat and wide open and there’s a lot of poverty in the Delta. By working with C Spire and through this project, the connectivity in Mississippi and in the Delta has improved tremendously. So being able to get the technology into the homes and being able to have technology that is patient-centered and intuitive, I think that’s a big piece, because, from what we experienced, a lot of patients in the Mississippi Delta had very limited technical knowledge, if any. There were actually patients who graduated from this program who had never touched a device, never owned a computer, have never done anything on the Internet, and they were able to not only understand the technology but were using it daily. And now they are some of our biggest champions and are now blogging about program. Having that expertise to be able to engage the patients and make it work in patient’s homes, the impact of that was immeasurable.

The technology enables patient-clinician video visits

What were some of the lesson learned during the pilot that will help you as you expand the program?

During the pilot project, the tablet that we used with patients in the Mississippi Delta was a larger tablet, which wasn’t as portable, and that’s something that has changed, so now patients get iPad minis. And, originally with the program, with some of the devices, such as the scales or glucometers, were tethered by plugs and wires, and that gets complicated for patients. The least amount of technical things that we need the patients to do, the more likely they are to comply with the program. So now, all they have to do is push a power button on a glucometer and stick their finger.

Why did you decide to expand the program both in and out of state?

When we first started rolling this program out, I thought we would have to be out selling this program, but it’s actually coming the other way. There has been persistent interest from other hospitals and health systems, employers, health plans and physician practice groups looking to employ similar remote management programs among their respective populations. They see the tremendous cost savings and health improvements and that benefits everybody.

There is a lot of work that goes into making these programs successful. That’s why we’re having success with organizations partnering with us, as we’ve built the expertise, with 13 years in telehealth. The beauty of telehealth is that whether the patient is in Alabama or Alaska, if I can connect them through cellular technology or Wi-Fi to the Internet, I can monitor those patients anywhere.

UMMC's Center for Telehealth clinicians

So we’re currently working with independent providers and payers, in and out of state, to look at patient populations and identifying certain patients to enroll in the program. AT UMMC, through our telehealth and RPM services, we’re able to focus on diabetes and pediatric diabetes, as well as congestive heart failure, COPD and hypertension. After that we’re looking at asthma and even neonatal uses, so patients who graduate from the ICU but still need to be monitored from a weight standpoint. So there are many new and exciting things going on with the expansion of the program. I see the benefit for patients outside of Mississippi and throughout the country for programs like this. We’re going to try to address as many of the healthcare outcome needs as we can. Our program will continue to innovate as we try to find the solutions that help patients improve their health.

What is your perspective on state and federal policies regarding reimbursement for telehealth services?

If you look at how states perform nationally on telehealth reimbursement, Mississippi gets an A rating. From a state standpoint, we have great legislation and it’s nation-leading. We’re in communication with our federal delegation and the federal legislation that they’re trying to push out, the Connect for Health Act, will help us tremendously from a federal standpoint, So right now, Medicare does not pay for remote patient monitoring, and Medicare also limits where telehealth will be paid for based on geographic language. So if you’re in an urban area, Medicare doesn’t pay for telehealth, but for rural areas, they will. Access to care is not limited solely to geographic means. There are people in cities all over the country who do not have access to care and it shouldn’t be based on urban versus rural. We are currently pushing for as much help as we can get on the federal landscape.


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NCQA Moves Into the Population Health Sphere With Two New Programs

December 10, 2018
by Mark Hagland, Editor-in-Chief
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The NCQA announced on Monday that it was expanding its reach to encompass the measurement of population health management programs

The NCQA (National Committee for Quality Assurance), the Washington, D.C.-based not-for-profit organization best known for its managed health plan quality measurement work, announced on Dec. 10 that it was expanding its reach to encompass the population health movement, through two new programs. In a press release released on Monday afternoon, the NCQA announced that, “As part of its mission to improve the quality of health care, the National Committee for Quality Assurance (NCQA) is launching two new programs. Population Health Program Accreditation assesses how an organization applies population health concepts to programs for a defined population. Population Health Management Prevalidation reviews health IT solutions to determine their ability to support population health management functions.”

“The Population Health Management Programs suite moves us into greater alignment with the focus on person-centered population health management,” said Margaret E. O’Kane, NCQA’s president, in a statement in the press release. “Not only does it add value to existing quality improvement efforts, it also demonstrates an organization’s highest level of commitment to improving the quality of care that meets people’s needs.”

As the press release noted, “The Population Health Program Accreditation standards provide a framework for organizations to align with evidence-based care, become more efficient and better at managing complex needs. This helps keep individuals healthier by controlling risks and preventing unnecessary costs. The program evaluates organizations in: data integration; population assessment; population segmentation; targeted interventions; practitioner support; measurement and quality improvement.”

Further, the press release notes that organizations that apply for accreditation can “improve person-centered care… improve operational efficiency… support contracting needs… [and] provide added value.”

Meanwhile, “Population Health Management Prevalidation evaluates health IT systems and identifies functionality that supports or meets NCQA standards for population health management. Prevalidation increases a program’s value to NCQA-Accredited organizations and assures current and potential customers that health IT solutions support their goals. The program evaluates solutions on up to four areas: data integration; population assessment; segmentation; case management systems.”

 

 

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At the D.C. Department of Health Care Finance, Digging into Data Issues to Collaborate Across Healthcare

November 22, 2018
by Mark Hagland, Editor-in-Chief
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The D.C. Department of Health Care of Finance’s Kerda DeHaan shares her perspectives on data management for healthcare collaboration

Collaboration is taking place more and more across different types of healthcare entities these days—not only between hospitals and health insurers, for example, but also very much between local government entities on the one hand, and both providers (hospitals and physicians) and managed Medicaid plans, as well.

Among those government agencies moving forward to engage more fully with providers and provider organizations is the District of Columbia Department of Health Care Finance (DHCF), which is working across numerous lines in order to improve both the care management and cost profiles of care delivery for Medicaid recipients in Washington, D.C.

The work that Kerda DeHaan, a management analyst with the D.C. Department of Health Care, is helping to lead with colleagues in her area is ongoing, and involves multiple elements, including data management, project management, and health information exchange. DeHaan spoke recently with Healthcare Informatics Editor-in-Chief Mark Hagland regarding this ongoing work. Below are excerpts from that interview.

You’re involved in a number of data management-related types of work right now, correct?

Yes. Among other things, we’re in the midst of building our Medicaid data warehouse; we’ve been going through the independent validation and verification (IVV) process with CMS [the federal Centers for Medicare and Medicaid Services]. We’ve been working with HealthEC, incorporating all of our Medicaid claims data into their platform. So we are creating endless reports.

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Kerda DeHaan

We track utilization, cost, we track on the managed health plan side the capitation payments we pay them versus MLR [medical loss ratio data]; our fraud and abuse team has been making great use of it. They’ve identified $8 million in costs from beneficiaries no longer in the District of Columbia, but who’ve remained on our rolls. And for the reconciliation of our payments, we can use the data warehouse for our payments. Previously, we’d have to get a report from the MMIS [Medicaid management information system] vendor, in order to [match and verify data]. With HealthEC, we’ve got a 3D analytics platform that we’re using, and we’ve saved money in identifying the beneficiaries who should not be on the rolls, and improved the time it takes for us to process payments, and we can now more closely track MCO [managed care organization] payments—the capitation payments.

That involves a very high volume of healthcare payments, correct?

Yes. For every beneficiary, we pay the managed care organizations a certain amount of money every month to handle the care for that beneficiary. We’ve got 190,000 people covered. And the MCOs report to us what the provider payments were, on a monthly basis. Now we can track better what the MCOs are spending to pay the providers. The dashboard makes it much easier to track those payments. It’s improved our overall functioning.

We have over 250,000 between managed care and FFS. Managed care 190,000, FFS, around 60,000. We also manage the Alliance population—that’s another program that the district has for individuals who are legal non-citizen residents.

What are the underlying functional challenges in this area of data management?

Before we’d implemented the data warehouse, we had to rely on our data analysis and research division to run all the reports for us. We’d have to put in a data request and hope for results within a week. This allows anyone in the agency to run their own reports and get access to data. And they’re really backed up: they do both internal and external data reports. And so you could be waiting for a while, especially during the time of the year when we have budget questions; and anything the director might want would be their top priority.

So now, the concern is, having everyone understand what they’re seeing, and looking at the data in the same way, and standardizing what they’re meaning; before, we couldn’t even get access.

Has budget been an issue?

So far, budget has not been an issue; I know the warehouse cost more than originally anticipated; but we haven’t had any constraints so far.

What are the lessons learned so far in going through a process like this?

One big lesson was that, in the beginning, we didn’t really understand the scope of what really needed to happen. So it was underfunded initially just because there wasn’t a clear understanding of how to accomplish this project. So the first lesson would be, to do more analysis upfront, to really understand the requirements. But in a lot of cases, we feel the pressure to move ahead.

Second, you really need strong project management from the outset. There was a time when we didn’t have the appropriate resources applied to this. And, just as when you’re building a house, one thing needs to happen before another, we were trying to do too many things simultaneously at the time.

Ultimately, where is this going for your organization in the next few years?

What we’re hoping is that this would be incorporated into our health information exchange. We have a separate project for that, utilizing the claims data in our warehouse to share it with providers. We’d like to improve on that, so there’s sharing between what’s in the electronic health record, and claims. So there’s an effort to access the EHR [electronic health record] data, especially from the FQHCs [federally qualified health centers] that we work closely with, and expanding out from there. The data warehouse is quite capable of ingesting that information. Some paperwork has to be worked through, to facilitate that. And then, ultimately, helping providers see their own performance. So as we move towards more value-based arrangements—and we already have P4P with some of the MCOs, FQHCs, and nursing homes—they’ll be able to track their own performance, and see what we’re seeing, all in real time. So that’s the long-term goal.

With regard to pulling EHR information from the FQHCs, have there been some process issues involved?

Yes, absolutely. There have been quite a few process issues in general, and sometimes, it comes down to other organizations requiring us to help them procure whatever systems they might need to connect to us, which we’re not against doing, but those things take time. And then there’s the ownership piece: can we trust the data? But for the most part, especially with the FHQCs and some of our sister agencies, we’re getting to the point where everyone sees it as a win-wing, and there’s enough of a consensus in order to move forward.

What might CIOs and CMIOs think about, around all this, especially around the potential for collaboration with government agencies like yours?

Ideally, we’d like for hospitals to partner with us and our managed care organizations in solving some of these issues in healthcare, including the cost of emergency department care, and so on. That would be the biggest thing. Right now, and this is not a secret, a couple of our hospital systems in the District are hoping to hold out for better contracts with our managed care organizations, and 80 percent of our beneficiaries are served by those MCOs. So we’d like to understand that we’re trying to help folks who need care, and not focus so much on the revenues involved. We’re over 96-percent insured now in the District. So there’s probably enough to go around, so we’d love for them to move forward with us collaboratively. And we have to ponder whether we should encourage the development and participation in ACOs, including among our FQHCs. Things have to be seen as helping our beneficiaries.

What does the future of data management for population health and care management, look like to you, in the next several years?

For us in the District, the future is going to be not only a robust warehouse that includes claims information, vital records information, and EHR data, but also, more connectivity with our community partners, and forming more of a robust referral network, so that if one agency sees someone who has a problem, say, with housing, they can immediately send the referral, seamlessly through the system, to get care. We’re looking at it as very inter-connected. You can develop a pretty good snapshot, based on a variety of sources.

The social determinants of health are clearly a big element in all this; and you’re already focused on those, obviously.

Yes, we are very focused on those; we’re just very limited in terms of our access to that data. We’re working with our human services and public health agencies, to improve access. And I should mention a big initiative within the Department of Health Care Finance: we have two health home programs, one for people with serious mental illness issues, the other with chronic conditions. The Department of Behavioral Health manages the first, and the Department of Health Care Finance, my agency, DC Medicaid, manages the second. You have to have three or more chronic conditions in order to qualify.

We have partnerships with 12 providers, in those, mostly FQHCs, a few community providers, and a couple of hospital systems. We’ve been using another module from HealthEC for those programs. We need to get permission to have external users to come in; but at that point, they’d be able to capture a lot of the social determinants as well. We feel we’re a bit closer to the providers, in that sense, since they work closely with the beneficiaries. And we’ve got a technical assistance grant to help them understand how to incorporate this kind of care management into their practice, to move into a value-based planning mode. That’s a big effort. We’re just now developing our performance measures on that, to see how we’ve been doing. It’s been live for about a year. It’s called MyHealth GPS, Guiding Patients to Services. And we’re using the HealthEC Care Manager Module, which we call the Care Coordination Navigation Program; it’s a case management system. Also, we do plan to expand that to incorporate medication therapy management. We have a pharmacist on board who will be using part of that care management module to manage his side of things.

 

 


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