Transcript Panel at the Health Technology Forum

Date
April 19th, 2013 (Friday)
8:00AM-7:30PM
Location
UCSF Mission Bay Conference
Center
1675 Owens Street,
San Francisco, CA 94158
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Starting point
People are not the
sum of their disease
states
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People typically have >1 condition
Loneliness as critical risk factor
43% of 1,604 seniors
60+ reported feeling
lonely
More likely to develop or experience
decline, difficulties in:
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Activities of daily living
Upper extremity tasks
Mobility
Climbing
Associated with nearly 2x increase in risk
of death
- Archives of Internal Medicine, June 2012
We can do better …
•Medicare beneficiaries with two or more
conditions and functional limitations have the
highest costs
15%
of beneficiaries
=
32%
of Medicare costs
Individuals who are dually eligible for Medicare and
Medicaid are a key subset of this population
Using Technology to Support Care
for Individuals with Complex Needs
Lisa Mangiante, MPP, MPH
April 19, 2013
What is a “Complex” Patient?
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No single definition, similarities across populations
Medical condition(s) often complicated by psychosocial
issues
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Social isolation
Decreasing independence
Loss of familial relationships
Lack social supports
Depression (in elderly Medicare, this is most common)
Other serious mental illness (SMI)
Navigating the health system confusing & care is
fragmented, resulting in lack of engagement and nonadherence
While often many things going on that affect health, it’s
not always about number of issues, but the particular
combination
Examples of “Complex” Patients
Uninsured/Medicaid/Dual Eligible (from FUHSI)
65 % chronic medical conditions, many with 2 or 3
54% substance abuse disorders
33 % mental illness
45% homeless
Seniors w/ Medicare (from IOCP, CMHCB)
69% Congestive Heart Failure
43% Pain
32% Diabetes Mellitus
29% Depression/Psychological (under-reported)
25% Gastrointestinal
18% COPD/ Asthma
Often more than one condition
Use of Technology
Riverbend Community Mental Health Center
Purpose: Assess feasibility and effectiveness of telehealth + care
management for people with Serious Mental Illness (SMI) and
co-morbid medical illness
Major Depression
Schizophrenia or Schizoaffective Disorder
BiPolar Disorder
PTSD
Plus
Congestive Heart Failure
COPD
Diabetes
Chronic Pain
•Received remote monitoring device to help manage their
medical condition (vital signs, self management & education)
•Used almost daily (~5x per week)
Phase I Successful…
Clients with SMI were engaged relatively easily to
use the device (Health Buddy)
Paranoia or fear of the device present only in a very
small number of clients
Compliance was high - clients anthropomorphized
the device so felt less isolated and more supported
by clinical team
Positive effects on health measures, symptoms,
self-management and illness knowledge
Results were especially strong for clients with
diabetes
Clients wanted more – prompts helped with specific
techniques that helped manage symptoms
…And Led to Phase II
Purpose: Assess effectiveness of telehealth + care management for
people with SMI and psychiatric instability
2 hospital admissions or ER visit in past year, or
>10 calls to crisis line over 3 months
Several dimensions of improvement possible
psychiatric symptoms
service use
illness self management
improvements in:
High cost service use, including ER, crisis team and
hospitalizations
Psychiatric symptoms (reduced symptoms, depression, overall
severity)
Illness self-management and knowledge
Sense of well-being
Quality of life
Use of Technology
Care Management for High Cost Beneficiaries Demo
•Purpose: Assess feasibility and effectiveness of telehealth + care
management for seniors with complex illness
 Seniors with Heart Failure, Diabetes and COPD
 Often with co-morbid conditions
 High risk due to frequent hospital admissions and ED use and risk
scoring techniques
Results
 Reductions in cost and hospital use (9% - 13%) for entire
population in study
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Most dramatic in CHF, followed by COPD
Results achieved with only 1/3 actually using device
Parting Thoughts
 Both examples used technology to support the
work of a person (not standalone)
Workforce impact: technology in both examples enabled
care managers to maintain higher caseloads
MD impact: patients came to visits better prepared and
with better understanding of their conditions, so time
more productive
CMHCB results were dramatic: greater patient
engagement in actually using technology could
achieve huge outcomes – but issue not specific to
technology
Citations
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Lewin Group. Summary report of evaluation findings. Published by
the California HealthCare Foundation and The California
Endowment. 2008. www.chcf.org.
Sample Population Profile provided courtesy of Milliman based on
Medicare 5% Sample 2010, Northern California
Riverbend Example: unpublished data
Baker L, Johnson S, McCauley D, Birnbaum H. Integrated
telehealth and care management program for Medicare
beneficiaries with chronic disease linked to savings. Health Aff
(Millwood). 2011; 30(9):1689-1697.
VA Care Innovations
Transforming care delivery for improved
patient & provider experience
VA Overview
• 22 Million Veterans
• 8.75 Million VA Enrollees
• 6.2 Million Patients Treated
VA Patient Aligned Care
Team
• Patient-centered
• Ongoing relationship with a primary care
team
• Patient is full partner with team
• Whole person orientation
• Improved communication
VA Telehealth - 2012
• Provided care to 500K patients
• 1.4 million episodes of care
• 49% Rural patients
• 29% annual patient growth.
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Clinical Video
Telehealth
• 150K patients
– FY2012
• 44 clinical specialties
• Access to specialist and primary care
services
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Store-and-Forward
Telehealth
• 260K patients - FY2012
• Local acquisition of clinical Images
• Remote interpretation
• Care Areas:
• TeleRetinal Imaging
• TeleDermatology
• TelePathology.
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Home Telehealth
• 120K patients – FY2012
• Chronic care
management
• Acute care management
• Health promotion/disease
prevention.
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TeleMental Health
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217K telemental health consultations - FY 2012
76K patients
over 800,000 consultations since FY2003
Areas of focus:
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post-traumatic stress disorder
Depression
Bipolar disorder,
behavioral pain
Evidence-based psychotherapy
compensation and pension exams
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Telehealth Outcomes
• Utilization Reduction
• Bed days of care – 58%
• Hospital admissions – 38%
• Mental health care bed days of care - 56%
• Annual Savings - $2,000 per patient
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Patient Satisfaction
• Home Telehealth - 85% mean score
• Store-and-Forward Telehealth –96% mean
score
• Clinical Video Telehealth score
93% mean
VA Innovation Center
• Accelerating VA transformation
• Employee innovations
• Industry innovations
• Prize challenges
• Special projects
Strategies for Designing
Programs and Products for
Persons with Complex
Needs
Health Technology Forum
April 19, 2013 San Francisco
David Lindeman, PhD
Director
Center for Technology and Aging
www.techandaging.org
CTA Technology Demonstration Grants
2010-2012
• Medication Monitoring and Adherence
• Remote Patient Monitoring
• Technologies for Improving Post Acute Care
Transitions
• Mobile Health Solutions
 Improve efficiency of care delivery
 Improve health outcomes
 Reduce the cost of care
 Improve chronic disease management
 Increase the rate of adoption
Program Impact: Advancing the
Triple Aims
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12 programs focused on reducing 30-day readmissions
– 10 succeeded in reducing readmissions
– 5 programs achieved a reduction of 50% or more.
All 15 programs measuring patient satisfaction and engagement
with care management reported marked improvements
10 programs measured cost savings and ROI
– 9 demonstrated significant cost savings and positive ROI
Program Impact:
Demonstrating Success At Scale
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Of 22 programs, 10 have demonstrated scalability within
their organizations or externally to other organizations and
10 others are capable of being taken to scale.
Of the 10 programs taken to scale, 6 have been expanded
throughout a health care system, while 4 have been
replicated nationally.
Central Texas
Coach Tool
mHealth Diabetes Management
•HealthInsight
•Regional Health Care System and Community Clinics
Salt
Lake City, Utah – ONC Beacon Community
•SMS-based mobile program
•Improving diabetes care management and education in safety net population
Family Health Centers of San Diego
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Community Health Center and Clinic, San Diego, CA
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SMS-based mobile program
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Improving diabetes education and behavior change in Spanishspeaking safety net population
Care4Life. Reminder:
Time to check your
BEFORE meal glucose.
Reply with your
BEFORE meal glucose
reading (e.g. 125).
Care4Life | Glucose
• User canMonitoring/Education
set glucose reminders according to their doctor’s
recommendations (e.g., before breakfast daily)
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System sends glucose reminders & provides immediate feedback
User can track all glucose recordings on web portal
System sends education messages & tips
Glucose reminder
Care4Life. Reminder:
Time to check your
BEFORE meal
glucose. Reply with
your BEFORE meal
glucose reading (e.g.
125).
System feedback
Care4Life. Before meal
readings under 70 can
be dangerous. Do you
know what to do when
readings fall below
your target? Text LOW
for more info
Glucose recordings
graph on web portal
Care4Life Diabetes Texting
Program
•Lessons Learned
Patient driven: Patient engagement – the holy grail
Patient enrollment: Multiple methods to enroll patients
Provider efficiencies critical: Minimal cost to provider; no new work;
build enrollment and program operations into workflow
Patient Data: Data can motivate and empower clinicians
Challenges: Scalability; attention to patient privacy; linkage to EMRs
Telehealth and Remote Patient Monitoring
for CHF and COPD
•Sharp HealthCare
• Integrated Delivery System, San Diego, CA
• Remote patient monitoring to improve care
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Care4Life. Reminder:
Time to check your
BEFORE meal glucose.
Reply with your
BEFORE meal glucose
reading (e.g. 125).
management for patients with CHF and
COPD
Patients with multiple chronic conditions;
Medicare, Medicaid and uninsured
Sharp HealthCare Remote Patient Monitoring
Goal: Reduce 30-day readmissions by 30% from 22% to 15%
Patient Population: Underserved
(Medi-Cal, Unfunded, County Medical
Services) with primary or secondary
diagnosis of CHF or COPD
Intervention: Mobile health device
used daily to measure pulse oximetry
and functional status via yes/no
questions coupled with nurse
education and health coaching which
included at least two home visits
Lean Six Sigma Department
Sharp HealthCare RPM Program
Lessons Learned
• Program Staffing/Coordinator: Time invested in recruitment of staff
resources is time well spent
• Patient Selection and Enrollment: Program can’t help every patient;
inclusion/exclusion criteria is critical
• Assessment of Patient Environment/Resources: Lack of landlines;
lack of primary care physicians
• Organizational Support: Need for senior /executive leadership
support
mHealth Medication Adherence
•Front Porch Center for Technology Innovation and
Wellbeing
• Continuing Care Retirement Center, Los Angeles,
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Care4Life. Reminder:
Time to check your
BEFORE meal glucose.
Reply with your
BEFORE meal glucose
reading (e.g. 125).
CA
Cell phone texting
Addressing medication adherence among active,
independent older adults using a mHealth
medication texting solution
Front Porch mHealth Program
•Demonstrating Senior Medication
Adherence with Cell Phone Texting
Reminders
•Goal:
Improve medication adherence among active,
independent older adults through mHealth solution.
•Outcomes:
 Mobile alerts and monitoring led to
improved medication adherence.
 Replicable model that combines
education, training, and other
resources.
Front Porch Medication Adherence
Program
•Lessons Learned
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Utilization: Significant variation in consumer utilization
Patient engagement: Consumer champions are key; embrace
feedback & engage in dialogue
Communications: Personalize discussions to consumers and
organizations
Technology integration and interoperability: Need to consider
at outset
Plan for success: Make sure program will scale; have a Plan B
Using Technology to Support Persons
with Complex Needs
Technology is 10% of the issue
90% of technology deployment and adoption is:
Organizational leadership - Champion
Organizational familiarity with change management
Staff engagement and buy-in
Work flow processes/standardized
Patient selection, engagement, consumer champions
Technology deployment strategy
Communication and staff/patient training
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Tools and Protocols
ADOPT Toolkit
ROI of RPM Calculator Do-it-Yourself Tool
The Center for Technology and Aging
[email protected]
www.techandaging.org
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