In January 2013, University Hospitals Rainbow Babies & Children’s Hospital launched the Rainbow Care Connection, a pediatric accountable care organization (ACO) with a $12.7 million CMS innovation grant to support children in Northeast Ohio, a third are enrolled in Medicaid. This innovative ACO has developed several successful mobile health initiatives to drive care collaboration with patients as part of their Physician Extension Team. This blog focuses on two key mobile health initiatives; iPads Minis for children with complex chronic conditions and HealthSpotSM, a community- based telemedicine kiosk.
iPad Mini For Care Collaboration
“We wanted to help children with chronic medical conditions, especially those who have difficulty speaking or getting around. For children that cannot walk, it is challenging to get them to the office. By giving them an iPad Mini, these children are able to communicate with their care team including physicians, nurses, social workers and dieticians”, explains Dr. Richard Grossberg, Medical Director of University Hospitals Center for Comprehensive Care. “Our goal with this project is to reduce office and ER visits with this video connectivity.”
In partnership with UH’s Rainbow Care Connection, the Center for Comprehensive Care strives to pioneer innovative ways to support children with complex chronic conditions, which can often seem overwhelming from a family’s perspective. As medical care continues to grow more complex, healthcare professionals acknowledge that families may need support beyond the clinic and hospital walls in order to be successful.
Children with complex chronic conditions make up about 5% of children who access health care services but account for up to 50% of Medicaid dollars spent. “We were looking for an additional layer to outpatient care; providing families with an opportunity to manage less acute issues in the comfort of their own home”, Dr. Grossberg shares. “Launched in December 2013, we felt that video calls would be the most innovative and cost effective solution to accomplish this and have currently distributed 10 iPad mini devices to families.”
How do video calls work? A family uses their iPad mini to conduct a “video call” with the office. During their telemedicine visit, a Comprehensive Care nurse helps the family triage what is happening and can resolve or escalate care to a physician/nurse practitioner or acute care setting when needed. Additional applications of the video call are being trialed including conducting nutritional counseling and education by UH’s Comprehensive Care dietitians and therapeutic counseling completed by their Comprehensive Care social workers.
After the video call, the visit summary is documented and sent to the patient’s PCP. If a video call is escalated to include an ED or hospitalization, the UH acute care team has full electronic access to all of the video calls and assessment notes. Having the necessary tools to help guide a family though those moments when their child’s complex conditions go awry and help them overcome barriers to care is critical to helping families receive better care, achieve better health and gain a healthcare partner to share in their patient experiences.
UH’s Rainbow Care Connection aims to reduce ER costs by finding new ways to support patients who go the ER with minor medical problems.
“Since we know that 70% of Medicaid patients in the ER can be managed in a less acute setting, we were looking for an alternative to provide access to care after hours. We wanted to test offering a solution in a community setting to see if this population would feel more comfortable getting after hours care in their own neighborhood rather than from a medical setting. We felt that telemedicine would be the most cost effective solution to accomplish this”, shares Dr. Andrew Hertz, Medical Director of University Hospitals Rainbow Care Connection. We had already piloted a HealthSpotSM kiosk running in our clinic and were ready to place a kiosk into a community setting”, Dr. Hertz explains.
“We decided on the HealthSpotSM kiosk vs other telemedicine units because of the incredible patient experience provided by the HealthSpotSM unit, including diagnostic equipment and the ability to transmit real-time vital signs and physical images.” Dr. Hertz and his team thought carefully about where to place the kiosk. “We started with a zip code analysis of patients coming into our ER to select potential locations and met with Community Neighborhood Association Leaders to discuss options. We chose the Friendly Inn Settlement (community building) in Cleveland and launched the program in October 2013.”
How does the HealthSpotSM kiosk work? A patient and their family members step into the fully enclosed kiosk with a medical assistant who helps support them during their high-definition video conference visit with the doctor who may be located a few towns away. “Our doctor is on the computer screen, with video and audio connectivity to instruments (i.e. scale, blood pressure cuff, stethoscope, otoscope, thermometer, dermascope, pulse oximeter) and decides which tools to use and when by unlocking the door at the right time. It is cool when they unlock it. It is magical to see the door open and the instrument there. Our patients and their families see what physician is seeing as they use their different devices. It is a wonderful educational experience”, describes Dr. Hertz.
Patients use the HealthSpotSM kiosk to take care of minor ailments and get check-ups, as an alternative to an emergency room visit. A parent/guardian can accompany a child from age three to 18 during their visit to the UH Rainbow HealthSpotSM station during weekdays from 5:30 – 11 p.m. and weekends from 1 – 11 p.m.
Since the launch of HealthSpotSM, Dr. Hertz and his team at UH have met with over 50 patients, with problems including rashes, fever, strep throat and pink eye.
After the remote appointment with the doctor, the visit summary is documented and sent manually to the patient’s PCP. “Our physicians currently document the visit on paper and fax it to the PCP who may be outside of the UH network. Over 50% of these patients are not in UH Rainbow’s system so we share their information like a retail clinic. We have an interest in having HealthSpotSM integrate this visit information into our hospital EMR,” explains Dr. Hertz.
“Anytime we can spend time with a patient in their own environment, we can better understand and address their needs.” Dr. Hertz adds that by understanding why patients choose the ER as their source of care enables his team to identify opportunities to change that behavior and meet patient needs. Certainly, having after-hours access to quality care in the inner city is valued by patients since the ER is often their only after-hours option.
Patients and family caregivers have had a very positive experience with the telemedicine visit within UH’s HealthSpotSM kiosk. 85% have indicated that if they did not have the HealthSpotSM visit, they would have gone to the ER. Over 90% would use it again. Here are some comments around value of the visit to them:
It's convenient and less time consuming.
I love the equipment and technology.
The one on one with the doctor.
That you get to see what's going on inside the little areas most doctors won't show you.
Close to home and speed of service.
Very helpful for my community.
Future Opportunities for UH Patient & Family Engagement
The team at the UH Rainbow Babies & Children’s Hospital Rainbow Care Connection is already planning ways to use the HealthSpotSM kiosk to bring care access to other patient populations. “Next we want to use telemedicine to enhance access to care in rural areas, where there are not a lot of specialists or after hours care options. We are planning to place a kiosk in a community building or a school”, Dr. Hertz adds.
In addition to expanding the HealthSpotSM kiosks, Dr. Hertz is interested in finding patient engagement tools that will help patients receive care through their phones to support the lower social economic population that tends to own mobile phones rather than computers. “No one has developed the mobile app for patients to receive care through smart phones which would enable a ‘meaningful clinical interaction’,” concludes Dr. Hertz.
You cannot turn on the television or look at a newspaper today without being reminded of the obesity epidemic facing our nation. According to a CDC study, over 37% of U.S. adults are obese, while about 70% are overweight.
Obesity has been associated with certain chronic conditions such as diabetes (type 2), cardiovascular disease and stroke. Last summer, American Medical Association classified Obesity as a disease, and the National Heart, Lung and Blood Institute recently published guidelines recommending that primary care physicians provide obesity counseling to all patients with Body Mass Index over 25 (which classifies them as overweight).
Many Americans try to lose weight but do not have the tools or professional guidance to be successful. Most physicians don’t have the training or tools to provide a comprehensive weight management program in their practice, and sometimes refer patients to commercial programs that are not clinically supervised.
RediClinic has stepped in to help. “We have developed a medically supervised program which is not just about weight loss but about health management”, explains Danielle Barrera, Chief Operating Officer at RediClinic. “When we developed this program in 2009, we noticed that many programs on the market were missing critical elements of a successful weight management program, and did not incorporate healthcare professionals, who are well positioned to have a significant impact on their patients’ lifestyle and health decisions.”
According to IDC’s Connected Health 2014 Predictions, “Retail Clinics Will Disrupt the U.S. Healthcare System”. Most people think about Retail Clinics as a place for getting flu vaccinations or addressing acute problems such as strep throat or ear infections. Retail Clinics are bringing more services to the community and some are now offering preventive services (i.e. physical exams) and chronic disease monitoring.
Over the past two years, RediClinic has been offering a weight management program called Weigh Forward. Shoppers walk into one of their 30 locations inside grocery stores to sign up for the 10- week program. During the initial visit, the clinician does lab work to establish a base line to monitor progress in key health measures. Throughout the program, the clinician provides guidance and teaches life skills not only to lose weight, but keep it off.
“Our program is a ‘Connected Health’ model. Participants use the MyWeighForward platform to access educational information, track food and physical activity, and receive online coaching and social support between visits to the clinic. During weekly visits to RediClinic, the clinician reviews the participant’s program information (i.e. goals, lab work, tracking information and eCoaching activity) to deliver personalized guidance.”
RediClinic’s Weigh Forward program incorporates four key components which are reinforced both in- person and online through the program’s technology platform – myWeighForward.com:
1. Medical. Initial medical assessment with a comprehensive set of lab work, regular biometric monitoring and measurement, and weekly counseling by healthcare professionals.
2. Behavior Modification. Proprietary assessment tool developed at Yale's Prevention Research Center by Dr. David Katz (WeighForward’s Medical Director) to identify and address individual barriers to success and readiness to change, to create a personalized weight loss plan.
3. Diet & Nutrition. Online educational information on food choices, weekly meal plans with 500+ recipes, and access to a diet/nutrition e-coach.
4. Physical Activity. Customized activity plan based on preferences and abilities, access to fitness videos and the capability to collaborate with a fitness e-coach.
Consumer Experience with the Weigh Forward Program
Deborah Hastings signed up for RediClinic's 10- week Weigh Forward program to start shedding 60 pounds. Deborah's daughter is getting married in six months and Deborah wants to get around without pain in her knees and to fit into a new dress for this special event.
During her first appointment, she meets with a clinician for a comprehensive evaluation to discuss her health and weight loss goals and determine her overall health status and readiness for change. She learns that her cholesterol and blood pressure are both high and that she is at risk for Metabolic Syndrome.
She uses the MyWeighForward.com portal to follow a meal plan suggested by the clinician and dietician eCoach, view exercise videos, and to track both her food and physical activity.
Deborah is preparing for week #5 visit which is teaching her that it “takes a village” to help her achieve her goals, and she needs support from family, friends and office co-workers. She inputs her Visit objective, completes her checklist of specific tasks and selects a "Barriers to Bust", how to deal with family when they are sabotaging her diet. This barrier is posted on her Visit Plan which she will review with the clinician during her RediClinic visit. While Deborah finishes her homework, her clinician reaches out to the eCoach that Deborah has been working with to discuss nutrition concerns. Within the private clinical portal on the Weigh Forward platform, they discuss strategies for Deborah. During the upcoming visit, Deborah will work with the clinician on the barrier she has selected and will consider suggestions from her eCoach.
Deborah has taken advantage of the social community capabilities on the Weigh Forward platform. She created a profile with demographic information and indicated how much program information to share with other participants. Deborah has decided to share the “Busting the Barrier” badges that she has earned each week. Deborah searched to find others like her and has connected with over a dozen new friends. She has also found an online group with her same barriers and is looking to gain some new real life strategies to address them.
During her week #9 visit, her clinician will take a blood sample to compare key biometric markers to those measured at the beginning of the program. She will be able to view these measures and see her progress in reducing her cholesterol and Metabolic risk in her MyWeighForward program account .
With several months before her daughter’s big event, Deborah is motivated to extend the program. She is planning on paying for the "Boost Maintenance Program with ongoing access to MyWeighForward with e-coaching as needed, monthly clinician visits and weekly in-clinic visits for "body composition analysis/biometrics".
Connected Health Program Engagement & Results
Although the Weigh Forward Program was launched in 2011, it wasn’t until RediClinic moved to the new MyWeighForward Platform powered by Wellness Layers in October 2013 that they were able to offer enhanced functionality and support for patients and clinicians including:
- Personalized Consumer Experience & Outcome: Participants create their own mini- electronic health record which collects program information, preferences, visit planning, tracking data, social engagement and progress through health measures. Program participants have the convenience of seeing different clinicians within the same clinic based on appointment availability or in a different location since all RediClinic clinicians have access to the participant’s program information to deliver a consistently high quality and personalized experience.
- Social Engagement: WeighForward participants use the platform 24x7 for ongoing emotional and educational support through their weight loss journey.
- Clinician Support and Collaboration: Clinicians have their own portal, giving them access to information to support and consistently deliver the program and to privately and securely collaborate on care.
- Care Continuum: Participants can access a Program Summary with their program health measures to send to their own doctors. “If the patient has secure messaging with their physician, they can share this information to include in their EMR”, adds Barrera.
“Our results have been very positive. On average, our patients are losing 1- 2 lbs per week which is considered to be a healthy rate of weight loss, and are significantly improving their cardio-metabolic risk factors. In many cases our patients have moved from pre-hypertensive and hypertensive to normal and pre-diabetic to normal”, exclaims Barrera.
Comments from Program Participants
What I liked about the online part of the program was that it gave me homework to do to keep me accountable and focused.
I had been the 'queen of couch potatoes.' The best things about the program were the accountability each week, recipes and shopping list, and incredible support from the staff
Dr. David Katz's lesson on Trial by Aisle taught me to check ingredients lists for hidden sugars and salts, and to pick the shorter lists. The best thing about the program was it provided me with information to change my unhealthy lifestyle into a healthy lifestyle.
Future plans: New Business Model, New Technology Platform Capabilities
Today, most program participants walk into to RediClinic. However, RediClinic is now licensing the Weigh Forward program to other healthcare providers. “We’ve had significant interest and many pilot commitments from large healthcare systems and physician groups, as well as companies that operate retail, urgent care and worksite clinics. Everyone is looking for a turn-key weight and lifestyle management solution for their patients because obesity is so pervasive and expensive. Weigh Forward is one of the few comprehensive programs that is designed to be delivered by clinicians with no previous background in weight management,” Barrera adds.
Regardless of where the consumer is seen, in the clinic or in their PCP’s office, RediClinic is extending the capabilities of the WeighForward technology platform. “We are continuing to enhance the social networking capabilities of the platform, will introduce a mobile version later this year, and are beginning to develop modified versions of Weigh Forward that address chronic diseases, since the platform we’ve built is flexible and extensible”, concludes Barrera.
According to CDC research, over 30% of U.S. adults have Metabolic Syndrome, a set of five risk factors including high blood pressure, high blood sugar, large waist size, high triglycerides and low (good) cholesterol.
Sharp HealthCare, a Malcolm Baldrige National Quality Award winner, continues to provide a superior patient experience by investing in technologies to bring better care to patients and their families.
Last October, Sharp Memorial Hospital, a Sharp HealthCare hospital, began piloting GetWellNetwork's Interactive Patient WhiteBoard™ in their cardiology unit to communicate and collaborate with patients and their families about their care throughout their stay.
"Our goals for the pilot were to engage patients in their care, deliver information they need, help them understand their treatment plan, provide a way for them to interact with their care team and prepare for their discharge," explains Verna Sitzer, MN, RN, CNS, Manager, Nursing Innovation and Performance Excellence at Sharp Memorial Hospital.
Patients use the Whiteboard to learn about their care team, their day (i.e. goals, schedule, discharge activities) and participate in the personalized communication area to journal and share information. Patients use their Whiteboard to see tasks that need to be completed such as viewing educational videos that have been ordered and filling in a discharge planning questionnaire. A summary of the patient’s education activity and discharge information is accessible to the care team for review and follow up.
Sharp uses GetWellNetwork’s Interactive Patient Whiteboard to help care providers engage, educate and empower patients along the care continuum. This patient-centered platform, delivered across mobile devices, computers and televisions, enables Sharp to implement a new care delivery model called Interactive Patient Care (IPC). Based on the premise that a more engaged patient is a satisfied patient with better outcomes, GetWellNetwork’s IPC combines the tools, process and people to activate patients in their care, transform clinical practice and advance key performance measures.
During the Whiteboard pilot, the Sharp team learned about the importance of enabling better communication between the care providers and patients. "Our patients wanted to have critical information and to be able to write down questions for the care team for a more meaningful interaction. Knowing what to expect and when to expect it is important for patients so we made this a priority in the design of the display,” adds Sitzer
One of Sharp Healthcare's big accomplishments was to connect the Interactive Patient Care solution to their EMR to capture the patient's engagement and document progress towards their discharge education plan. “Having this connection was an essential condition for launching the technology throughout the healthcare system. Providers are able to integrate patient education into their daily workflow using the EMR for ordering education videos and obtaining results of the education”, explains Sitzer
Sharp Healthcare is in the process of rolling out the Interactive Patient Care solution to their other hospitals. Sharp Grossmont hospital implemented it early this year (February) and Sharp Mary Birch Hospital for Women and Newborns will begin this summer (July).
Sharp & Patient Engagement Framework
Last Fall, National eHealth Collaborative (NeHC) launched their Patient Engagement Framework. The Patient Engagement Framework is designed to guide providers along the path for meaningful use. Sharp Memorial Hospital has adopted this framework to further enhance the Interactive Patient Care Solution. Sitzer shares examples below and describes ways they are enabling patients to participate in the care process.
Stage 1: Inform Me
'We use the Interactive Patient Care solution to send the patient messages about what we need them to do during their stay so they can play an active role in their recovery. We have them watch a video on hospital safety when they are admitted and recommend other relevant educational information. We ask them if they would like to take a self-assessment of their risk for falling and provide them with a video about fall prevention”, describes Sitzer.
Stage 2: Engage Me
Sharp Healthcare puts their patients in the driver’s seat and gives them the option of when they would like to be engaged. Sharp has devised pathways to deliver and gather information from the patient. The 'discharge pathway' presents a set of questions when the patient is preparing for home to determine if there are obstacles that need to be addressed and confirm that all educational information has been viewed and understood. "Our motto is 'when the learner is ready, the teacher will appear’," shares Sitzer. "We want to give our patients control over their recovery."
Stage 3: Empower Me
By giving patients the information that they need, Sharp empowers them to participate in the care planning process, enabling them to ask questions of and provide answers to the care team. For example, patients are able to respond to assessment questions, message providers or services about their needs, or respond to focused surveys on their care or service experience. Their responses notify a provider to deliver patient and family- centered care.
Stage 4: Partner with Me
Care pathways can be tailored to meet various health conditions such as heart failure management. These modules rely on the patient partnering with providers to meet specific goals. For example within the heart failure module, patients must complete certain videos and comprehension questions to move to the next module or phase so that they get the necessary education and preparation for discharge.
Stage 5: Support my e-Community
The Sharp Healthcare team is planning to use the Interactive Patient Care system to support patients after they leave the hospital. "We are working on ways we can use this system to provide the patient with personalized education information when home through online and mobile channels," explains Sitzer.
In the future, Sharp Healthcare would like to tie in health-related devices to gather and monitor information about the patient to provide support or to intervene when needed.
July 24- 26, 2013 in Boston
Join our 2- hour Workshop to explore Social Engagement Strategies that activate consumers to participate in their health; sharing and tapping into peer lifestyle experiences and gaining expert guidance. You will see what healthcare leaders are investing in today, explore social eHealth opportunities for consumer engagement in the future and discuss how to launch a social strategy within your organization.
During the Workshop,
- Learn about key Social Engagement trends including social segmentation, social connect (programs & experts) and social data
- See examples of Social Engagement Approaches used by Healthcare Innovators; Payers & Providers
- Hear a Case Study of a Provider solution that “meaningfully” engages consumers with a private social community integrated with personalized content and communications
- Participate in a Social Engagement Planning Discussion; Considerations, Approaches and Mobile & Tele-health tie-in Opportunities
- Participate in a Group Innovation Exercise: Collectively define a specific social engagement initiative to positively impact consumer health (Workshop participants shape exercise)
Sherri Dorfman, MBA, Chief Executive Officer & Consumer eHealth Engagement Specialist, Stepping Stone Partners
Lucy Reynales, Director, Wellness Layers
Shelley Marshall, Web Marketing Manager, PinnacleHealth