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DateApril 19th, 2013 (Friday)

8:00AM-7:30PMLocation

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

People typically have >1 condition

Loneliness as critical risk factor

43% of 1,604 seniors 60+ reported feeling lonelyMore likely to develop or experience decline, difficulties in:

• 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, MPHApril 19, 2013

What is a “Complex” Patient?

No single definition, similarities across populations

Medical condition(s) often complicated by psychosocial issues 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 non-adherence

While often many things going on that affect health, it’s not always about number of issues, but the particular combination

Examples of “Complex” PatientsUninsured/Medicaid/Dual Eligible (from

FUHSI)65 % chronic medical conditions, many with

2 or 354% substance abuse disorders

33 % mental illness45% homeless

Seniors w/ Medicare (from IOCP, CMHCB)69% Congestive Heart Failure

43% Pain32% Diabetes Mellitus

29% Depression/Psychological (under-reported)25% Gastrointestinal18% 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 DepressionSchizophrenia or Schizoaffective Disorder

BiPolar DisorderPTSD

PlusCongestive Heart Failure

COPDDiabetes

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 IIPurpose: 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 possiblepsychiatric symptoms

service useillness 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

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• 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 InnovationsTransforming 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. 20

Home Telehealth•120K patients –

FY2012

•Chronic care management

•Acute care management

•Health promotion/disease prevention.

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TeleMental Health• 217K telemental health consultations - FY 2012

• 76K patients

• over 800,000 consultations since FY2003

• Areas of focus:

• post-traumatic stress disorder

• Depression

• Bipolar disorder,

• behavioral pain

• Evidence-based psychotherapy

• compensation and pension exams

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 - 93% mean score

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 ForumApril 19, 2013 San Francisco

David Lindeman, PhDDirector

Center for Technology and Agingwww.techandaging.org

CTA Technology Demonstration Grants 2010-2012

Medication Monitoring and AdherenceRemote 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

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

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 ManagementHealthInsight

•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

Care4Life. Reminder:

Time to check your

BEFORE meal glucose.

Reply with your

BEFORE meal glucose

reading (e.g. 125).

Family Health Centers of San Diego • Community Health Center and Clinic, San Diego, CA

• SMS-based mobile program

• Improving diabetes education and behavior change in Spanish-speaking safety net population

User can set glucose reminders according to their doctor’s recommendations (e.g., before breakfast daily)

System sends glucose reminders & provides immediate feedbackUser can track all glucose recordings on web portal

System sends education messages & tips

Care4Life | Glucose Monitoring/Education

Care4Life. Reminder:

Time to check your

BEFORE meal

glucose. Reply with

your BEFORE meal

glucose reading (e.g.

125).

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

Glucose reminder System feedback

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 management for patients with CHF

and COPD• Patients with multiple chronic

conditions; Medicare, Medicaid and uninsured

Care4Life. Reminder:

Time to check your

BEFORE meal glucose.

Reply with your

BEFORE meal glucose

reading (e.g. 125).

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

Sharp HealthCare Remote Patient Monitoring

Lean Six Sigma Department

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

Sharp HealthCare RPM Program

mHealth Medication AdherenceFront Porch Center for Technology

Innovation and Wellbeing • Continuing Care Retirement Center, Los

Angeles, CA• Cell phone texting

• Addressing medication adherence among active, independent older adults using a

mHealth medication texting solution

Care4Life. Reminder:

Time to check your

BEFORE meal glucose.

Reply with your

BEFORE meal glucose

reading (e.g. 125).

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 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

Tools and Protocols

ADOPT Toolkit

ROI of RPM Calculator Do-it-Yourself Tool

The Center for Technology and Aging

support@techandaging.org

www.techandaging.org

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