ImagineCare: Empowering Patients with Behavioral Science and Technology

ImagineCareEmpowering Patients withBehavioral Science and Technology

Jamie Thomson Experience Design Director

Olga Elizarova Senior Behavior Change Analyst

1. What is Behavior Change Design?

2. Behavior Change Design within ImagineCare

3. Results & Takeaways

TONIGHT’S TALK

Mad*Pow is a design agency that strives to help people improve their health and wellness, meet their financial goals, learn, and connect.

WHAT IS BEHAVIOR CHANGE DESIGN?

What is Behavior Change Design?

A set of processes and activities that are applied to design an interventionthat aims to change a defined and modifiable behavior.


Designing Systems of InterventionsMad*Pow Behavior Change Design Process

What are we trying to achieve?

How to achieve it?


System Outcomes & Target Population

Behavioral Outcomes for Individuals

Performance Objectives for Individuals

Behavioral Determinants

Design of Product, Messages, Materials, Activities

Implementation & Adoption

Intervention Functions & Behavior Change Techniques

Behavior Change Design within ImagineCare

BEHAVIOR CHANGE DESIGN, APPLIED

CONTEXT

Imagine a hospital that doesn’t want people to visit.

Not because we don’t care…

…but because we do.

CONTEXT

What are we trying to achieve?“The Triple Aim” of Improving the US Health Care System

Better care

Patient satisfaction

Clinician satisfaction and minimal burden

Better value

Reduced need for high-cost care (ER, Inpatient) through management and prevention

Correct level of care delivered when care is needed (ER vs Urgent Care vs PCP)

Reduced need for medications

Better health

Reduced mortality

Chronic conditions under control, or where possible, in remission

Improved quality of life for patients

STEP 1: SYSTEM OUTCOMES & TARGET POPULATION

Impact of condition – frequency in population, cost per capita

Available evidence about interventions & outcomes

Feasibility of interventions – technology, cost, logistics, burden

Overlap in conditions and behavioral objectives


Who can help us achieve those outcomes?ImagineCare chose to focus on people with health conditions that offered the greatest potential impact on the system outcomes, based on:

Hypertension

CHF

COPD

Diabetes

Depression

Medication adherence

Self monitoring

Dietary changes

Physical activity

Stress & psych health


Target population & behavior categoriesImagineCare’s pilot conditions and related modifiable behaviors

Hypertension

CHF

COPD

Diabetes

Depression

Medication adherence

Self monitoring

Dietary changes

Physical activity

Stress & psych health


For sake of example…We’ll use hypertension self monitoring to show how the behavior change design process plays out

STEP 2: BEHAVIORAL OUTCOMES FOR INDIVIDUALS

What behaviors have an impact on system outcomes?

What’s the behavior?

How often should it occur?

Are there any exception cases or special circumstances?

Why does the behavior impact outcomes?

RESEARCH QUESTIONS

• Help doctor and patient determine whether treatments are working

• Identify hypertensive crisis in the moment so patient can seek emergency care

• Increase patient awareness and engagement with care – halo effect can improve other behaviors

WHY?

Patients with uncontrolled blood pressure should measure their blood pressure once per day against a goal recommended by their physician, and take appropriate action based on readings.

BEHAVIORAL OUTCOME

STEP 3: PERFORMANCE OBJECTIVES FOR INDIVIDUALS

What tasks are performed as part of the behavior?

What do they need to do differently to achieve desired change?

How should the behavior typically play out, start to finish?

Any required resources?

Does anyone else need to be involved?

Where should it occur?

What barriers may exist? How can barriers be addressed?

RESEARCH QUESTIONS PERFORMANCE OBJECTIVES FOR MONITOR BP DAILY

• Recognize importance of monitoring BP

• Set goal for behavior and outcome

• Obtain BP cuff & learn to use

• Measure BP daily

• Compare reading to goal & take appropriate action

• If not measuring daily – identify barriers, problem-solve, adjust as needed

STEP 4: BEHAVIORAL DETERMINANTS

What factors increase likelihood of success?

CAPABILITY

Physical

Psychological

OPPORTUNITY

Physical

Social

MOTIVATION

Reflective

Automatic

The COM-B Model (Michie, et al) provides a framework for identifying behavioral determinants

BEHAVIOR

Michie S,vanStralen MM,WestR.(2011).Thebehaviour changewheel:Anewmethodforcharacterising anddesigningbehaviour changeinterventions,ImplementationScience,2011;6(42).doi: 10.1186/1748-5908-6-42

CAPABILITY

Physical

Skills to take a BP reading

Psychological

Knowledge about what needs to be measured, how and when

Knowledge of goal

Knowledge of what action is appropriate based on reading



OPPORTUNITY

Physical

Social

MOTIVATION

Reflective

Automatic

BEHAVIORMeasure BP Daily & Take appropriate action

OPPORTUNITY

Physical

Having a BP cuff

Having time to measure BP

Having resources or tools that will allow action to be taken

Social

Relationship with a clinician

Being able to openly use BP cuff in social environment

CAPABILITY

Physical


Psychological


Knowledge of goal




MOTIVATION

Reflective

Automatic




CAPABILITY

Physical


Psychological


Knowledge of goal



OPPORTUNITY

Physical

Having a BP cuff


Having resources or tools that will allow action to be taken

Social

Relationship with a clinician

Being able to openly use BP cuff in social environment

MOTIVATION

Reflective

Having a goal

Having motivation to take action

Social support & accountability

Automatic

Emotional reaction to condition and behavior

STEP 5: INTERVENTION FUNCTIONS & BEHAVIOR CHANGE TECHNIQUES

Education

Persuasion

Incentivization

Coercion

Training

Restriction

Environmental Restructuring

Modeling

Enablement

PRIMARY INTERVENTION FUNCTIONS

What are the primary functions of the intervention?


PERFORMANCE OBJECTIVES

Recognize importance of monitoring BP

Set goal for behavior and outcome

Obtain BP cuff & learn to use

Measure BP daily

Compare reading to goal & take appropriate action

If not measuring daily – identify barriers, problem-solve, adjust as needed

BEHAVIORAL DETERMINANTS

Skil ls to take a BP reading


Knowledge of goal


Having a BP cuff

Having resources or tools that wil l al low action to be taken

Having a goal



Social support & accountabil ity


Education

Persuasion

Incentivization

Coercion

Training

Restriction


Modeling

Enablement




PERFORMANCE OBJECTIVES

Recognize importance of monitoring BP

Set goal for behavior and outcome

Obtain BP cuff & learn to use

Measure BP daily

Compare reading to goal & take appropriate action

If not measuring daily – identify barriers, problem-solve, adjust as needed

BEHAVIORAL DETERMINANTS

Skil ls to take a BP reading


Knowledge of goal


Having a BP cuff

Having resources or tools that wil l al low action to be taken

Having a goal



Social support & accountabil ity


Education

Persuasion

Incentivization

Coercion

Training

Restriction


Modeling

Enablement




Which techniques are best suited to perform these functions, to influence the behavioral determinants and performance objectives?

We choose techniques and strategies from a large toolkit of theories and frameworks

Self Determination Theory – a theory of motivation concerned with supporting our natural or intrinsic tendencies to behave in effective and healthy ways. Conditions supporting the individual’s experience of autonomy, competence and relatedness are argued to foster the most volitional and high quality forms of motivation and engagement.

Social Cognitive Theory – describes a dynamic, ongoing process in which personal factors, environmental factors, and human behavior exert influence upon each other. According to SCT, self-efficacy, goals, and outcome expectancies are the three main factors that affect the likelihood that a person will change a health behavior.

Behavioral Economics & Game Mechanics – human decisions are strongly influenced by context, including the way in which choices are presented to us.


Michie S,RichardsonM,JohnstonM,AbrahamC,FrancisJ,HardemanW,EcclesMP,CaneJ,WoodCE.(2013).TheBehaviorChangeTechniqueTaxonomy(v1)of93hierarchicallyclusteredtechniques:buildinganinternationalconsensusforthereportingofbehaviorchangeinterventions,AnnalsofBehavioralMedicine,2013;46(1):81-95.doi:10.1007/s12160-013-9486-6

Identity13.1. Identificationofselfasrolemodel13.2. Framing/reframing13.3. Incompatiblebeliefs13.4. Valuedself-identify13.5. Identityassociatedwithchangedbehavior

Schedulesconsequences14.1.Behaviorcost14.2.Punishment14.3.Removereward14.4.Rewardapproximation14.5.Rewardingcompletion14.6.Situation-specificreward14.7.Rewardincompatiblebehavior14.8.Rewardalternativebehavior14.9.Reducerewardfrequency14.10.Removepunishment

Covertlearning16.1.Imaginarypunishment16.2.Imaginaryreward16.3.Vicariousconsequences

Self-belief15.1. Verbalpersuasionaboutcapability15.2. Mentalrehearsalofsuccessfulperformance15.3. Focusonpastsuccess15.4. Self-talk

GoalsandPlanning1.1. Goalsetting(behavior)1.2. Problemsolving1.3. Goalsetting(outcome)1.4. Actionplanning1.5. Reviewbehaviorgoal(s)1.6. Discrepancybetweencurrentbehaviorandgoal1.7. Reviewoutcomegoal(s)1.8. Behavioralcontract1.9. Commitment

FeedbackandMonitoring2.1.Monitoringofbehaviorbyotherswithoutfeedback2.2.Feedbackonbehavior2.3.Self-monitoringofbehavior2.4.Self-monitoringofoutcome(s)ofbehaviour2.5.Monitoringofoutcome(s)ofbehaviorbyotherswithoutfeedback2.6.Biofeedback2.7.Feedbackonoutcome(s)ofbehavior

SocialSupport3.1.Socialsupport(unspecified)3.2.Socialsupport(practical)3.3.Socialsupport(emotional)

NaturalConsequences5.1.Informationabouthealthconsequences5.2.Salienceofconsequences5.3.Informationaboutsocialandenvironmentalconsequences5.4.Monitoringofemotionalconsequences5.5.Anticipatedregret5.6.Informationaboutemotionalconsequences

Comparisonofbehavior6.1.Demonstrationofthebehavior6.2.Socialcomparison6.3.Informationaboutothers’approval

Associations7.1.Prompts/cues7.2.Cuesignalingreward7.3.Reduceprompts/cues7.4.Removeaccesstothereward7.5.Removeaversivestimulus7.6.Satiation7.7.Exposure7.8.Associativelearning

Repetitionandsubstitution8.1.Behavioralpractice/rehearsal8.2.Behaviorsubstitution8.3.Habitformation8.4.Habitreversal8.5.Overcorrection8.6.Generalisationoftargetbehavior8.7.Gradedtasks

Comparisonofoutcomes9.1.Crediblesource9.2.Prosandcons9.3.Comparativeimaginingoffutureoutcomes

Rewardandthreat10.1.Materialincentive(behavior)10.2.Materialreward(behavior)10.3.Non-specificreward10.4.Socialreward10.5.Socialincentive10.6.Non-specificincentive10.7.Self-incentive10.8.Incentive(outcome)10.9.Self-reward10.10.Reward(outcome)10.11.Futurepunishment

Regulation11.1.Pharmacologicalsupport11.2.Reducenegativeemotions11.3.Conservingmentalresources11.4.Paradoxicalinstructions

Antecedents12.1. Restructuringthephysicalenvironment12.2. Restructuringthesocialenvironment12.3. Avoidance/reducingexposuretocuesforthebehavior12.4. Distraction12.5. Addingobjectstotheenvironment12.6. Bodychanges

ShapingKnowledge4.1.Instructiononhowtoperformthebehavior4.2.Informationaboutantecedents4.3.Re-attribution4.4.Behavioralexperiments


GoalsandPlanning1.1. Goalsetting(behavior)1.2. Problemsolving1.3. Goalsetting(outcome)1.4. Actionplanning1.5. Reviewbehaviorgoal(s)1.6. Discrepancybetweencurrentbehaviorandgoal1.7. Reviewoutcomegoal(s)1.8. Behavioralcontract1.9. Commitment

FeedbackandMonitoring2.1.Monitoringofbehaviorbyotherswithoutfeedback2.2.Feedbackonbehavior2.3.Self-monitoringofbehavior2.4.Self-monitoringofoutcome(s)ofbehaviour2.5.Monitoringofoutcome(s)ofbehaviorbyotherswithoutfeedback2.6.Biofeedback2.7.Feedbackonoutcome(s)ofbehavior

SocialSupport3.1.Socialsupport(unspecified)3.2.Socialsupport(practical)3.3.Socialsupport(emotional)

NaturalConsequences5.1.Informationabouthealthconsequences5.2.Salienceofconsequences5.3.Informationaboutsocialandenvironmentalconsequences5.4.Monitoringofemotionalconsequences5.5.Anticipatedregret5.6.Informationaboutemotionalconsequences

Comparisonofbehavior6.1.Demonstrationofthebehavior6.2.Socialcomparison6.3.Informationaboutothers’approval

Associations7.1.Prompts/cues7.2.Cuesignalingreward7.3.Reduceprompts/cues7.4.Removeaccesstothereward7.5.Removeaversivestimulus7.6.Satiation7.7.Exposure7.8.Associativelearning

Repetitionandsubstitution8.1.Behavioralpractice/rehearsal8.2.Behaviorsubstitution8.3.Habitformation8.4.Habitreversal8.5.Overcorrection8.6.Generalisationoftargetbehavior8.7.Gradedtasks

Comparisonofoutcomes9.1.Crediblesource9.2.Prosandcons9.3.Comparativeimaginingoffutureoutcomes

Rewardandthreat10.1.Materialincentive(behavior)10.2.Materialreward(behavior)10.3.Non-specificreward10.4.Socialreward10.5.Socialincentive10.6.Non-specificincentive10.7.Self-incentive10.8.Incentive(outcome)10.9.Self-reward10.10.Reward(outcome)10.11.Futurepunishment

Regulation11.1.Pharmacologicalsupport11.2.Reducenegativeemotions11.3.Conservingmentalresources11.4.Paradoxicalinstructions

Antecedents12.1. Restructuringthephysicalenvironment12.2. Restructuringthesocialenvironment12.3. Avoidance/reducingexposuretocuesforthebehavior12.4. Distraction12.5. Addingobjectstotheenvironment12.6. Bodychanges

Identity13.1. Identificationofselfasrolemodel13.2. Framing/reframing13.3. Incompatiblebeliefs13.4. Valuedself-identify13.5. Identityassociatedwithchangedbehavior

Schedulesconsequences14.1.Behaviorcost14.2.Punishment14.3.Removereward14.4.Rewardapproximation14.5.Rewardingcompletion14.6.Situation-specificreward14.7.Rewardincompatiblebehavior14.8.Rewardalternativebehavior14.9.Reducerewardfrequency14.10.Removepunishment

Covertlearning16.1.Imaginarypunishment16.2.Imaginaryreward16.3.Vicariousconsequences

Self-belief15.1. Verbalpersuasionaboutcapability15.2. Mentalrehearsalofsuccessfulperformance15.3. Focusonpastsuccess15.4. Self-talk

ShapingKnowledge4.1.Instructiononhowtoperformthebehavior4.2.Informationaboutantecedents4.3.Re-attribution4.4.Behavioralexperiments

Michie S,RichardsonM,JohnstonM,AbrahamC,FrancisJ,HardemanW,EcclesMP,CaneJ,WoodCE.(2013).TheBehaviorChangeTechniqueTaxonomy(v1)of93hierarchicallyclusteredtechniques:buildinganinternationalconsensusforthereportingofbehaviorchangeinterventions,AnnalsofBehavioralMedicine,2013;46(1):81-95.doi:10.1007/s12160-013-9486-6

STEP 5: BEHAVIOR CHANGE TECHNIQUES

Selecting techniques

Having a blood pressure cuff

BEHAVIORAL DETERMINANT:

• Adding objects to the environment

SELECTED BEHAVIOR CHANGE TECHNIQUES:

Environmental restructuring

INTERVENTION FUNCTION:

STEP 5: BEHAVIOR CHANGE TECHNIQUES

Selecting techniques

Skills to be able to measure blood pressure

BEHAVIORAL DETERMINANT:

• Instructions on how to perform behavior

• Verbal persuasion about capabilities

• Biofeedback

• Social support (practical)

SELECTED BEHAVIOR CHANGE TECHNIQUES:

Training

INTERVENTION FUNCTION:

STEP 6: DESIGN OF PRODUCT, MESSAGES, MATERIALS, ACTIVITIES

Patient AppSensors

Patient

Clinician Dashboard

ImagineCare Clinicians

communicate viaIn-App TextsPhone CallsVideo Calls

data processed throughEvidence-based care pathways

Rules & preferences engineMachine learning & predictive analytics


Invitation to participatePersuasion, Incentivisation

Material Incentive

Large risk-bearing entities (ACOs, self-insured employers) invite at-risk populations to participate via email or offline outreach

Social Comparison

Credible Source

Duringafollow-upvisitatyourdoctor’soffice,astaffmembertalkswithyouaboutImagineCare,aprogramthatwillhelpyoumonitoryourbloodpressuredailyandencourageandsupportyouinthehealthchangesyouwanttomake.

Social Support (Practical)

Yourcollegehasintroducedanewprogramforwellnessandstressmanagement,calledImagineCare.

ENROLLMENT DESIGN

• From a trusted source

• Volitional

• Confidential

• Quick & simple as possible

• Mobile first

ACCESS MODEL – B2B2C

Information about health consequences


Welcome kitEnvironmental Restructuring, Incentivisation

Adding objects to the environment (provide a blood pressure cuff)

Material Reward


Guided setup processPersuasion, Education, Environmental Restructuring, Incentivization, Enablement

Prompts/cues; Instructions on how to perform behavior

Prompts/cues; Feedback on behavior;Discrepancy between current behavior and goal; Social support (practical)

Social reward

Taking the first reading


Environmental Restructuring, Training, Incentivization

Prompts/cues

Feedback on behavior; Social reward Feedback on behavior

Instructions on how to perform behavior

Biofeedback Instructions on how to perform behavior


Self monitoring via active and passive sensorsEducation, Incentivisation, Enabling

Goal for the outcome

Biofeedback

Self-monitoring outcomes

Action planning; Prompts/cues; Conserving mental resources

Self-monitoring behavior


Agreeing to a care planEnablement, Education, Incentivisation

Goal setting (behavior -measure BP daily)

Goal Setting (outcome -achieve prescribed range)

Action planning; Commitment; Behavioral contract;Social support (practical);Credible source;Restructuring the social environment


Communication, human support & triagingEducation, Enabling, Incentivization, Persuasion

Feedback on outcomes of behavior; Social reward

Feedback on outcomes of behavior; Problem solvingSocial support (emotional);Social support (practical)


Message design


Scenario:You’veachievedamilestoneinyourhealthandwellnessgoals.Whichmessagewouldyouratherreceive?

A B


A B

Youhaveachronicpulmonary(lung)diseaseandtheImagineCare teamcantellyou’vebeenusingrescuemedicationinhalersmoreoften

C


C

BrandedPolo

B

WhiteCoat

D

Casual

A

Scrubs



RESULTS & TAKEAWAYS

Results & Takeaways

2016 Pilot Results

N=2741, compared against matched control group

RESULTS

reduction in costof ER care

23%

Overall savings per patient per month

$255reduction in poorly controlled high blood pressure

50%satisfaction rating for ImagineCare Health Navigator & RN services

95%

the national employer health & wellness program engagement

4xreduction in hospital admissions

56%

*Engagementvs.TowersWatsonNationalSurveyofemployerhealthandwellnessprograms“Staying@Work Report2013/2014,UnitedStates”

“I remember struggling to get 10,000 steps each day, watching my heart rate increase with each round of 1,000 steps … my heart is grateful for everything you have given it.”

RESULTS

“He was patient, he went at her speed, he allowed her to practice…she is now able to do this on her own!”

–Caregiver for an 89-year-old ImagineCare customer

RESULTS

“The term ‘hypertensive’ now has the follow-up ‘inactive’ in my medical record.”

RESULTS

RESULTS

“I owe a debt to ImagineCare and am so appreciative of the experience and interactions I have had with your team. You have... quite literally... helped change my life. Thank you for everything!

Don’t just throw technology at the problem – consider the power of the human element.

TAKEAWAY #1

Take a structured, theory-grounded approach. Start from the evidence, and iterate from there.

TAKEAWAY #2

ImagineCare

Jamie Thomson Experience Design Director

Olga Elizarova Senior Behavior Change Analyst

Empowering Patients withBehavioral Science and Technology

Healthcare

ImagineCare: Empowering Patients with Behavioral Science and Technology