Changing the Healthcare Delivery Model: A Community Health Worker/Mobile Health Chronic Care Team Strategy

Transcription

1 Changing the Healthcare Delivery Model: A Community Health Worker/Mobile Health Chronic Care Team Strategy PI: Richard J Katz, MD - George Washington University School of Medicine Co-PIs: Michelle F Magee, MD Washington Hospital Center/Medstar Research Institute Gail Nunlee Bland, MD Howard University School of Medicine Co-Investigators Joshua Cohen, MD GWU Anne Cioletti, MD GWU Daniel Larbi, MD HU Asqual Getaneh, MD- WHC Research Team: Study Coordinators: Linda Witkin GWU, Dawn Payne- HU, Carine Nassar WHC Statistician Heather Young, PhD GWU Community Health Workers: Clayton Bourges, Tim Maveritt, Asha Hopkins Study Partners 1

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3 What s Missing in Mobile? A 2012 Pilot mhealth Trial Enhancing Diabetes and Hypertension Self-Management: A Randomized Trial of a Mobile Phone Strategy Hypothesis: mhealth will improve patient activation measures and clinical DMs and HTN measures Methods: 3 DC community clinics with on-site case manager 40 Medicaid patients with HbA1c >7% and BP >130/80mmHg Randomize to WellDoc Diabetes Manager vs Usual Care Results: No difference patient self-management, HbA1c, HEDIS measures, healthcare utilization over 6 months 3

4 If a patient records mhealth data is anyone listening? 4

5 PCORI: Changing the Healthcare Delivery Model: A Community Health Worker/Mobile Health Chronic Care Team Strategy Hypothesis: Diabetes care will be improved by combining CHW with mhealth compared to mhealth or CHW alone. Methods: Medicaid/Medicare patients with DM2, HbA1c >8.0, <10 of 13 wellness and clinical behaviors Voxiva Care4Life Diabetes mhealth system Community Health workers trained in DM and mhealth integrated into medical team Groups: 1) CHW alone, 2) mhealth alone, 3) CHW+mHealth Outcomes at 1 year: Primary: Improve wellness/clinical behaviors Secondary: HbA1c, HEDIS goals, healthcare utilization, med adjustments, patient and healthcare team satisfaction 5

6 Care4life Digital support service for people with diabetes Personalized & interactive Core components: 3 educational text messages/ week Interactive monitoring of blood glucose & blood pressure Flexible medication reminders Appointment reminders Exercise & weight tracking Content developed in collaboration with the American Diabetes Association Voxiva: study partner Interactive Text App Educational videos 6 Portal = for patient, CHW and doctor

7 Voxiva: Care4 Life System 7

8 Community Health Worker Roles Contact with Patients and Providers : 1. Conduct home and/or off-site visits requested by patients and healthcare team. A minimum of 2 in the first 2 months 2. Conduct weekly check in calls or clinical meetings for patients based on interest/need/request 3. Review with C4L monthly report with CHW+C4L subjects 4. Provide feedback to healthcare team Community Health Worker Checklist: 1. Medication issues: adjudication, supplies, access, med education, side effects, adherence 2. Diabetes specific issues: understand diabetes/ hypoglycemia, glucometer use, supplies, glucose testing schedule, additional diabetes education needs 3. Hypertension specific issues: home BP measurement, BP goals, low salt diet 4. Scheduling issues: assist with appointment scheduling/ transportation 5. Activity and exercise goals: review exercise plan 6. Diet advice and goals: weight loss plan, nutrition counseling referral, healthy food access and affordability, alcohol usage 7. Other health issues: hospitalizations, ER visits, urgent care visits, comorbidities, smoking cessation supports 8. Social needs: MD contacts, literacy, employment, dependent care, financial, housing needs, family or other supports 9. mhealth assistance: Encourage and support cell phone access/usage (texting), C4L engagement- glucose/bp entrees, retraining, questionnaires 8

9 PRELIMINARY RESULTS: mhealth Usage C4L+CHW C4L only # subjects #Average weeks f/u Total # glucose entries Median glucose entries/week Range

10 Conclusions 1. Preliminary observations in this program suggest CHWs act as digital navigators enhancing mhealth usage 2. CHWs training in and tracking of diabetes management and engagement with mhealth has been developed to address patient medical and social needs 3. Final data comparing CHW alone, mhealth alone or CHW+mHealth will be available in 2016.

11 Telehealth Technologies to Improve Patient- Centered Care: Next Steps Wendy Nilsen, PhD NSF, Smart and Connected Health Directorate for Computer & Information Science & Engineering

12 Telehealth Past work has been successful in trials, but less so in dissemination and implementation. Part of the issue is the stringent requirements of telehealth billing Additionally, the problem may stem from: Disease-centric focus Poorly designed tools Lack of understanding of human behavior These are all addressable and have been developing through the broader field of mhealth and health technology

13 Continuum of health technology tools Measurement Sensor sampling in real time Integration with health data Diagnostic Point of care diagnostics Portable imaging Biomarker sensing Clinical decision making Treatment Dissemination of health information Chronic disease management Service Access Remote treatment Disease surveillance Prevention and wellness interventions Remote Clinical trials Global Service Access Remote treatment Dissemination of health information Disease surveillance Medication tracking and safety Disaster support/care Prevention and wellness interventions

14 Who uses Mobile? EVERYONE

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17 Seniors and Cell Phone Adoption

18 Reality of Mobile Devices Digital Medical Tools and Sensors: Topol, Steinhubl and Torkamani, JAMA, 2015

19 Customizability/Intimacy My language, my apps right from the start. Image from: hola-bonita

20 Consumer Technology and New Expertise Consumer technology provides opportunities for engagement that rival non-health competition for time Can t health be enjoyable or desired? Image from:

21 Flexibility/Real time Flexibility of delivery: On my schedule When I want it Real time information Support/information when and where they are needed Information/Support that develops with my needs Integrated into my life Image from:

22 Centralization of communication Mobile devices can be a health hub Communication with care team Photos To ask or do lists Messaging Interventions and information programs Along side of other self-tracked information

23 Reducing the Burden of Data Image from:

24 Representativeness of Clinical Research Green LA, Miller RS, Reed FM, Iverson DC, Barley GE. How Representative of Typical Practice are Practice-Based Research Networks? Arch Fam Med, 1993; 2: Image from: /teachinghospitals/

25 Barriers for Telehealth/Health Technology Research has shown multiple barriers to the deployment of health technology. These include: Privacy/Security Interoperability Malpractice Payment Licensure/State Regulations

26 Privacy Security Privacy = keeping personal health info from improper disclosure Security = collection of technical and procedural mechanisms in place to protect privacy of health info. Good security should result in privacy Threats to privacy mostly related to policies that encourage or do not forbid sharing of information NOT to inadequate security. Is mobile information EXTRA vulnerable?

27 What are the tradeoffs? And why is it worth it? Health technologies offer chances to make major advances in health care, prevention and treatment Precisely because we CAN know so much, and because we can link data to time, event, and context Real- (or near-) time monitoring and feedback Engagement with and access to own data. Simple procedures can reduce risk Automatic data wipes Teaching and rewarding privacy practices

28 Barriers for Telehealth/Health Technology Interoperability Between devices is growing Third party data-fusion to integrate data from different devices/sources Systems like Open mhealth, developing data standards With the EHR is still hard ONC s work on Interoperability and Meaningful Use should support integrating patient data

29 Barriers for Telehealth/Health Technology Malpractice Develop systems of actionable data Create a science base where this becomes best practice Payment* Increase in payer support Indirect Benefits of Hospitals Providing Telehealth Penalty/Cost Avoidance Geographic Reach/Branding Short-supply specialists Patient Satisfaction Licensure/State Regulations *

30 Where is PCORI s Role in Telehealth Support translation of evidenced-based practice into digital formats for remote participation & scalability Support exploration of the needs of participants to make health technologies usable and safe Translation of the science of user-centered design, humancomputer interaction, form factors, to health Explore what data is people believe is private Explore how people perceive the tradeoffs between health technologies and standard practice & which areas offer extra value for which populations Understand the systems in which teleheath will be embedded to increase uptake

31 For more information contact: Wendy Nilsen, PhD Smart and Connected Health, NSF