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

Care Team Strategy

1

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

Voxiva: Pam Johnson, PhD

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

If a patient records mHealth data is anyone listening?

4

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

Care4life

6

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

Portal = for patient , CHW and doctor

Educational videos

Voxiva: Care4 Life System

7

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

PRELIMINARY RESULTS: mHealth Usage

C4L+CHW C4L only

# subjects 44 44

#Average weeks f/u 27 25

Total # glucose entries 3805 2819

Median glucose entries/week 2.4 2.0

Range 0-14.4 0-21.8

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.

Telehealth Technologies to Improve Patient-Centered Care: Next Steps

Wendy Nilsen, PhDNSF, Smart and Connected Health

Directorate for Computer & Information Science & Engineering

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

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

Who uses Mobile?EVERYONE

Seniors and Cell Phone Adoption

http://www.pewinternet.org/2014/04/03/older-adults-and-technology-use/

Reality of Mobile Devices

Digital Medical Tools and Sensors: Topol, Steinhubl and Torkamani, JAMA, 2015

Customizability/Intimacy

My language, my apps right from the start.

Image from: http://lacrafteria.mx/2014/04/07/fondo-de-pantalla-para-iphone-4-y-5-hola-bonita

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: http://www.digitaltrends.com/home-theater/a-glimpse-into-the-future-of-tv/

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: http://www.marybethdahl.org/wp-content/uploads/2013/02/MP900409753.jpg

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

Reducing the Burden of Data

Image from: http://www.beadinggem.com/2008/08/electronic-sensing-jewelry-real-mood.html

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; 2:939-949. Image from:

https://geiselmed.dartmouth.edu/ed_programs/teachinghospitals/

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

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?

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

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

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

*http://www.techhealthperspectives.com/2013/04/10/why-not-getting-paid-directly-for-telehealth-may-not-matter/

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, human-

computer 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

For more information contact:

• Wendy Nilsen, PhD• Smart and Connected Health, NSF

• wnilsen@nsf.gov

• 703-292-2568