Virtua Navigates Orthopedic Patients Pre- & Post-Surgery with Improved Patient Engagement and Care Coordination
With an aging population and increase in chronic conditions including obesity, the demand for hip and knee operation is increasing dramatically. A study in the Journal of Bone & Joint Surgery estimates by 2030 “demand for total hip arthroplasties to grow by 174% to 572,000 and demand for primary total knee arthroplasties by 673% to 3.48 million procedures”.
At the 2016 Consumer Electronics Show (CES) in January, UnitedHealthcare launched Solutions for Caregivers, an online program that provides resources for caregivers and their family; personalized information, a discounted marketplace of products and services and care circle community for ongoing support.
UnitedHealthcare is addressing the evolving needs of a large population of caregivers. According to the Caregiving in the U.S. 2015 report by the National Alliance for Caregiving (NAC) and AARP Public Policy Institute, an estimated 43.5 million adults have provided unpaid care during the prior 12 months, 34.2 million (79%) offering care for an adult age 50+.
“Many caregivers are searching for relevant resources but often don’t know where to start. Solutions for Caregivers addresses the needs of family caregivers through case management services and online resources that help caregivers more effectively care for their loved ones,” shares Dr. Richard Migliori, EVP and Chief Medical Officer, UnitedHealth Group.
According to the Caregiving in the U.S. 2015 report, caregivers spend an average of 24 hours each week helping their loved ones. Many caregivers experience their own physical, emotional and financial strain as a result of their caregiving role. Half of the caregivers indicated “they had no choice in taking on their caregiving responsibilities,” and 40% report being in high-burden situations. When asked about their health, 17% said ”it is fair or poor”, compared with 10% of the general adult population.
Many caregivers (60%) admit they had to make a workplace accommodation, such as taking time off or reducing work hours. On average, caregivers assist with “4.2 out of 7 Instrumental Activities of Daily Living (IADLs),” including transportation, grocery/other shopping, or housework. Most caregivers (84%) report an interest in receiving more information such as “keeping their loved one safe at home” and “managing their own stress.”
UnitedHealthcare has conducted extensive research with family caregivers to understand their challenges around caring for a loved one. Vidya Raman-Tangella, M.D., head of UnitedHealthcare’s Innovation Center of Excellence, explains, “We heard that each journey is a ‘unique’ and ‘personal’ experience. Family caregivers are often not prepared and do not know where to begin, which causes anxiety. Some caregivers need support recognizing ‘what is good’ when making decisions for their loved one. Finally, UnitedHealthcare heard that the family caregivers did not want to feel alone and wanted to work together with others in their care circle.”
Vidya and her innovation team set out to define a solution based on these caregiver needs. The team started with a portal front end to house a set of tools to help caregivers:
Personalized Information – educational articles and videos that are tailored to the specific medical issues and needs of the care recipient and caregiver. UnitedHealthcare’s articles support the topics requested by caregivers (i.e. safety, stress). Users can save an article for future reference or share with others (i.e. siblings, health coach and clinician).
Marketplace – set of vetted discounted products and services to support the caregiver and care recipient’s conditions and challenges. Product categories include “assistive products”, “home monitoring”, “home safety” and “medication management.” Service categories span “financial”, “in-home care”, “nutrition” and “transportation”. Regarding “nutrition,” caregivers can order meals that are tailored to the care recipient’s health condition (i.e. low salt, low sugar). UnitedHealthcare’s marketplace is designed to support caregivers for activities they undertake on a regular basis, including transportation, shopping and house work.
One service option is for a “Care Manager” who can help the family plan or respond to care recipient/caregiver needs, via online, phone or consult (secure messaging). Some caregivers may have a health plan benefit that covers the care manager service, while others have the option of paying the hourly fee.
Currently, UnitedHealthcare has mostly national companies and a growing number of regional and local offerings in the marketplace. Based on the care recipient’s zip code, there may be a national service provider such as CareLinx, which offers services in the specified geography.
Community Support – centralized place where caregivers and friends of a loved one can connect, share insights and concerns (i.e. how does mom look today), add and view medical appointments & meetings on a daily/weekly/monthly calendar, post and assign tasks (i.e. a ride to the doctor’s appointment) and access a library of documents such as medication lists, doctors list, health records and a living will. The solution serves as a repository of this information, however there is no integration with the EMR or any clinical information
Caregivers can also invite others, such as clinicians and in-home caregivers, and enable them to securely access information and communicate on a common platform.
Although other companies promote online caregiver offerings today, UnitedHealthcare has designed a 'personalized caregiver solution'. During the sign-up process, the caregiver creates a profile by responding to set of questions about the care recipient; relationship, age, zip code, conditions and challenges. The caregiver also indicates their own health conditions and challenges.
For example, when family caregiver Carla responds that her 86-year-old mother has hypertension and diabetes and is dealing with mobility issues, and she (the caregiver) is experiencing depression, Carla will see articles, videos, products and services that are relevant to both of their needs.
Caregiver Solution Pilot
UnitedHealthcare is providing the Solutions for Caregivers program to large employers at no additional cost for employees to access the online services. As of January 2016, Solutions for Caregivers is being promoted to over 1 million employees. Currently, Solutions for Caregivers is also accessible to the public. For people using the employer-sponsored version, the company can cover the costs associated with care management services, enabling caregivers to access more holistic support. In comparison, people accessing the consumer site, or instances where the employer has not purchased the additional care management services, can pay out of pocket for these resources. In both versions, caregivers can access customized content, shop from the marketplace, and use the myCommunity resources.
UnitedHealthcare has received positive comments about their Caregiver solution, that it “saves time” and they would “recommend it to other caregivers”. To date, UnitedHealthcare has also noticed that many users are in the early stages of caregiving.
Future Solutions for Caregivers
“While it will take the rest of 2016 to build the volume of users, we will continue to grow our marketplace through strategic partnerships with product and service companies. We are especially interested in technology solutions for caregivers”, shares Dr. Vidya Raman-Tangella.
UnitedHealthcare is planning to leverage all customer service touch points to identify caregivers who are currently moving along the care journey or will be on the journey soon as potential users of the solution.
“Throughout the year, we will learn how this program is delivering value to caregivers and care recipients. With Boomers turning 70, we will be particularly interested to see how our offering will be used to support the boomers as they retire as well care for their loved ones”, explains Dr. Raman-Tangella.
“This program and others from UnitedHealthcare are making it easier and more convenient to people to take charge of their health and the health of their loved ones. By using technology and personalized resources, we are helping people to live healthier lives”, Dr. Migliori concludes.
- Short online health assessment to determine if you are a candidate
- Wireless scale provided to you, for daily weigh-ins
- Group of peers who will be your online “team”
- Online interactions with a dedicated, professional health coach
- Daily and weekly tracking of your progress with your coach and team
- The information has been helpful. I know that if I do what it says, I can avoid diabetes. If I don't, I am almost sure to be a diabetic.
- Nice to have others going through the same struggles and working together for improvement
- Currently in the 9th week of the program and I have lost 17 pounds. I love the app. I hope that at the end of the 16 weeks my scale will continue to work with the app and the tools I have been using will still be there.
In January 2015, Stanford Medicine launched ClickWell Care, a new type of Primary Care clinic which leverages technology to allow patients to virtually connect with their own Stanford primary care clinicians and wellness coaches via video or phone visits. Patients use the MyHealth mobile app to schedule and conduct a video visit and share home health device data with the care team. Through this model, patients can choose to receive all of their primary care including integrated wellness coaching virtually, unless the physician indicates the need to come into the clinic for vaccinations, pap smears, procedures, or other physical exam needs.
“Initially we created this virtual model for our ACO. We knew that 18-30 year olds were not interacting with primary care and were choosing to go to the Emergency Department or urgent care for their needs. During focus groups with this patient population, we learned they were so busy and didn’t have time to come into the office but really valued the relationship with their doctor. They wanted to receive care from their doctor but it wasn’t available in a way that was convenient to them. We knew that we needed to use technology to help support this relationship and not replace it”, explains Sumbul Desai, Medical Director ClickWell Care and Vice Chair of Strategy and Innovation in the Department of Medicine at Stanford University School of Medicine.
ClickWell clinicians and coaches support healthy patients and the ‘rising risk’ (e.g. up to 2 conditions), who are employees of Stanford University, Stanford Adult and Children’s Hospitals. With this highly educated, tech savvy patient population, there is a tremendous opportunity to leverage mobile tools to enhance the patient experience.
Patients see a doctor for primary care visits and engage with a wellness coach on health goals (i.e. weight loss, stress, activity, and nutrition) and to receive support for chronic conditions (i.e. diabetes, hypertension and hyperlipidemia). “The average age of a ClickWell patient is 36 years old. However, we have a growing group of 40-65 year olds, part of the ‘rising risk’ population, who prefer to do the majority of their visits virtually. These patients feel comfortable interacting by phone or video because they have a better understanding of the healthcare system and their health goals than our younger patients”, Desai shares.
The ClickWell Care program is designed to give patients complete control over how they want to access and interact with their doctor/coach and convenience of extended hours. Although patients have the option of scheduling a face to face appointment, they are incentivized to participate in a “no fee” virtual phone or video visit. Patients simply log into the MyHealth portal for their virtual appointment.
To date in the ClickWell program, there have been 2,142 visits; 43% conducted in-person, 32% through phone visits and 25% via video visits. ClickWell staff have seen 1,223 patients. Although 30% of new patients start off with a virtual visit, most prefer to meet their doctor first in-person. After an initial face to face visit, 60% opt to see their doctor virtually for their return visits via phone or video.
All patient information from the virtual visit is transmitted to the Epic EMR and is accessible through the MyHealth portal. Patients can ask follow up questions through the portal. When patients need to have blood work done, they are directed to the lab without having to come into the doctor’s office, and lab results are incorporated into the EMR with portal access. “Stanford was the first to use Epic’s integrated telemedicine service because we wanted this visit information available to patients in the portal and clinicians in their daily workflow”, confirms Lauren Cheung, Physician, ClickWell Care, and Medical Director, Strategic Innovations at Stanford University School of Medicine.
“One myth about telemedicine is that many patients choose to do video visits over phone visits. The truth is that it is an extra effort for the patient to participate in a video visit since the patient needs to be in front of a computer or mobile screen versus the phone visit which can be done while walking around”, Cheung adds.
“Back in 2013, we rolled out video visits as part of our primary care practice but we didn’t see a strong uptake. When we conceived the ClickWell Care program, we knew that we needed to introduce wellness coaching to provide a complete overall healthcare experience and deliver a higher level of healthcare service to our patients”, describes Desai.
Strong collaboration with IT and Operations have been pivotal in implementing this new care model. Through this collaboration, ClickWell has been able to leverage the new MyHealth app developed internally and has worked closely with IT to improve the platform and video visit capabilities to provide an excellent patient experience.
As part of the ClickWell Care program, the MyHealth mobile app helps strengthen care collaboration. The doctor/coach prescribes the health tracking app to the patient as a way to monitor key measures which may include steps, weight and blood pressure. The patient uses the MyHealth app to upload tracking data from Withings, Fitbit and Apple HealthKit to the EMR, sharing health status between visits. “When I see a patient with blood pressure trending higher, I ask the patient to schedule an online visit so that we can discuss how to address this through diet or medication changes”, Cheung explains.
ClickWell Lessons Learned
The Stanford Medicine team has gained insight into ClickWell Care program usage, the telehealth platform and mobile app to bring the most value to primary care patients and providers. They understand that it is not about the technology but instead about how the technology is put into the care model through a program.
Patients have shared many positive comments about the ClickWell Care program:
“Video visits allowed me to continue with pressing work concerns, instead of taking time off work to travel to a clinic. Video visits allowed me to chat with a Doctor late in the evening, and appointments were very easy to get. I felt that my virtual care was more personalized and provided a better experience.”
“I have not had many medical issues until recently. It is such a relief being able to ask questions and get answers quickly. My wellness appointments have me watching my diet and exercise regimen. Everything is done efficiently. I cannot say enough about the whole team that has been watching over me.”
“My experience with the ClickWell Clinic has been extremely informative and remarkably efficient. The flexibility they offer works perfect for people with busy schedules, without sacrificing the quality of care. The model of the Clinic makes other forms of healthcare communication feel outdated.”
“I have never had better communication and quicker responses than I have since becoming part of this program. I travel a lot and therefore keeping up via phone calls is not that practical. Being able to send messages electronically and to have an appointment via video chat is ideal.”
Doctors and wellness coaches have provided mostly positive feedback as well:
“Overall my experience with virtual visits in the clinic has been very positive. Compared to my previous experience with only in-person visits, it seems like the virtual option may make wellness patients more likely to continue with follow-ups. The integration with the doctors is also helpful in learning more about the patients and providing well-rounded care. It is a unique experience to be able to discuss treatments so closely with the patient’s doctors and in such a timely manner.”
“The integration of clinical care with wellness coaching has been phenomenal. I couldn’t imagine going back to health coaching without it. I am able to provide more targeted, individualized, and thorough care to my patients since I have full access to their medical records, provider notes, and work directly with their primary care physicians. Working directly alongside physicians has helped me to expand my knowledge on chronic disease management, stay up to date on clinical guidelines and recommendations.”
“As a provider, the technologies we use in this clinic allow us to quickly connect with our patients and address concerns for our patients proactively. The extended hours also allow for expanded patient access, as well as a flexible schedule for providers who staff the clinic who may desire alternative hours outside of the usual 9-5 business day.”
“Through our discussions with patients, we have also heard some suggestions for change. In the beginning, we were contacting patients to convince them to switch from in person to virtual visits. This frustrated some patients and most wanted to stay with the modality that they had initially chosen”, Desai shares.
Future ClickWell Care
As with other healthcare systems across the country, Stanford Medicine sees what is happening with the retail pharmacies increasing care access to patients. However, they believe this only fragments care because the visits are outside of the patient/doctor relationship. ClickWell Care is designed to be “longitudinal” and not episodic.
In 2016, Stanford Medicine is looking to extend into specialty care. “We are interested in integrating preventative cardiology for our patients since care entails discussing and improving risk factors for cardiovascular disease, which can be done virtually. Preventative cardiology patients would also benefit from wellness coaching to improve their risk factors for disease.
We also want to expand the use of connected health devices. Currently, very few patients upload and share their data with our care team. We are planning to incorporate this health tracking into a program for a patient population (e.g. specific chronic conditions) and integrate this information into clinical workflow to ensure that these patients receive excellent care. With our Precision Health initiative, we are not just interested in treating illness but rather finding tools to deliver a personalized health and wellness experience to ensure the best outcomes”, Desai concludes.
During the last eighteen months, the Ochsner Health System has moved into new territory, meeting consumers where they are, from their OBar, a retail genius format to patient hypertension pilots with the Apple Watch to drive behavior change.
As an innovative healthcare organization, Ochsner, a large Louisiana- based health network with 12 hospitals, 40 clinicians and an a 1,000+ Physician Group Practice, is committed to helping consumers use mobile and wearable connected health tools for self- management and care collaboration
It all started back in late 2013 when Dr. Richard Milani, now Chief Clinical Transformation Officer and Vice Chair of Cardiology at Ochsner, observed what was going on nationally, a tremendous growth of mobile phone and smart apps. “At the time, I noticed that a lot of people didn’t know much about the health apps and wearables or were fearful about how to use them. My background is in preventive medicine”, explains Dr. Milani. “I saw a powerful opportunity for Ochsner to empower consumers to use mobile technology to enhance their health, opening the door to favorable behavior change.”
OBar, Retail Genuis Bar with Apps & Devices
After more than nine months of planning, Ochsner launched their OBar in early 2014 at the new Ochsner Center for Primary Care and Wellness. The OBar is located in the lobby to attract people walking by as well as patients. The retail store is welcoming with digital tablets loaded with vetted mobile apps to support consumer health, “non-clinical” genius types to answer questions, provide guidance and sell discounted devices (i.e. Activity Tracker, wireless scale, blood pressure cuff and glucometer). “We created this retail setting to show people how to make themselves healthier on their own, independent of their health system. We also felt that as a health system, we could show you which health apps were good and can help you get the app loaded on your phone to begin using it.”
Ochsner wanted to go further, tying the OBar into their primary care services. Dr. Milani and his team created a prescription pad for their PCP offices, which lists the types of available apps and devices. The doctor simply checks off, hands the patient a prescription pad sheet and directs him downstairs to the OBar. Since this extension into primary care, clinicians have heard back from their patients about how the apps and devices have helped them make better health choices around activity, diet and their disease. Patient feedback has motivated these clinicians to tell others about the OBar.
Dr. Milani went on to explain that the OBar initiative is not designed to be a profit center. As a non-profit, Ochsner is most interested in helping people stay healthy and has invested in a retail format as a way to be sticky to attract and keep consumers coming back. As with any retail store, visitors walk in and out which makes it challenging to capture and measure the value that consumers have gained from using these apps and devices. Through anecdotes, however, Ochsner has heard about the weight loss, the knowledge about “buying the right foods” and the ability to better “understand my disease”, which has helped many consumers visiting the OBar.
Apple HealthKit & Epic Integration for Connected Health
Ochsner was the first hospital to integrate the Apple HealthKit with their Epic system. This integration powers their Connected Health programs. While the patient is still in the hospital, she is given a tablet to answer a detailed questionnaire. Hypertensive patients, for example, are asked sodium consumption, medication adherence and affordability, social situations, depression, physical activity, BMI, sleep, Health literacy, Patient activation and more. Ochsner believes that patients respond more truthfully to the tablet.
“We are phenotyping patients based on their specific disease and psycho- social measures that are fed into algorithms to personalize the care plan and decision support tools”, Dr. Milani explains. “Ochsner started with Heart Failure in early 2014, with a program for CHF patients to avoid readmissions through weight monitoring. In February 2015, we launched our Hypertension Digital Medicine Program, monitoring blood pressure and heart rate. “With the HealthKit/Epic integration, we are able to use the patient’s unique responses to the survey combined with the monitoring data to tailor the intervention to the individual”, adds Dr. Milani. Ochsner care providers monitor the dashboard to determine which patients are the priority today and to see the task check list for action.
The national data reflects that currently, only 50% of individuals diagnosed with hypertension (high blood pressure) have their blood pressure under control, or at goal. Lack of achieving goal blood pressure means that these individuals have significantly higher rates of stroke, heart disease and kidney failure. Ochsner has enrolled only patients that have failed to meet control blood pressure goals, and using this integrative approach, has achieved more than 60% control rates within 2 months.
Dr. Milani and his team wanted the patient to see his progress in the program and designed an insightful report, which visually displays results and progress, quantifies risk and describes how the patient can reduce that risk. This program report is available in the patient portal and is also mailed monthly to the patient. “We decided to mail the report because we wanted the patient to have the opportunity to share the report with their family and to have the discussion about how they are doing in controlling their blood pressure in order to strengthen every day support”, admits Dr. Milani.
In addition to the program report, program participants receive ongoing mobile texts for motivation and encouragement.
Ochsner closely tracks, monitors and has presented very positive patient outcomes of their Integrated & Connected Health programs. One interesting insight that Dr. Milani has shared is that these participants are more successful in the beginning when they have the OBar support. “A Hypertensive patient can go to our OBar, get the program app downloaded on her phone and a demonstration about how to use the devices. This is especially important with older patients who may not feel comfortable getting set up over the phone. We realize the importance of providing this face to face technology support for our Connected Health program and are adding OBars to our other regions”, confirms Dr. Milani. Ochsner is planning to launch three more retail OBars by the end of the year.
Apple Watch for Patient Pilot
Dr. Milani views the Apple Watch as a behavioral change tool. As a foundation, this is a wearable, with many non-health features which captures the consumer’s attention and motivates consumer engagement. It takes the consumer’s focus off the phone and onto the wrist to communicate time as well as personal and professional messages.
Ochsner is designing a study to understand the potential for changing the consumer’s behavior around health. They will be enrolling hundreds of hypertensive patients with the goal of increasing physician activity and improving medication adherence.
Dr. Milani mentioned two of the health related Apple Watch apps which he plans to incorporate to help patients achieve the pilot goals. “There is a WebMD app which is a great medication reminder. It taps you on your wrist and shows you the picture of the pill that you need to take at that time. This is important because 50% of patients with chronic disease do not take their medications as prescribed. The second built-in app is for physical activity which can be used to set goals. It will tap me and remind me to stand up every 50 minutes. I can also see how I am doing against my activity goals”, shares Dr. Milani.
For the Apple Watch pilot, Ochsner will compare the outcomes and behavior change for patients in their Hypertension Digital Medicine Program with a subset of patients who also have the Apple Watch medication and activity reminders and tracking. Throughout the pilot, Dr. Milani and his team will be closely monitoring whether and how these apps impact positive patient behavior change.