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Entries in chronic care management (6)

Ochsner Health System’s Digital Medicine Program Success

January 12, 2023

Digital Medicine is a nationally recognized, clinically proven program revolutionizing how we treat chronic conditions combining digital tools and engagement with a dedicated care team.

Ochsner O Bar Supports Patient's Digital Health needsIn 2015, Ochsner Health launched its first Digital Medicine Program for Hypertension. Since publishing success outcome measures in The American Journal of Medicine, Ochsner’s Chief Clinical Transformation Officer Dr. Richard Milani, and his team have built on the framework to support patients with chronic conditions (e.g., Diabetes, COPD) and Maternal care. Over 30,000 patients have participated in an Ochsner Digital Medicine Program.

With the cost of chronic care, including indirect costs (productivity loss) reaching $3.7 trillion a year, Ochsner is focused on better managing chronic care through three key levers: medication management, behavioral change, and frequent data collection from home.

Milani believes that a successful Digital Medicine Program must:

use the latest guidelines for medication management, important because ideal medications are always changing, and a certain medication may be more effective for one patient (profile) than another.
be designed with behavioral science to impact lifestyle change, which includes everything from delivering the right type and timing for nudges to aligning patient needs with right level of high touch care support.
leverage data captured and presented within a reasonable time so that clinicians can respond before the patient’s health becomes a problem.

Dedicated Team, Centralized Monitoring

Ochsner’s Digital Medicine programs are supported by a dedicated team of over 60 professionals, including clinicians, coaches, pharmacists, physical therapists, behavioral scientists, IT developers, technology engineers, user experience, content specialists, data scientists and advanced analytics.

Team members help patients throughout their program journey, with onboarding, educating and ongoing care support. An important benefit of having one Digital Medicine team is that the program can be personalized to the patient’s specific needs (e.g., required monitoring devices) and supported by the same clinician and coach.

EMR Foundation

“The technology foundation of our Digital Medicine Programs is the EMR Epic,” explains Milani. “Our patients are given clinically validated devices approved for the program, with device data flowing into the EMR.”

Ochsner has evaluated and selected a set of devices for this program for each condition, which patients are required to use to connect into the Program. Ochsner distributes the devices and is the point of contact for any technical issues.

Patients access their Digital Medicine Program through the Epic portal My Chart (via website and patient mobile app), where they can view trends on device measures, access educational information, complete assessments, and exchange messages with the Digital Medicine Care team.

“For our clinicians, we have designed dashboards which help triage and prioritize patients based on incoming patient health data including Social Determinants of Health,” says Milani “We have set up alerts for our program care team based on selected physiological and inputted measures. Other providers of the patient’s care can access information in Epic, including a Monthly Report.

Patient Digital Medicine Program Experience

Ochsner Digital Medicine Patient After a referral from his physician, patient Peter (not his real name) is invited through Epic to participate in Ochsner’s Hypertension Program. Participating in the program means that Peter can reduce time off from work and save time driving time for some appointments.

Peter has the option of having the device(s) and program setup information mailed to him, or if nearby, Peter can stop by Ochsner’s O Bar – a physical location that allows patients to test drive more than 100 Ochsner-approved health apps and purchase devices. There’s a technology specialist behind the counter to answer questions and give app demonstrations. (Think genius bar to support patient health technology).

Once Peter sets up his blood pressure monitor, his measures are sent to his care team. If any measures are out of range, his care team will reach out to discuss any possible changes needed. Peter’s coach sets up personalized messages regarding lifestyle changes needed and reminders to keep him on track with taking his medication and taking his readings. Peter can communicate with his coach via SMS texting, My Chart messages or via phone.

“We are seeing that patients prefer to communicate asynchronously with their clinicians and coaches, so we are giving them the tools to do so,” says Milani.

Digital Medicine Program Success

“We evaluate success based on a few key measures,” says Milani. “We look at outcomes and are seeing a consistent 2-3 times improvement in control rates with our program. We also look at Net Promoter Scores (NPS) and we are getting very high patient satisfaction scores of 87-90.”

Ochsner recently conducted a pilot program (beginning in June 2020 and ongoing) to investigate how digital medicine with remote patient management can improve outcomes for Medicaid patients battling chronic diseases like Hypertension and Type 2 Diabetes. The results were statistically and clinically significant. Enrollment in Ochsner Digital Medicine brought nearly half of all out-of-control Hypertension patients under control at only 90 days, which was 23% more likely than usual care. Control rates continued to improve as patients remained in the program during its first 18 months. More impressively, 59% of people with poorly-controlled diabetes achieved control over their condition as part of the digital program – a rate twice as high as usual care.

Most patients achieved control of their hypertension and diabetes within 90 days of beginning the program, even those who had poor control prior to enrollment.

In addition to improving health outcomes, participation in the digital medicine program resulted in high patient satisfaction, with a net promoter score greater than 91 for Medicaid participants. This is consistent with the high patient satisfaction with digital chronic disease management programs at Ochsner among non-Medicaid patients.

“We're offering patients compassionate human care combined with the power of technology, and we’ll continue to expand these programs to help more patient populations”, Milani concludes.

Success in their words

Patients:

“My care team has been really helpful. They’ve explained things to me… offered me suggestions. I really like the fact of daily accountability. I’ve lost about 103 pounds. I feel better. I have energy that I didn’t have a year ago.”

“I know I’m sleeping better–my hair, my skin, my vision–just different things that you start to notice that we take for granted that are all tied into our blood pressure and blood sugar. I’m a living testimony that it (the program) works! I know for a fact Ochsner Digital Medicine has saved my life.”

“I feel like this is more normal. Someone’s got my back and… I will be able to use [the program] for the rest of my life.”

“The Ochsner Digital Medicine Care Team helped me by guiding me in every way possible – giving me tips on my diet and adjusting my medication on the fly. They are a good support team.”

Staff:

“I love the Ochsner Digital Medicine program. As a physician, I love having the Digital Medicine team helping me because it’s like having other coaches on the team.” Dr. Victoria Smith

Ochsner’s Digital Medicine Program is available to employees across their health system.

“The Ochsner Digital Medicine program is one of the most important components of healthcare for our (employees). If I can offer better benefits and possibly reduce healthcare costs, why wouldn’t I? We have had employees sign up for the hypertension and Type 2 diabetes programs and have seen many positive results in a short period of time. The program lets your employees know how much they mean to you by investing in them”, Chief of Administration, Chris Kaufmann

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UCSF's Comprehensive Co-Design Approach for Pediatric Patients growing up with Chronic Illness

April 27, 2021

The journey for pediatric patients with multiple co-morbidities can be complex, with some patients receiving care from 20+ providers. Jan Yeager, Service Designer, UCSF shared experiences co-designing a Chronic Illness Center with patients, caregivers, UCSF physicians and clinicians, and community providers at MadPow’s 2021 Health Experience Design Conference.

5 Questions in 5 mins, Interview by Sherri Dorfman, MBA, CEO Stepping Stone Partners

Q1. What are your stakeholder groups and how are they engaged in UCSF’s Pediatric Care Service Design process?

A1. Because this is a complex undertaking, we wanted to make sure that we integrated all of the key perspectives in our design process. We have a core team including myself, three providers and a program manager and then three formal workgroups. Two of the groups work fairly independently and are focused on two important facets of wellness, mental health and transition to adult care. The latter is critical to ensure the care ecosystem on the pediatric side can be replicated on the adult side. Our main working group “Clinical Care Delivery & Design Group” includes nurses, NPs, social workers, parents and young adult patients. We meet monthly to review our work in progress and collectively work through issues. We are also lucky to have access to the volunteer-based UCSF Youth Advisory Council and the Family Advisory Council which we tap into for input on aspects of our work.

Q2. What has been your biggest challenge working with these different stakeholder groups?

A2. It’s less of a challenge and more of a learning how to bridge different styles of communicating and working in the context of the design process. Physicians are excellent verbal communicators for example, while designers tend to communicate visually. Designers have a ‘try it out’ mindset, which can be uncomfortable in a risk averse environment. Not every tool we have introduced has been embraced, so that has been a learning too, finding the right way to situate a tool into the work.

Q3. How have you addressed this challenge, working together on defining a better pediatric patient experience?

A3. It’s mainly been through putting the tools into practice. For example, continually translating the dialog into visual models so that everyone can collectively view, reflect and discuss has helped shape the work. It’s becoming a familiar way to both communicate and work.

Q4. As you reflect on this Service Design process over the past year, what has been the most surprising?

A4. According to our initial plan introduced over a year ago, we would have been much further along in the design process. But we are essentially still in the discovery phase looping back continuously as we uncover a need for more data or to include a perspective we overlooked. This may be because of the complexity of the patient population we are designing for and as well as the need to collaborate with a large number of stakeholders as we weave all the pieces together.

Q5 Based on what you know now, what would you have done differently to guide this project?

A5. We would have started with a more formal orientation to Human Centered Design methods and tools. Some team members came into lead roles a few months into the project and we missed an opportunity to better align our roles and process. It’s been a continuous learning experience but we are beginning to see the foundation laid from the past year’s efforts.

UCSF’s Pediatric Care Service Design process benefited from input and guidance provided by patient -centric and patient representative stakeholders, creating a holistic and better care experience.

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Kaiser Permanente’s Reimagining Health Promotion & Behavior Change with Patients

April 26, 2021

As one of the largest metabolic and bariatric surgery centers in the world, Kaiser Permanente Southern California sought to reimagine how it prepared and supported its patients every step of their journey. Kelly Dumke, DrPH, Senior Learning Consultant from Kaiser Permanente’s Center for Healthy Living presented their Human Centered Design process insights at MadPow’s Health Experience Design Conference HxD 2021 within the Person- Centered Care Experiences track.

5 Questions in 5 mins, Interview by Sherri Dorfman, MBA, CEO Stepping Stone Partners

Q1. As a “non-designer”, how did you learn to approach this member program through a new lens?

A1. At the very beginning of this initiative, the Human Centered Design (HCD) at Kaiser Permanente Training taught me how to use the core tools and practices of human centered design and also gave me coaching as I learned to apply it. Their model of both practicing HCD and spreading the mindset and methods throughout Kaiser Permanente is truly inspiring. Overall, human centered design empowered me to embrace designing WITH patients (and not just for them) and it makes my job more fun and (hopefully) much more impactful.

Q2. You mentioned working with your clinicians to identify patients either going through or considering going through the bariatric program. Your data indicated that there were disparities in outcomes. How did you capture insights from patients who were not successful?

A2. Our clinicians gave us names of many patients who had gone through our program, but we found that those who were willing to talk and join our codesign sessions were typically successful with the surgery. We were not getting the perspective of those who were not as successful or struggled along the journey. We realized that we needed to do a set of ethnographic interviews to understand their specific situations to uncover barriers. We also interviewed caregivers to gain insight into their support system.

Q3. What was the biggest surprise that your team uncovered about these bariatric patients during the “Understand Phase”?

A3. We had a patient tell us “I had surgery on my stomach, not on my mind”. We realized how important it was to design this program not only to prepare a patient, but to address and support their mental and emotional health before and after the surgery. Many patients also disclosed experiences with trauma in the past that may play into maladaptive coping mechanisms that contributed to weight gain.

Q4 While imagining solutions for your patients, you invited the staff to be join the process. How did their perspective enhance the design process?

A4. We invited our staff to observe the patient’s co-design to hear needs firsthand. Then we asked the staff to participate in a co-design session and brainstorm solutions and ideas together with patients. For example, one operational issue that surfaced was that some patients did not even feel comfortable coming into our medical centers that didn’t have furniture that could accommodate different body types. Together, we explored solutions such as larger more comfortable chairs for patients in the waiting area.

Q5. How did your project team use the patient centered design insights to build a stronger understanding between patients and providers?

A5. During workshops, we devised eleven personas to define different reasons why patients were in the program such as losing weight to get other surgeries or improving their health. By sharing these profiles with the staff, we helped them better understand the differences in patient motivations for the surgery. We also created a top 10 list of what patients want you to know up front when considering surgery, which enables the staff to more effectively set expectations with patients at the start of the program.

Notice how Kaiser Permanente has co-created with patients and staff to design a better care experience at every journey step, across different channels, from in- person appointments to digital patient education tools.

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Ochsner Health System’s O Bar & Digital Medicine Program Success & Expansion

October 27, 2020

Ochsner Mobile O BarOver five years ago, Ochsner Health launched their O Bar (Apple genius-like concept) to support patients getting started with digital health tools. Today, Ochsner has nine physical O Bars located in the bottom floor of their health centers and one mobile O Bar.

Although any Ochsner patient can visit the O Bar to begin using a curated set of digital health apps and devices, patients who are invited to join a digital medicine program can go to the O Bar to get set up with selected digital tools to manage and monitor their health journey. Digital medicine program participants have the option to have their digital tools sent via the mail, without going to the O Bar and can call their program tech support for any assistance. Pre-Covid, about 5-10% of patients chose to receive their digital health tools by mail. During the pandemic, it is mostly all mail.

Ochsner Hypertension Digital Medicine ProgramTo date, Ochsner Health is offering digital management initiatives for hypertension, diabetes, pregnancy and the latest COPD program. Patients do not need to have access to WIFI to participate, just a smartphone or tablet. Less than 5% of patients participating in the digital medicine program use the tablet and instead have their apps downloaded to their smart phone.

“Our digital medicine programs are realizing 2-3x better outcomes rates than the standard of care”, explains Dr. Richard Milani, Chief clinical transformation officer and innovationOchsner Medical Director, Ochsner Health. “In order to understand how these programs were designed, it is important to take a step back and think about how we need to help patients manage their chronic condition(s). First, we need more frequent data to know at any point in time if their chronic disease is under control. Second we must make sure individuals are prescribed guideline-directed pharmacotherapy. With the number of new medications coming onto the market and medical research about the profile of patients experiencing the best outcomes, we must be sure patients are having the best chance to achieve an optimal outcome. Finally, we need engage our patients on the “right behaviors” (e.g. nutrition, fitness, stress reduction).”

"We set up our digital medicine programs to be supported by a dedicated team who interacts with and manages the patient’s condition(s)”, shares Dr. Milani. “Their doctor invites the patient to join the program, but it is a digital medicine team who responds to the incoming data and alerts from the digital health tools.” Ochsner’s digital medicine team consists of a pharmacist/APP to help the patient with the “right guideline-directed medicine” and a health coach to provide guidance on lifestyle decisions using behavioral health science techniques. Patients that are on two of Ochsner’s digital medicine programs engage with the same pharmacist/APP and health coach, creating a holistic approach to patient care.

Patients access all of digital health tools in the digital medicine program area with their patient portal. A patient logs in to access patient education information (videos), communicate with her team by scheduling a phone call or sending asynchronous messages and view monthly reports which shows how she is doing, and progress made over time. The patient can also contact the digital medicine team for technical support for their digital tools, which is rare because these connected devices are easy to use for even less tech savvy patients.

Ochsner Connected Mom Pregnancy Digital Medicine ProgramIn addition to appropriate connected devices given to patients to capture and transmit key measures (e.g. diabetes/wireless glucometer, hypertension/ wireless blood pressure cuff, COPD/wireless inhaler and pregnancy/ wireless blood pressure cuff & wireless scale), patients receive texts to capture changes in condition (e.g. COPD severity level), track self- efficacy measures or to be notified of a health concern (e.g. warning about the poor air quality level). Patients have the option of connecting in and sending more information such as weight measures from their own digital scale or steps from their fitness tracker to share with the digital medicine team.

Program Success Measures & Expansion Plans

Ochsner has enrolled more than 15,000 patients across their digital medicine programs.

Over the past 5 years, Ochsner has received positive feedback from their digital management team (e.g. Pharmacist, Health Coach) and from patients in the program.

“The role of a clinical pharmacist isn’t always to add more medicine. We work with each person to incorporate lifestyle changes and medications that are right for them. This includes stopping or decreasing medicine doses when lifestyle changes lead to improved health.” -- Carrie, Clinical Pharmacist

“I work with individuals to make small, achievable goals that will not only improve their health, but ultimately improve the way they feel mentally and physically. This allows the patient to feel confident in themselves to make healthier choices in any situation.” – Christina, Professional Health Coach

“I like that it is private. I don’t have to take a blood pressure reading at a Walgreens or CVS. It’s encouraging to know that the lifestyle choices I’m making as well as my compliance to my drug regiment is having a positive effect.” – Alan, Digital Medicine Hypertension Program

“For anyone who has doubts about joining the program, I would say step out and take the journey.” – Lance, Digital Medicine Diabetes Program

“You get a lot out of Ochsner Digital Medicine. You get a family who is by your side every step of the way.” - Gaylan, Digital Medicine Hypertension Program

In addition to patient and staff feedback, Ochsner uses a set of quantitative measures to evaluate success. Dr. Milani is proud to share the Net Promoter Score of patients in the digital medicine program of 87.5, which indicates a high level of recommending the program to others.

Dr. Milani explains, “the key success measure is the reengineering of chronic disease care into a new model of care delivery. Our metrics of success are control measures for the disease (i.e. better blood pressure control, better diabetes control, etc.).”

Ochsner has plans to grow their digital medicine programs in 2021. “We are expanding the population we currently serve and will be adding more disease categories (like lipid management and others). We look at the prevalence of disease burden and the opportunities for better control when deciding on new digital medicine programs,” Dr Milani concludes.

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Carolinas HealthCare System Pilots Prevent PreDiabetes Program via Virtual Group Coaching

February 2, 2016

OMADA HEALTH CONSUMER VIEW

The Centers for Disease Control and Prevention (CDC) has revealed that 86 million, 1 in 3 Americans now have prediabetes, and 9 out of 10 of them don’t even know they have the condition. Unless there is an intervention, 15% to 30% of people with prediabetes will develop type 2 diabetes within 5 years. The CDC predicts that if current trends continue, 1 in 3 Americans will have diabetes by 2040. On average, diabetes patients cost approximately $10,000 more every year than those without the condition. Like many chronic conditions, risk for type 2 diabetes can be reduced through lifestyle changes.

“We knew that we needed a way to leverage technology to assist our employees who have prediabetes. With our employees spread across 900 locations in North and South Carolina, one huge challenge was figuring out how to motivate employees to participate in a prediabetes program that required them to go to a defined place (building) at a defined time, every week, and do this for 16 weeks.” explains Dr. Zeev Neuwirth, Senior Medical Director of Primary Care at Carolinas HealthCare System.

Carolinas HealthCare System (CHS) was approached by Omada Health with a solution. Omada's online Prevent platform delivers a 16- week National Diabetes Prevention Program recognized by the CDC, with two years of peer-reviewed published data demonstrating effectiveness.

Neuwirth explains further, “We were very interested in the Omada solution. First, it had some really sophisticated and elegant behavior change mechanisms making it much easier for people to create and maintain healthier habits. Second, it was online and asynchronous – meaning that people did not have to show up at a certain time,or certain place. They could use the program from the comfort of their home, and at any time of day or night which makes it much easier for people to sign up and stay with the program. Third, Prevent is based on a proven 16-week program. The Omada platform provides the social connection with a health coach and other participants to sustain behavior change, continuous real-time feedback and daily tasks for habit formation."

“When I participated in the program, I looked at my weight on the Omada scale daily. This led me to be much more aware of my eating and exercise habits. But even more than that, having the bluetooth enabled scale in my house, connected to the coach, I felt like I was part of a larger community, all focused on becoming healthier. Stepping onto that scale almost felt like being transported – the social connectivity factor was much more powerful than I anticipated”, Neuwirth shares.

In early 2015, CHS began offering this solution to employees (called teammates) at risk for developing type 2 diabetes. To promote this new program, CHS leveraged their LiveWell Team which had trusted relationships with teammates across different locations for a “boots on the ground” approach. CHS teammates were emailed a complete Prevent program description, with their participation responsibilities clearly communicated.

Prevent Program includes:

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

Interested teammates clicked on the email link to answer the Prevent screening questions. Qualified teammates enrolled into a cohort of 10-12 anonymous teammates, were assigned to a coach from Omada Health and received a Welcome package with a bluetooth scale.

During the 16-week Prevent “Core” phase, participants complete one interactive health lesson each week, covering physiological, social and psychological aspects for change reinforced with interactive games. After the Core phase, teammates move into the “Sustain” phase with access to more education and a broader peer group for ongoing support.

OMADA HEALTH COACH VIEWTeammates and their coach collaborate via the Omada Health platform. The coach monitors progress and gives real-time feedback via private messaging, group discussion board, text messaging or by phone. Teammates use food and activity trackers to capture high level daily eating, drinking and movement and engage in “healthy competition” messaging with other group members. Cohorts keep them motivated and accountable. Teammates can see the cohort member’s progress towards the weight goal displayed on the group dashboard by a green circle around their profile picture. Only the coach can view each teammate’s detailed progress page with tracked weight, food and activity information.

Prevent Program Positive Response

To date, over 400 teammates have participated in the Prevent program, with 245 completing the 16-week program.

“Teammates have found it beneficial to participate in the program”, explains Kati Davis, Director Benefit Planning and Wellness at Carolinas HealthCare System. “They are guided by trained coaches, supported by cohorts and can participate when it is convenient for them, from wherever they are.. at home or the work.”

CHS is evaluating the program success through quantitative measures (i.e. weight loss, program engagement) and qualitative feedback.

“Although the primary goal was to engage teammates in the program, we have been very happy with the results - 40% of our Prevent participants have lost more than 5% of their weight. When you are considering the risk for prediabetes, this weight loss has a big impact on the health of the teammate.”

“Our teammates are engaging with the Prevent platform an average of 12+ times each week, completing educational lessons, weigh-ins, tracking food/activity, participating in discussions and exchanging private messages with their coach”, Davis adds.

Teammate comments:

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.

Future Direction for Carolinas HealthCare

“We're working to move away from self-reported health activities to activities that require additional accountability and social support”, describes Davis. “We feel the support from the coach and cohort is very powerful to rejoice in the teammate’s success”.

CHS is currently considering to offer the Prevent program to a wider population at risk for Metabolic Syndrome, where weight is an important factor to monitor and manage.

Neuwirth concludes, “From the perspective of a forward-thinking healthcare provider organization, we are excited about the potential of making significant improvements in the health of the multiple populations we care for – our employees, our much larger patient population, and the communities that we serve in the Carolinas. Reducing the number of people who transition from PreDiabetes to Diabetes is one of the largest levers we have to improve the health of populations and communities. What makes this particular Omada Prevent Program attractive to providers and employers is that it makes it a lot easier and much more doable for the people we are trying to help.”

Note: The Omada Health screen shots above do not display real health data.