Date April 19th, 2013 (Friday) 8:00AM-7:30PM Location UCSF Mission Bay Conference Center 1675 Owens Street, San Francis

1. Date April 19th, 2013 (Friday) 8:00AM-7:30PM LocationUCSF Mission Bay Conference Center 1675 Owens Street, San Francisco, CA 94158 1 1

2. Starting point People are not the sum of their disease states

3. People typically have >1 condition

4. Loneliness as critical risk factor 43% of 1,604 seniors 60+ reported feeling lonely More likely to develop or experience decline, difficulties in: • Activities of daily living • Upper extremity tasks • Mobility • Climbing Associated with nearly 2x increase in risk of death - Archives of Internal Medicine, June 2012

5. We can do better … • Medicare beneficiaries with two or more conditions and functional limitations have the highest costs 15% of beneficiaries 32% of Medicare costs = Individuals who are dually eligible for Medicare and Medicaid are a key subset of this population

6. Using Technology to Support Care for Individuals with Complex Needs Lisa Mangiante, MPP, MPH April 19, 2013

7. What is a “Complex” Patient? No single definition, similarities across populations Medical condition(s) often complicated by psychosocial issues Social isolation Decreasing independence Loss of familial relationships Lack social supports Depression (in elderly Medicare, this is most common) Other serious mental illness (SMI) Navigating the health system confusing & care is fragmented, resulting in lack of engagement and non-adherence While often many things going on that affect health, it’s not always about number of issues, but the particular combination

8. Uninsured/Medicaid/Dual Eligible (from FUHSI) 65 % chronic medical conditions, many with 2 or 3 54% substance abuse disorders 33 % mental illness 45% homeless Seniors w/ Medicare (from IOCP, CMHCB) 69% Congestive Heart Failure 43% Pain 32% Diabetes Mellitus 29% Depression/Psychological (under-reported) 25% Gastrointestinal 18% COPD/ Asthma Often more than one condition Examples of “Complex” Patients

9. Purpose: Assess feasibility and effectiveness of telehealth + care management for people with Serious Mental Illness (SMI) and co-morbid medical illness Major Depression Schizophrenia or Schizoaffective Disorder BiPolar Disorder PTSD Plus Congestive Heart Failure COPD Diabetes Chronic Pain Received remote monitoring device to help manage their medical condition (vital signs, self management & education) Used almost daily (~5x per week) Use of Technology Riverbend Community Mental Health Center

10. Clients with SMI were engaged relatively easily to use the device (Health Buddy) Paranoia or fear of the device present only in a very small number of clients Compliance was high - clients anthropomorphized the device so felt less isolated and more supported by clinical team Positive effects on health measures, symptoms, self-management and illness knowledge Results were especially strong for clients with diabetes Clients wanted more – prompts helped with specific techniques that helped manage symptoms Phase I Successful…

11. Purpose: Assess effectiveness of telehealth + care management for people with SMI and psychiatric instability 2 hospital admissions or ER visit in past year, or >10 calls to crisis line over 3 months Several dimensions of improvement possible psychiatric symptoms service use illness self management improvements in: High cost service use, including ER, crisis team and hospitalizations Psychiatric symptoms (reduced symptoms, depression, overall severity) Illness self-management and knowledge Sense of well-being Quality of life …And Led to Phase II

12. Use of TechnologyCare Management for High Cost Beneficiaries Demo Purpose: Assess feasibility and effectiveness of telehealth + care management for seniors with complex illness Seniors with Heart Failure, Diabetes and COPD Often with co-morbid conditions High risk due to frequent hospital admissions and ED use and risk scoring techniques Results Reductions in cost and hospital use (9% - 13%) for entire population in study Most dramatic in CHF, followed by COPD Results achieved with only 1/3 actually using device

13. Both examples used technology to support the work of a person (not standalone) Workforce impact: technology in both examples enabled care managers to maintain higher caseloads MD impact: patients came to visits better prepared and with better understanding of their conditions, so time more productive CMHCB results were dramatic: greater patient engagement in actually using technology could achieve huge outcomes – but issue not specific to technology Parting Thoughts

14. Citations Lewin Group. Summary report of evaluation findings. Published by the California HealthCare Foundation and The California Endowment. 2008. www.chcf.org. Sample Population Profile provided courtesy of Milliman based on Medicare 5% Sample 2010, Northern California Riverbend Example: unpublished data Baker L, Johnson S, McCauley D, Birnbaum H. Integrated telehealth and care management program for Medicare beneficiaries with chronic disease linked to savings. Health Aff (Millwood). 2011; 30(9):1689-1697.

15. VA Care Innovations Transforming care delivery for improved patient & provider experience

16. VA Overview • 22 Million Veterans • 8.75 Million VA Enrollees • 6.2 Million Patients Treated

17. VA Patient Aligned Care Team • Patient-centered • Ongoing relationship with a primary care team • Patient is full partner with team • Whole person orientation • Improved communication

18. VA Telehealth - 2012 • Provided care to 500K patients • 1.4 million episodes of care • 49% Rural patients • 29% annual patient growth.

19. Clinical Video Telehealth • 150K patients – FY2012 • 44 clinical specialties • Access to specialist and primary care services

20. Store-and-Forward Telehealth • 260K patients - FY2012 • Local acquisition of clinical Images • Remote interpretation • Care Areas: • TeleRetinal Imaging • TeleDermatology • TelePathology.

21. Home Telehealth • 120K patients – FY2012 • Chronic care management • Acute care management • Health promotion/disease prevention.

22. TeleMental Health • 217K telemental health consultations - FY 2012 • 76K patients • over 800,000 consultations since FY2003 • Areas of focus: • post-traumatic stress disorder • Depression • Bipolar disorder, • behavioral pain • Evidence-based psychotherapy • compensation and pension exams

23. Telehealth Outcomes • Utilization Reduction • Bed days of care – 58% • Hospital admissions – 38% • Mental health care bed days of care - 56% • Annual Savings - $2,000 per patient

24. Patient Satisfaction • Home Telehealth - 85% mean score • Store-and-Forward Telehealth –96% mean score • Clinical Video Telehealth - 93% mean score

25. VA Innovation Center • Accelerating VA transformation • Employee innovations • Industry innovations • Prize challenges • Special projects

26. Strategies for Designing Programs and Products for Persons with Complex Needs Health Technology Forum April 19, 2013 San Francisco David Lindeman, PhD Director Center for Technology and Aging www.techandaging.org

27. CTA Technology Demonstration Grants 2010-2012 • Improve efficiency of care delivery • Improve health outcomes • Reduce the cost of care • Improve chronic disease management • Increase the rate of adoption • Medication Monitoring and Adherence • Remote Patient Monitoring • Technologies for Improving Post Acute Care Transitions • Mobile Health Solutions

28. Program Impact: Advancing the Triple Aims • 12 programs focused on reducing 30-day readmissions – 10 succeeded in reducing readmissions – 5 programs achieved a reduction of 50% or more. • All 15 programs measuring patient satisfaction and engagement with care management reported marked improvements • 10 programs measured cost savings and ROI – 9 demonstrated significant cost savings and positive ROI

29. Program Impact: Demonstrating Success At Scale • Of 22 programs, 10 have demonstrated scalability within their organizations or externally to other organizations and 10 others are capable of being taken to scale. • Of the 10 programs taken to scale, 6 have been expanded throughout a health care system, while 4 have been replicated nationally. Central Texas Coach Tool

30. mHealth Diabetes Management Care4Life. Reminder: Time to check your BEFORE meal glucose. Reply with your BEFORE meal glucose reading (e.g. 125). • Family Health Centers of San Diego • Community Health Center and Clinic, San Diego, CA • SMS-based mobile program • Improving diabetes education and behavior change in Spanish-speaking safety net population • HealthInsight • Regional Health Care System and Community Clinics Salt Lake City, Utah – ONC Beacon Community • SMS-based mobile program • Improving diabetes care management and education in safety net population

31. Care4Life | Glucose Monitoring/Education Care4Life. Reminder: Time to check your BEFORE meal glucose. Reply with your BEFORE meal glucose reading (e.g. 125). Care4Life. Before meal readings under 70 can be dangerous. Do you know what to do when readings fall below your target? Text LOW for more info Glucose recordings graph on web portal Glucose reminder System feedback • User can set glucose reminders according to their doctor’s recommendations (e.g., before breakfast daily) • System sends glucose reminders & provides immediate feedback • User can track all glucose recordings on web portal • System sends education messages & tips

32. Care4Life Diabetes Texting Program • Lessons Learned • Patient driven: Patient engagement – the holy grail • Patient enrollment: Multiple methods to enroll patients • Provider efficiencies critical: Minimal cost to provider; no new work; build enrollment and program operations into workflow • Patient Data: Data can motivate and empower clinicians • Challenges: Scalability; attention to patient privacy; linkage to EMRs

33. Telehealth and Remote Patient Monitoring for CHF and COPD Care4Life. Reminder: Time to check your BEFORE meal glucose. Reply with your BEFORE meal glucose reading (e.g. 125). • Sharp HealthCare • Integrated Delivery System, San Diego, CA • Remote patient monitoring to improve care management for patients with CHF and COPD • Patients with multiple chronic conditions; Medicare, Medicaid and uninsured

34. Sharp HealthCare Remote Patient Monitoring Goal: Reduce 30-day readmissions by 30% from 22% to 15% Patient Population: Underserved (Medi-Cal, Unfunded, County Medical Services) with primary or secondary diagnosis of CHF or COPD Intervention: Mobile health device used daily to measure pulse oximetry and functional status via yes/no questions coupled with nurse education and health coaching which included at least two home visits Lean Six Sigma Department

35. Sharp HealthCare RPM Program • Lessons Learned • Program Staffing/Coordinator: Time invested in recruitment of staff resources is time well spent • Patient Selection and Enrollment: Program can’t help every patient; inclusion/exclusion criteria is critical • Assessment of Patient Environment/Resources: Lack of landlines; lack of primary care physicians • Organizational Support: Need for senior /executive leadership support

36. mHealth Medication Adherence Care4Life. Reminder: Time to check your BEFORE meal glucose. Reply with your BEFORE meal glucose reading (e.g. 125). • Front Porch Center for Technology Innovation and Wellbeing • Continuing Care Retirement Center, Los Angeles, CA • Cell phone texting • Addressing medication adherence among active, independent older adults using a mHealth medication texting solution

37. Front Porch mHealth Program • Demonstrating Senior Medication Adherence with Cell Phone Texting Reminders • Goal: Improve medication adherence among active, independent older adults through mHealth solution. • Outcomes: • Mobile alerts and monitoring led to improved medication adherence. • Replicable model that combines education, training, and other resources.

38. Front Porch Medication Adherence Program • Lessons Learned • Utilization: Significant variation in consumer utilization • Patient engagement: Consumer champions are key; embrace feedback & engage in dialogue • Communications: Personalize discussions to consumers and organizations • Technology integration and interoperability: Need to consider at outset • Plan for success: Make sure program will scale; have a Plan B

39. Technology is 10% of the issue 90% of technology deployment and adoption is: Organizational leadership - Champion Organizational familiarity with change management Staff engagement and buy-in Work flow processes/standardized Patient selection, engagement, consumer champions Technology deployment strategy Communication and staff/patient training Using Technology to Support Persons with Complex Needs

40. Tools and Protocols ADOPT Toolkit ROI of RPM Calculator Do-it-Yourself Tool

41. The Center for Technology and Aging • support@techandaging.org • www.techandaging.org

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