More than two years ago, Mass General launched their Ambulatory Practice of the Future, an innovative primary care clinic for employees and adult dependents. Developed as a Patient-Centered Medical home and ACO, today they support 3,000 enrolled patients with three doctors and two nurse practitioners.

This innovative practice was designed for and with patients for a better patient experience. Their experience begins with the initial greeting and extends through ongoing care interactions. There is a strong focus on patient education and empowerment. The care team collaborates to support each patient both in person and online. One of the goals of the practice is to reach patients where they are both physically and with their health.

Designed to Support Shared Decision Making

Once patients enter the welcoming and intimate care setting at The Ambulatory Practice of the Future (APF), they are ready to collaborate with their clinician. Sitting side by side, they review the medical record together and begin the discussion with health goals.

“We actually added a data field to the record called ‘Health and Life Balance Plan’ where we document  mutually agreed upon goal(s) for the coming weeks and months and then it is easily reviewed by the patient via their portal after the visit and in preparation for upcoming follow- up encounters”, explains Dr David Judge, Medical Director, Ambulatory Practice of the Future, Massachusetts General Hospital.

This collaborative approach has helped patients who have not historically been able to get engaged around a goal. Dr Judge shares a story about a 54 year old woman with diabetes who was reluctant to discuss next steps in management due to her fear of taking insulin. After allowing her to shape the goals with a focus on other areas of lifestyle management initially, coaching to realize some success and encouraging patience with the process, she has recently decided to proceed with insulin therapy.

Patient Engagement Tools

APF uses shared decision making videos developed by the Foundation for Informed Medical Decision Making to educate patients about screening tests and in managing specific medical issues such as prostate cancer.

Between their visits, patients can access the portal to view their medical information and communicate securely with their clinician. Although the care team can access the EMR from their mobile devices, APF expects that patients will be able to access their portal and records via mobile devices in the near future.

Patients can currently participate in an online visit with their care team. Dr Judge describes one of the complex patients that they monitor closely with frequent virtual visits.  “Mr. K is struggling with end stage renal failure, congestive heart failure and it has become difficult for him to come for office visits. Between scheduled virtual visits, emails from the patient and his wife and monitoring by visiting RNs, we are able to manage his needs fairly well with rare office visits.  We are on the verge of implementing true remote monitoring technologies but currently the patient or RN need to  report the measures (i.e. blood pressure, weight, blood sugar, PHQ 9 depression score, etc.).”

On the prevention side, several employees are using mobile apps to track their daily lifestyle choices regarding exercise and nutrition and sharing the information with their clinicians during their visits.

Future Path to Patient Engagement

During my panel at the recent Shared Decision Making Conference, Dr Judge spoke about some exciting new ways APF will be leveraging technology to engage their patients.

“We will be piloting the concept of 'apprenticeship' in which patients go through a more formal education process with coaching and demonstration of increased knowledge and skill to push the boundary on self management. We are developing programs tailored to specific medical conditions (i.e. HTN, DM and Depression). Goal setting for each patient helps the team to understand how to customize the program and to identify what specific barriers may be preventing success.”

“As we have done with diabetes, we expect that patients will learn not only to change their  lifestyle and make healthier choices but also adjust medication in the management of multiple chronic diseases. The care team will be able to monitor and assist but patients will truly drive their own care more effectively from day to day”, adds Dr Judge.

APF is starting a pilot soon using a mobile tablet that “allows very easy synchronous communication to transmit monitored blood pressure and to enable the patient and team to collaborate around lifestyle management and medication adjustment”. 

The term “apprenticeship” is being used by Dr. John Moore at MIT Media Lab. Dr Judge explains, “I think it appropriately describes the next step in the evolution of making shared decisions with patients. Beyond that is potentially a mastery of health and the potential for patient - to - patient support to grow.  We are hoping to launch both face- to -face and virtual peer to peer interactions in the near future.”  

Technology plays a vital role in Shared Decision Making. Join me as I lead this dynamic panel session and learn how you can leverage tools for improved patient centered decisions.

• Piloting and evaluating SDM tools in the Patient Centered Medical Home to drive physician- patient collaboration for better outcomes
• Leveraging a mobile decision support tool to effectively educate consumers and enable them to evaluate their care options anywhere, anytime
• Discovering and defining a Shared Decision Making opportunity to empower and engage seniors and their families

Moderator:

Sherri Dorfman, MBA
CEO, Consumer eHealth Engagement Specialist, Stepping Stone Partners

Panelists:

> Kyra Bobinet, MD, MPH, Head of Senior Care Solutions, Aetna Emerging Business Group

> David C. Judge, MD, Medical Director, Ambulatory Practice of the Future, Massachusetts General Hospital

> Zev Lavon, MBA, PhD, Director, Enterprise Solution Architecture, CareFirst BlueCross BlueShield

Join me and my panelists at the World Congress Shared Decision Making Conference. 

In 2008, Cisco launched their LifeConnection’s onsite health center which uses a Patient- Centered Medical Home model. Today, it supports over 42,000 employees and their families at Cisco’s corporate campus in San Jose, CA.

Cisco’s LifeConnections' Center offers primary and pediatric care integrated with care services including disease/condition management, health coaching, mental health, pharmacy, physical therapy and chiropractic as well as acupuncture services.

Cisco now has two physical LifeConnections' Health Centers, one at their headquarters and a second location at the Cisco Bangalore, India campus.  In addition, they operate a telehealth location in the Raleigh-Durham area of North Carolina.

Employees access LifeConnections’ services online for health management. “Within our Cisco LifeConnections' portal, our employees and their families can schedule appointments in real-time, view their medical records, communicate securely with their physicians and even send their doctor an attached document such as a food or exercise log”, explains Katelyn Johnson, Manager, Integrated Health at Cisco Systems. 

Cisco’s approach supports the findings from a recent Accenture Connected Health Pulse Survey which found that most patients (90%) want to use technology to self-manage which includes accessing their medical information, booking their doctor’s appointments and refilling their medications. The survey also revealed that patients do not want to give up the interaction with their doctor. 

Technology Transforms the Patient Experience

Working closely with employees and families, Cisco designed the LifeConnections’ Health Center to bring convenience, better care and transparency to the consumer.

Through ongoing interviews with patients, Cisco has heard feedback from consumers who:

     “Do not want to be burdened by the administration of healthcare”

     “Want technology to take away what I don’t like to do (i.e. clip board,

          discharge payment)”

     “Want to spend more time with my physician”

Cisco has used this insight to determine ways to leverage technology within the LifeConnections’ Health Center to increase patient satisfaction including:

Kiosk: Patients come into the Health Center and use a tablet to have a “paperless, self-service, check in” including verifying demographic information, paying co-pays and signing consent forms, taking less than five minutes of their time. 

Flat Screen Monitors in Care Suite: Within the patient-centric care suites, the patient and physician sit side by side to view and discuss health information projected on the flat screen such as the medical record with the latest vitals and lab results, x-rays and educational content about the patient’s condition. Cisco emphasizes the importance of providing transparency to the patient by showing them their medical record, in real time, during the visit. 

HealthPresence in Care Suite: Cisco has recently partnered with Stanford Hospital and Clinics to enable patients to access specialty care (tele-dermatology) through the use of Cisco’s own telemedicine solution called HealthPresence. A nurse assists the patient in the LifeConnections’ Health Center while the Dermatologist connects from the Stanford Outpatient center.  Cisco has found that connecting specialists with patients using this solution offers greater access to specialty care, reduces appointment wait times, and improves patient satisfaction. 

Matching Technology to the Employee Profile

Cisco has put healthcare technology in place to meet the needs and profile of their employees and families.

 “We are a high technology company and our many of our employees are engineers who literally live on-line.  Their average age is 42 years. Our employees expect our healthcare experience to mirror the way they work – which is surrounded by technology.  Specifically, they want technology to help enable care, remove access barriers and overall enhance their experience as a patient.” shares Sharon M. Gibson, Director Healthcare Business Transformation at Cisco.  “Not only do they want to see more information about their health status but they want to see trending data for themselves to better understand how their health stats change over time and how their behavior impacts those results.”

“Our employees are busy and always on the move.  They want to take care of their health in an efficient way.  Soon, we will also offer patients the option of e-visits with their doctors through WebEx, for example”, explains Sharon. “Online or e-visits would help engage employees in their health, whether from home or even remote sites, and bring the convenience that they demand”. 

ManyStrong Social Community SupportAs soon as he walked through the door at Starbucks, I knew something was terribly wrong. I have known Ben for more than ten years and he has never looked like this. Ben appeared extremely exhausted, had lost his smile and gained a few pounds since our last tea together.

After he dropped his keys on the small round table and sat down next to me, I asked Ben what was happening. His elderly mother had fallen again in her bathroom. Ben had been shlepping her from the hospital to her apartment, running to the pharmacy to change her medication for the third time this week and food shopping to make sure she had what she needed. As I listened to Ben, I wondered how his brother Rob or other family members were helping out. Just because Ben is the oldest child doesn’t mean that he needs to take on all of the responsibility. Caring for his mother day in and day out was taking a toll on my friend’s health.

When he stopped talking to take a breath, I started telling Ben about ManyStrong, the new social community initiative from UnitedHealth Group.  ManyStrong is a free new social tool that Ben can use to create an online community to support his mother, Evelyn.  When friends and family ask “how can help”, Ben can invite them to Evelyn’s private community which has tools for them to contribute in some way.

Over the past few years, I have worked with many different social communities but this one is different: 

Personalized Social Community On Demand: Ben can create a community for the specific purpose of supporting his mother.  Within the community, Ben can provide updates and request the help that he truly needs to care for his mother. Knowing Ben, it is easier for him to ask for help this way than it is to pick up the phone to call those who had offered help in the past.

Action Driven Support:  By following the link in Ben’s email invitation, friends and family can provide support in their own way. After all, some are a few miles away and others are across the country.

 - Financial Support: They can donate money which will be placed on a cash card or purchase a gift card for Evelyn.  

- Motivational Support: Her loved ones can leave care messaging to encourage Evelyn on a daily basis, motivating her to get stronger.  

- Story Telling For Support: Ben and others in Evelyn’s community can upload  pictures and videos to share. Seeing a photo of Evelyn walking after her fall may bring  relief to her loved ones. Ben can enter comments that “mom has her dancing shoes  ready” which may bring a smile to their faces, easing their anxiety for a moment.

- Physical Support: When Ben adds new requests for help within the ManyStrong  community, friends and family can take on the responsibility to make a meal, run an errand to the store, spend time with Evelyn or simply check- in on her. The  calendaring feature automatically tracks the need and the person taking on that need for all to see  in the community. 

ManyStrong Back Story

“We created ManyStrong simply to help people more easily help each other.  When people we know get sick, or go through a sudden medical emergency or other serious health event, we naturally want to help them.  They are our friends, our families, people we care about.  It’s tough to know how to help. And with everything that person is dealing with, it’s hard to find out what you can do to help without putting additional stress on them and their family.  That’s where ManyStrong comes in”, explains Kunjorn Chambundabongse (KC), VP Innovation and R&D, UnitedHealth Group.

When serious health issues arise, people turn to online communities for support. Many communities are designed for the individual with the health problem but not necessarily to support the caregiver.  In their February 2011 Peer- to -Peer Healthcare research, Pew found 59% turn to family, friends and fellow patients when needing “emotional support in dealing with a health issue”.

How is UnitedHealth providing a unique social community solution?  KC clarifies ManyStrong’s differentiation. “Yes there are many communities out there doing pieces of this.  Some sites focus on the medical and clinical related side, allowing people to connect with others going through similar illnesses and share treatment data.  Other sites focus on the non-clinical side, such as fundraising or keeping people informed through journaling/blogging.  And you have many people using the big sites like Facebook, but privacy and security are huge problems with something as serious as health.  ManyStrong brings all these tools into one place in a private and secure way, and allows the caregiver community manager to create a safe spot for people to rally together to support a person or family they care about.”

The ManyStrong social community solution can be used to support many different situations such as for a child with the long term illness, a senior aging at home or a co-worker battling a disease. Sometimes companies cannot envision the use cases before launching their offering into the marketplace.  KC has thought about the various situations and shares ”we don’t know exactly how people will use Many Strong but we make it our mission to learn from them. When we look at users or potential users of Many Strong, we ask if there is any way that we can make the product better for that family, that community, for the people they’re supporting based on how they’re using it.  One community could have hundreds or even thousands of supporters, or it could have a handful of very close supporters.”  

What does success look like? KC explains “success to us is about celebrating the actions of people helping one another.  Millions of messages of encouragement, millions in donations to families, and millions of hours of volunteered time… so many beautiful and meaningful actions.  Success to us is seeing all these actions across our country and across the world, one community at a time.”

During their initial beta phase, UnitedHealth is offering the entire community site for free and is even covering the transaction fee on the donated money.  KC describes their evolving business model for the ManyStrong Community. “Eventually we will need to charge small fees to cover bank transaction processing costs. We are also exploring integration with other service providers such as meal delivery, professional in-home care, and other features to provide even more options for people to give. We may earn referral fees from these merchant partners over time. While the site may earn some revenue, our mission is to give back profits to charitable organizations that will further benefit users of ManyStrong.”

Note: December 2013, UnitedHealth discontinued their ManyStrong website. 

With the weak economy and strong pressure from healthcare reform, employers are investing in new approaches to lower healthcare costs and lift employee productivity. Increasingly employers are investing in strategies to engage employees in their own health and reward them to motivate needed behavior change.

According to the recent Annual Towers Watson/National Business Group on Health Employer Survey on Purchasing Value in Healthcare, employers indicated that two of their top three healthcare strategies for 2012 are to “develop/expand healthy lifestyle activities” and “adopt/expand use of financial incentives.”

In July 2011, Humana launched their HumanaVitality program, which is designed to both guide and reward the employee for participating in their health and making better lifestyle decisions. “Our members tell us that they are hooked as soon as they use the Vitality Age app to determine their age and learn about how their behaviors influence their health. And as they participate in the HumanaVitality program, members interact with the Vitality Age app to see how they are positively impacting their age,” explains Stuart Slutzky, chief, product innovation, HumanaVitality.

Although employee incentive programs around health are not new, Humana has incorporated several innovative strategies into their Vitality solution.

Personalized Program Design: “We are using information from the employee’s health assessment, claims information and online health behaviors to personalize their pathway,” describes Stuart. Each member sees a set of recommended activities and has the option to select any of over 30 activities to gain points.

In addition to an individualized approach, Humana has decided to test a segment strategy after determining that the pathway is similar for members that are moving through a life stage change. Humana has created a special pathway for expectant mothers, as their first target segment. This means that members who are pregnant view a special set of activities and programs that are relevant to remain healthy throughout their maternity.

Program Reward Structure: Humana has designed their program with different status levels for reward attainment. “Our members begin with a blue status and can move up four tiers to platinum over time as they collect enough Vitality Points™.  When climbing to a new status level, they unlock a larger discount in the rewards mall,” shares Stuart. “Humana is also working closely with small group employers in select states to offer a premium reduction based on the percent of employees that achieve silver or higher Vitality Status. Employers may choose to pass the premium reduction to employees reaching silver, gold or platinum Vitality Status."  This premium discount is in addition to rewards individual employees can redeem in the HumanaVitality Mall based on their own points earned.  

Humana has defined the mall to appeal to members that have different motivations. “Spenders” can get instant gratification by purchasing with their Vitality Bucks.  “Savers” can accumulate their bucks for larger prizes. Soon “Givers” will be able to donate their rewards to charity.

Through their “Jackpot Rewards,” Humana uses a gaming mechanic of randomness to select a program participant to win prizes, which are based on their status level. For example, blue status member can win movie tickets or yoga mat but a platinum status member can win a flat-screen television or iPad.

Program to Program Connection: “Our members get rewards points when they enroll in one of our health programs. We are working on rewarding the member with more points for ongoing participation in our health program such as Weight Management. In addition to tying rewards for coaching program usage, our coaches can see the member’s efforts and earnings to date and can promote different point opportunities during their interactions to motivate the member,” Stuart explains.

Consumer-Driven Program Development: The HumanaVitality team listens closely to members participating in the program. They have set up a process to gather feedback that members share through the email and call center channels, as well as Facebook and Twitter, and the team discusses these ideas and suggestions to define program enhancements. “Recently, we heard one of our members ask us to provide points when their kids participate in athletic events.  This was a great suggestion and is now another activity that we reward under the program.” 

Program Success Evaluation: One key program measure is participation. Humana has expanded the ways that members can participate to earn points including obtaining preventive screenings, exercising regularly, donating blood, getting CPR-certified and quitting smoking. The newest way for members to earn points is by playing their Ubisoft “Your Shape” fitness game on their Xbox.

HumanaVitality’s Future Direction for Engagement

The HumanaVitality team is working on developing a deeper personalized experience by looking at the member’s past behaviors and recommending healthy activities, which match her interests. This is similar to the way Netflix suggests movies based on past viewing behavior.

Humana is also gathering lots of data on how consumers are using their rewards program. “We are applying data analytics to evaluate program engagement beyond participation. We will look at status level movement and actions tied to behavior change,” explains Stuart.

“In the future we will continue to expand the program to ensure we’re providing support and optimizing outcomes for all members – from members with severe conditions to marathon runners,” added Stuart.  “New reward partnerships will ensure the program provides relevant and aspirational rewards that foster improved health.”