In January 2013, University Hospitals Rainbow Babies & Children’s Hospital launched the Rainbow Care Connection, a pediatric accountable care organization (ACO) with a $12.7 million CMS innovation grant to support children in Northeast Ohio, a third are enrolled in Medicaid. This innovative ACO has developed several successful mobile health initiatives to drive care collaboration with patients as part of their Physician Extension Team. This blog focuses on two key mobile health initiatives; iPads Minis for children with complex chronic conditions and HealthSpot^SM, a community- based telemedicine kiosk.

iPad Mini For Care Collaboration

“We wanted to help children with chronic medical conditions, especially those who have difficulty speaking or getting around.  For children that cannot walk, it is challenging to get them to the office. By giving them an iPad Mini, these children are able to communicate with their care team including physicians, nurses, social workers and dieticians”, explains Dr. Richard Grossberg, Medical Director of University Hospitals Center for Comprehensive Care. “Our goal with this project is to reduce office and ER visits with this video connectivity.”

In partnership with UH’s Rainbow Care Connection, the Center for Comprehensive Care strives to pioneer innovative ways to support children with complex chronic conditions, which can often seem overwhelming from a family’s perspective. As medical care continues to grow more complex, healthcare professionals acknowledge that families may need support beyond the clinic and hospital walls in order to be successful.

Children with complex chronic conditions make up about 5% of children who access health care services but account for up to 50% of Medicaid dollars spent. “We were looking for an additional layer to outpatient care; providing families with an opportunity to manage less acute issues in the comfort of their own home”, Dr. Grossberg shares. “Launched in December 2013, we felt that video calls would be the most innovative and cost effective solution to accomplish this and have currently distributed 10 iPad mini devices to families.”

How do video calls work? A family uses their iPad mini to conduct a “video call” with the office. During their telemedicine visit, a Comprehensive Care nurse helps the family triage what is happening and can resolve or escalate care to a physician/nurse practitioner or acute care setting when needed. Additional applications of the video call are being trialed including conducting nutritional counseling and education by UH’s Comprehensive Care dietitians and therapeutic counseling completed by their Comprehensive Care social workers.

After the video call, the visit summary is documented and sent to the patient’s PCP.  If a video call is escalated to include an ED or hospitalization, the UH acute care team has full electronic access to all of the video calls and assessment notes.  Having the necessary tools to help guide a family though those moments when their child’s complex conditions go awry and help them overcome barriers to care is critical to helping families receive better care, achieve better health and gain a healthcare partner to share in their patient experiences.

HealthSpot^SM Station

UH’s Rainbow Care Connection aims to reduce ER costs by finding new ways to support patients who go the ER with minor medical problems.   

“Since we know that 70% of Medicaid patients in the ER can be managed in a less acute setting, we were looking for an alternative to provide access to care after hours. We wanted to test offering a solution in a community setting to see if this population would feel more comfortable getting after hours care in their own neighborhood rather than from a medical setting. We felt that telemedicine would be the most cost effective solution to accomplish this”, shares Dr. Andrew Hertz, Medical Director of University Hospitals Rainbow Care Connection. We had already piloted a HealthSpot^SM kiosk running in our clinic and were ready to place a kiosk into a community setting”, Dr. Hertz explains.

“We decided on the HealthSpot^SM kiosk vs other telemedicine units because of the incredible patient experience provided by the HealthSpot^SM unit, including diagnostic equipment and the ability to transmit real-time vital signs and physical images.” Dr. Hertz and his team thought carefully about where to place the kiosk. “We started with a zip code analysis of patients coming into our ER to select potential locations and met with Community Neighborhood Association Leaders to discuss options. We chose the Friendly Inn Settlement (community building) in Cleveland and launched the program in October 2013.”

How does the HealthSpot^SM kiosk work? A patient and their family members step into the fully enclosed kiosk with a medical assistant who helps support them during their high-definition video conference visit with the doctor who may be located a few towns away. “Our doctor is on the computer screen, with video and audio connectivity to instruments (i.e. scale, blood pressure cuff, stethoscope, otoscope, thermometer, dermascope, pulse oximeter) and decides which tools to use and when by unlocking the door at the right time. It is cool when they unlock it. It is magical to see the door open and the instrument there. Our patients and their families see what physician is seeing as they use their different devices. It is a wonderful educational experience”, describes Dr. Hertz.

Patients use the HealthSpot^SM kiosk to take care of minor ailments and get check-ups, as an alternative to an emergency room visit. A parent/guardian can accompany a child from age three to 18 during their visit to the UH Rainbow HealthSpot^SM station during weekdays from 5:30 – 11 p.m. and weekends from 1 – 11 p.m.

Since the launch of HealthSpot^SM, Dr. Hertz and his team at UH have met with over 50 patients, with problems including rashes, fever, strep throat and pink eye. 

After the remote appointment with the doctor, the visit summary is documented and sent manually to the patient’s PCP. “Our physicians currently document the visit on paper and fax it to the PCP who may be outside of the UH network. Over 50% of these patients are not in UH Rainbow’s system so we share their information like a retail clinic. We have an interest in having HealthSpot^SM integrate this visit information into our hospital EMR,” explains Dr. Hertz.  

“Anytime we can spend time with a patient in their own environment, we can better understand and address their needs.” Dr. Hertz adds that by understanding why patients choose the ER as their source of care enables his team to identify opportunities to change that behavior and meet patient needs.  Certainly, having after-hours access to quality care in the inner city is valued by patients since the ER is often their only after-hours option. 

Patients and family caregivers have had a very positive experience with the telemedicine visit within UH’s HealthSpot^SM  kiosk. 85% have indicated that if they did not have the HealthSpot^SM  visit, they would have gone to the ER. Over 90% would use it again. Here are some comments around value of the visit to them:

It's convenient and less time consuming.

I love the equipment and technology.

The one on one with the doctor.

That you get to see what's going on inside the little areas most doctors won't show you. 

Close to home and speed of service.

Very helpful for my community.

Future Opportunities for UH Patient & Family Engagement  

The team at the UH Rainbow Babies & Children’s Hospital Rainbow Care Connection is already planning ways to use the HealthSpot^SM kiosk to bring care access to other patient populations. “Next we want to use telemedicine to enhance access to care in rural areas, where there are not a lot of specialists or after hours care options. We are planning to place a kiosk in a community building or a school”, Dr. Hertz adds.   

In addition to expanding the HealthSpot^SM kiosks, Dr. Hertz is interested in finding patient engagement tools that will help patients receive care through their phones to support the lower social economic population that tends to own mobile phones rather than computers. “No one has developed the mobile app for patients to receive care through smart phones which would enable a ‘meaningful clinical interaction’,” concludes Dr. Hertz. 

You cannot turn on the television or look at a newspaper today without being reminded of the obesity epidemic facing our nation. According to a CDC study, over 37% of U.S. adults are obese, while about 70% are overweight.

 Obesity has been associated with certain chronic conditions such as diabetes (type 2), cardiovascular disease and stroke. Last summer, American Medical Association classified Obesity as a disease, and the National Heart, Lung and Blood Institute recently published guidelines recommending that primary care physicians provide obesity counseling to all patients with Body Mass Index over 25 (which classifies them as overweight).

Many Americans try to lose weight but do not have the tools or professional guidance to be successful. Most physicians don’t have the training or tools to provide a comprehensive weight management program in their practice, and sometimes refer patients to commercial programs that are not clinically supervised.

RediClinic has stepped in to help. “We have developed a medically supervised program which is not just about weight loss but about health management”, explains Danielle Barrera, Chief Operating Officer at RediClinic. “When we developed this program in 2009, we noticed that many programs on the market were missing critical elements of a successful weight management program, and did not incorporate healthcare professionals, who are well positioned to have a significant impact on their patients’ lifestyle and health decisions.”

According to IDC’s Connected Health 2014 Predictions, “Retail Clinics Will Disrupt the U.S. Healthcare System”. Most people think about Retail Clinics as a place for getting flu vaccinations or addressing acute problems such as strep throat or ear infections. Retail Clinics are bringing more services to the community and some are now offering preventive services (i.e. physical exams) and chronic disease monitoring.  

Over the past two years, RediClinic has been offering a weight management program called Weigh Forward. Shoppers walk into one of their 30 locations inside grocery stores to sign up for the 10- week program. During the initial visit, the clinician does lab work to establish a base line to monitor progress in key health measures.  Throughout the program, the clinician provides guidance and teaches life skills not only to lose weight, but keep it off.

“Our program is a ‘Connected Health’ model. Participants use the MyWeighForward  platform to access educational information, track food and physical activity, and receive online coaching and social support between visits to the clinic. During weekly visits to RediClinic, the clinician reviews the participant’s program information (i.e. goals, lab work, tracking information and eCoaching activity) to deliver personalized guidance.”

RediClinic’s Weigh Forward program incorporates four key components which are reinforced both in- person and online through the program’s technology platform – myWeighForward.com: 

RediClinics Patient Portal on MyWeighForward Platform

1. Medical. Initial medical assessment with a comprehensive set of lab work, regular biometric monitoring and measurement, and weekly counseling by healthcare professionals.

2. Behavior Modification. Proprietary assessment tool developed at Yale's Prevention Research Center by Dr. David Katz (WeighForward’s Medical Director) to identify and address individual barriers to success and readiness to change, to create a personalized weight loss plan.   

3. Diet & Nutrition. Online educational information on food choices, weekly meal plans with 500+ recipes, and access to a diet/nutrition e-coach.

4. Physical Activity. Customized activity plan based on preferences and abilities, access to fitness videos and the capability to collaborate with a fitness e-coach.

Consumer Experience with the Weigh Forward Program

Deborah Hastings signed up for RediClinic's 10- week Weigh Forward program to start shedding 60 pounds. Deborah's daughter is getting married in six months and Deborah wants to get around without pain in her knees and to fit into a new dress for this special event.

During her first appointment, she meets with a clinician for a comprehensive evaluation to discuss her health and weight loss goals and determine her overall health status and readiness for change. She learns that her cholesterol and blood pressure are both high and that she is at risk for Metabolic Syndrome.

She uses the MyWeighForward.com portal to follow a meal plan suggested by the clinician and dietician eCoach, view exercise videos, and to track both her food and physical activity.  

Patient prepares for visit with clinician at RediClinic

Deborah is preparing for week #5 visit which is teaching her that it “takes a village” to help her achieve her goals, and she needs support from family, friends and office co-workers. She inputs her Visit objective, completes her checklist of specific tasks and selects a "Barriers to Bust", how to deal with family when they are sabotaging her diet. This barrier is posted on her Visit Plan which she will review with the clinician during her RediClinic visit. While Deborah finishes her homework, her clinician reaches out to the eCoach that Deborah has been working with to discuss nutrition concerns. Within the private clinical portal on the Weigh Forward platform, they discuss strategies for Deborah. During the upcoming visit, Deborah will work with the clinician on the barrier she has selected and will consider suggestions from her eCoach. 

Deborah has taken advantage of the social community capabilities on the Weigh Forward platform. She created a profile with demographic information and indicated how much program information to share with other participants. Deborah has decided to share the “Busting the Barrier” badges that she has earned each week. Deborah searched to find others like her and has connected with over a dozen new friends. She has also found an online group with her same barriers and is looking to gain some new real life strategies to address them.

During her week #9 visit, her clinician will take a blood sample to compare key biometric markers to those measured at the beginning of the program. She will be able to view these measures and see her progress in reducing her cholesterol and Metabolic risk in her MyWeighForward program account .

With several months before her daughter’s big event, Deborah is motivated to extend the program. She is planning on paying for the "Boost Maintenance Program with ongoing access to MyWeighForward with e-coaching as needed, monthly clinician visits and weekly in-clinic visits for "body composition analysis/biometrics".  

Connected Health Program Engagement & Results

Although the Weigh Forward Program was launched in 2011, it wasn’t until RediClinic moved to the new MyWeighForward Platform powered by Wellness Layers in October 2013 that they were able to offer enhanced functionality and support for patients and clinicians including: 

• Personalized Consumer Experience & Outcome: Participants create their own mini- electronic health record which collects program information, preferences, visit planning, tracking data, social engagement and progress through health measures. Program participants have the convenience of seeing different clinicians within the same clinic based on appointment availability or in a different location since all RediClinic clinicians have access to the participant’s program information to deliver a consistently high quality and personalized experience.
• Social Engagement: WeighForward participants use the platform 24x7 for ongoing emotional and educational support through their weight loss journey.
• Clinician Support and Collaboration: Clinicians have their own portal, giving them access to information to support and consistently deliver the program and to privately and securely collaborate on care. RediClinic's Clinician Portal on MyWeighForward Platform
• Care Continuum: Participants can access a Program Summary with their program health measures to send to their own doctors. “If the patient has secure messaging with their physician, they can share this information to include in their EMR”, adds Barrera.

“Our results have been very positive. On average, our patients are losing 1- 2 lbs per week which is considered to be a healthy rate of weight loss, and are significantly improving their cardio-metabolic risk factors. In many cases our patients have moved from pre-hypertensive and hypertensive to normal and pre-diabetic to normal”, exclaims Barrera.

Comments from Program Participants 

What I liked about the online part of the program was that it gave me homework to do to keep me accountable and focused.

I had been the 'queen of couch potatoes.' The best things about the program were the accountability each week, recipes and shopping list, and incredible support from the staff

Dr. David Katz's lesson on Trial by Aisle taught me to check ingredients lists for hidden sugars and salts, and to pick the shorter lists. The best thing about the program was it provided me with information to change my unhealthy lifestyle into a healthy lifestyle.

Future plans: New Business Model, New Technology Platform Capabilities

Today, most program participants walk into to RediClinic. However, RediClinic is now licensing the Weigh Forward program to other healthcare providers. “We’ve had significant interest and many pilot commitments from large healthcare systems and physician groups, as well as companies that operate retail, urgent care and worksite clinics. Everyone is looking for a turn-key weight and lifestyle management solution for their patients because obesity is so pervasive and expensive. Weigh Forward is one of the few comprehensive programs that is designed to be delivered by clinicians with no previous background in weight management,” Barrera adds.

Regardless of where the consumer is seen, in the clinic or in their PCP’s office, RediClinic is extending the capabilities of the WeighForward technology platform. “We are continuing to enhance the social networking capabilities of the platform, will introduce a mobile version later this year, and are beginning to develop modified versions of Weigh Forward that address chronic diseases, since the platform we’ve built is flexible and extensible”, concludes Barrera. 

Aetna's Lifestyle Social Community on CaféWell

According to CDC research, over 30% of U.S. adults have Metabolic Syndrome, a set of five risk factors including high blood pressure, high blood sugar, large waist size, high triglycerides and low (good) cholesterol.

World Congress Leadership Summit on Mobile Health, July 25-27th in Boston

Over the past three years, I have participated in this interesting event by running a workshop or panel.

Health Plans are finding new ways to bring value to consumers by empowering them with tools and guidance to manage their health while on the go.

At many conferences, health plans present their newest mobile application or texting campaign to engage consumers.

UnitedHealth Group announced their latest move at the recent Consumer Electronics Show to integrate several mobile health applications into their OptumizeMe solution, through partnerships with CareSpeak Communications, FitNow and FitBit. UnitedHealth is integrating content and tools to bring new capabilities to both consumers and caregivers.

Through the CareSpeak Communications’ partnership, consumers sign up to receive two-way texts to help them manage their medication and condition. UnitedHealth delivers CareSpeak’s personalized messaging to provide relevant content to each consumer segment ( e.g. asthma, diabetes, cancer, etc). A patient with diabetes opts in to receive customized education and reminder messages and can give a caregiver permission to monitor her health. The patient’s clinician is also kept in the loop with medication and condition management data to discuss during patient interactions. Patients are further engaged by receiving text based educational quizzes and viewing online reporting showing their effectiveness in managing their medication and condition over time.

With the integration of FitNow’s Lose It! mobile app, consumers can better manage their weight through fitness and food tracking tools, educational nutrition information, motivational reminders and social peer support.

From the FitBit integration, consumers automatically track their physical activity instead of having to key it in. Since this activity data is no longer self reported, UnitedHealth Group can use validated information to drive their rewards program. The FitBit app also tracks the consumer’s sleeping behavior for a more complete view of their health.

Integration Delivers Insight

UnitedHealth Group has invested in this set of mobile technologies to capture and connect multiple sources of data for a holistic view covering the consumer’s physical activity, dietary behavior, medication adherence, biometric and mood information.

“With these partnerships in place, we are connecting all the pieces of data across our platform for a common view for the consumer to self manage and share with their coach while creating a personalized experience”, explains Nick Martin, VP Innovation and R&D, UnitedHealth Group.

This supports the trend for “integrated end to end health to care solutions” where technology connects with care management platforms and programs, as noted by IDC Health Insights’ analyst Janice Young.

Coach/CareGiver & Consumer Collaboration

Nick Martin describes how the OptumizeMe application is being used by the consumer with their coach.  “Let’s say you are trying to lose weight. Your coach can push messages to your mobile which are educational and supportive. And if you give your coach permission, she can see your tracked physical activity”.  Think about how much more motivated and accountable the consumer will feel when her coach is monitoring and responding to her daily progress.  On the health side, the asthma patient can give access to her caregiver to monitor and address medication compliance issues. Her caregiver can also send encouraging and educational messages between visits.

UnitedHealth’s partnerships deliver new capabilities to their OptumizeMe mobile app giving consumers a new way to remain in close contact with their coach and to self manage with the social support from caregivers. With the power of the personalized information pushed and pulled from the consumer’s mobile phone, UnitedHealth Group can successfully generate both stronger consumer engagement and better health outcomes.