The recent bundled payments for cardiac care announcement represents a tremendous opportunity for hospitals to consider alternative models of care for patients with AMI, CABG and heart failure. Bundles (and value-based care in general) emphasize cost control, readmission prevention and high patient satisfaction. Given the relatively fixed costs of inpatient care, these goals will be achieved by focusing on better post-discharge planning, shifting care to patients’ homes and engaging them to promote adherence to post-discharge care plans.
Consistent with the triple aims of healthcare, hospitals will face two major challenges in relation to how to deliver “great” care. The first challenge is - how does one achieve high quality patient interactions at scale. A typical mid-sized hospital sees approximately 1000 eligible cardiac patients every year. How does one engage all eligible patients while maintaining low administrative and staff overhead? The second is, quality control – regardless of staff available, all patients must receive quality care that is personalized to them. Closely related to these challenges is the need to achieve high patient satisfaction and self-confidence in being able to manage their own health.
The deployment and use of mobile technologies (in particular - smartphone-based technologies) represents one opportunity to address the issues aligned above. Smartphones represent in many ways an attractive platform to engage and coach patients– they are increasingly ubiquitous, always within an arm’s reach of the patient, have anytime-anywhere connectivity and permit flexible interfaces that can be tuned to a patient’s individual needs. Smartphone-driven technologies can provide hospitals the means to take their services to patients’ homes instead of requiring them to be present in person.
So, how can mobile technologies can be used for the benefits of patients at home? For patients, mobile technologies can provide convenient coaching, on-demand education, a sense of community and connectedness. For providers, these technologies can provide actionable information to promote patient adherence, prioritize which patients need the most attention and gain context into what their patients are like outside the clinic.
Perhaps the most exciting promise of smartphones is the tremendous potential they offer in providing home-based coaching. Through web-based interfaces, a provider can engage patients via regular phone or video calls to check in on patients, act as a source of information, identify any problems faced and tweak treatment plans. Using secure text messaging, a provider can engage patients who are not compliant to their treatment regimens and provide encouragement to patients who are doing well. A patient can also engage their provider with questions and seek advice when necessary. A provider can also deliver a myriad of educational resources such as lifestyle changes, post-discharge treatment options directly into their patient’s hands. Patient responses to these materials can be tracked and used to further personalize content.
Mobile applications also provide patients an easy to use to tool for self-management. Through self-report or connected peripherals, patients can keep track of their vital signs and symptoms and use the collected data to keep track of their post-discharge progress. Collected data can also be used by patients to engage in data-driven conversations. Data can also shift the emphasis of these conversations away from consolidation and more into enhancing the patient-provider relationship. The mobile application can also deliver specific interventions such as tailored exercise or stress management programs. Compliance to daily regimens can also be encouraged through pre-programmed reminders. Providing patients with tools for self-management also opens up the opportunity for encouraging lifelong self-care beyond the initial discharge period.
Mobile applications can also provide a sense of community to patients. An important part of the post-recovery process is being around other individuals who have gone through similar experiences. Through such associations, patients can provide and receive support, exchange tips, offer encouragement and develop relationships that can help them cope with day-to-day issues faced. These social experiences can in turn drive meaningful long-term behavior change that can be maintained well-beyond the initial recovery period.
The deployment of a smartphone-driven program also benefits providers - using patient generated data and sophisticated algorithms, a hospital can identify patients who need immediate attention either because of a recently reported symptom or lack of compliance. Providers also have an easy-access channel to remind patients about upcoming appointments or engage patients if they miss any. These benefits are key ingredients in a successful readmission prevention strategy. Increased patient-provider communication can lead to higher patient satisfaction, an important component in quality scores.
Naturally, several issues must be considered by a cardiac program when implementing mobile technologies for post-acute care. The first and most important is the goal – what is the program trying to achieve? Examples of goals include – increase patient participation, increased follow ups, higher attendance to center-based sessions, reduced waitlists, change in clinical outcomes, reduced readmissions or increase touch points with providers. Proper identification of a program’s metrics of success is the lynchpin around which all other program details revolve.
A program must also consider the business and economics of utilizing such technologies. While profit-making is not always a goal, it is important that hospitals not lose revenue when implementing smartphone-driven interventions. This can be addressed by creating and vetting a business plan that addresses the direct (through current billable revenue) and indirect (through readmission prevention or avoidance of penalties) returns on investment. A great plan will also model the attendance/patient volume required to offset the costs of purchasing and operating these platforms in keeping with the definitions of success. As these programs are often implemented in phases, a hospital system also needs to know how much it can spend from its budget in the first of year of implementation and what milestones need to be achieved at each phase.
Another point of consideration is in workflow management – a program needs to able to understand which members of its care team will be responsible for delivering the program and the number of hours that will be carved out per day dedicated to making the program a success. In our experience, the highest successes are achieved in those programs where a point person from the nurse care team has “owned” responsibility and devotes a set number of hours for patients on a regular basis. A common refrain heard is that often the additional hours required to devote to a program detract from previously established workflows. In such scenarios, it is helpful to for the provider to reiterate the reason why the program was implemented in the first place through the various forms of return on investment described earlier and continuously monitor against those metrics. If changes to workflow are needed, then they should be made.
Population readiness is also important – how technology savvy is a patient population and how amenable is that group of patients to adopt technologies such as with mobile phones? In our experience, we find that this is increasingly less of an issue with each passing year, particularly as younger patients graduate into the at-risk patient pool for acute coronary events. Also, low technology penetration can easily be addressed by supplying additional devices and designing workflows to train patients to use these devices. It is important that any smartphone-based application is appropriately designed keeping the target population in mind. These design decisions must be backed up with appropriate real-world evidence.
As with any technology, a successful mobile application-based program must also cater to all technical requirements in the healthcare space including HIPAA compliance and data encryption. Any provider facing interface must be made accessible via secure portals. And let’s not forget the elephant in the room –. integration with the hospital’s electronic health record. When possible, data from mobile technologies should be integrated into the patient’s medical record to create a complete medical picture of the patient and enable patient data to be accessible to any physician within the system. This can result in better care by coloring the patient’s profile with at-home behavioral patterns.
As hospitals move toward value-based care, capturing every ounce of efficiency and cost effectiveness will be necessary to satisfy the triple aims of quality, cost and patient satisfaction. Increasing evidence shows that mobile applications represent a tremendous opportunity to directly impact these aims in a convenient, cost-effective and scalable manner. It is thus imperative that hospitals adopt such strategies to continue to make a positive impact in their patients’ lives.