KY HIMSS Leveraging Innovative Ways to Connect with Patients at Covenant Care Practices
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Leveraging Innovative Way to Connect with Patients at Covenant Care Practices- Our experience using a mobile pre-visit assessment, Clinical Decision Support, and remote Monitoring Tools to engage and improve health outcomes in "Rising Risk" patients
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KY HIMSS Leveraging Innovative Ways to Connect with Patients at Covenant Care Practices
- 1. Leveraging Innovative Ways to Connect with Patients at Covenant Care Practices Our experience using a mobile pre-visit assessment, clinical decision support and remote monitoring tools to engage and improve health outcomes in "Rising Risk" patients
- 2. About The Presenter Dr. Natalie Davis Chief Medical Officer PreventScripts
- 3. Conflict Of Interest Disclosure • Per PIMS standards, Natalie Davis, MD, Category of Conflict, and company of conflict, example below: • Natalie Davis, MD Chief Medical Officer of PreventScripts, Founder
- 4. Agenda • Learning Objectives • Covenant Care Background • Overview of Digital Health Technologies Used • Partnership Goals • Workflow Challenges • Impact • Lessons Learned • Opportunities to Optimize Clinical Integration and Patient Outcomes
- 5. Learning Objectives • Assess Population Health Stratification Data from 5,000+ Pre-visit Patient Self Assessment tool Reports administered through a Web- based App. • Analyze Patient Engagement Use Data from Prevention Remote Monitoring Enrolled Patients with Metabolic Syndrome. • Analyze Health Outcomes Data from Prevention Remote Monitoring Enrolled Patients with Metabolic Syndrome.
- 6. Introducing Covenant Care Practices •54,415 Outpatient Visits in 2021 •17,018 Total Patients in EHR •4 Locations in Tennessee •12 Providers •43 Employees
- 7. Covenant Cares Recognition & Honors
- 8. The Problem Geolocated in Center of Obesity Epidemic
- 9. Covenant Care Population: The Trifecta Obesity Diabetes Hypertension
- 10. Covenant Care Practices: Our Top Problems
- 11. Goals Of Our Partnership • Assess patients by collecting, scoring, and sending patients’ risk report to their chart • Engage patients in their health risks and assess motivation pre-visit • Facilitate patient-provider prevention conversation during any visit • Intervene with the eligible, motivated patients at-risk of developing metabolic disease
- 12. Timeline
- 13. Overview Of Digital Health Tools Patient Name:Bridget Thomasson DOB: 1974-07-11 Provider: Mandy Childers Date of Report: 9th February 2023. REMOTE MONITORING RESULTS Starting BMI: 45 BIOMETRIC DATA most recent blood pressure: not taken most recent blood sugar 159 average 30 day blood sugar not taken # blood sugar readings taken in 30 days: N/A # scale data points (30 days): 9 PREVENTION PLANS STARTED RECENTLY DATE STARTED Eat more fruit 2022/10/06 Eat more fruit 2022/09/22 ENGAGEMENT DATA times opened app: 76 times opened app last month: 29 total times stepped on scale since enrollment: 72 average daily step count: 276 LAST MONTH THIS MONTH daily average water intake: 0 oz 0 oz daily average veggie intake: 0.00/8 0.00/8 daily average fruit intake: 0.00/4 0.00/4 7 BLOOD PRESS BLOOD SUGAR WEIGHT last update now last update now last update now 0 lb 145/89 0 Health Biometrics WATER STEPS VEGETABLES last update now last update now last update now 0 oz Health Behaviors Welcome Box Delivered Avg reimbursement $55/patient/month Patient Education 5 &Support Program !"#$% PrevenTips &''($% )*+,-$% Progress SURVEY Care Team Calls 20 minutes data review / call Avg reimbursement: $50/patient/month Monthly Report to EHR/Patient Chart Results Smoking Cessation Preventive Counseling Patient education to generate more cessation visits Up to 20 visits per year per provider (Avg. reimbursement $30 – $45 / 15 minute visit) (up to $125/year) 6 ADD‐ONS Patient Name: Alex Rupert DOB: Jan. 26, 1996 Provider: Olivia Hutcheson Date of Report: 22nd July 2022 PATIENT ASSESSMENT RESULTS ADA/CDC Prediabetes Risk Test* 3 PROMIS Short Form v1.0 – General Self- Efficacy 4a* 52.2 PROMIS ADULT short form - global - version 1.2* 43.5 42.3 Motivation Level Medium motivation BMI 34.31 Patient-reported Chronic Condition Status No * validated survey instruments BILLING REMINDERS Survey 1 ADA Risk: CPT code: 96160 Survey 2 PROMIS Self-Efficacy: CPT Code: 96160 Survey 3 PROMIS Global Health Short Form: CPCode: 96160 RECOMMENDATIONS + INSTRUCTIONS We recommend the following pathway for this patient. Below you will find instructions for this pathway. For more information on these recommendations, click here: preventscripts.com Patient Not Eligible Prevention Emails Assess Chronic Condition PreventScripts Prevention Remote Monitoring PreventScripts Preventive Counseling PreventScripts Tobacco Cessation INSTRUCTIONS FOR PATIENT ENROLLMENT This patient is a good candidate for Remote Patient Monitoring. PreventScripts will work with your patient to start reducing risks and improving overall health and wellbeing, on their own schedule. The clinic will help to support the patient by monitoring progress via the app, and checking in with the patient monthly. PreventScripts will help the patient take small steps toward healthy choices over time. 1 At time of visit, identify and code ONE chronic diagnosis for eligibility. Possible chronic disease diagnosis could be: hypercholesterolemia, hyperlipidemia, obesity, overweight, metabolic syndrome, stage one hypertension, etc. 2 Inform Patient of Program: (possible talking point ideas) 3 Patient Setup: MA/Nurse brings in a sample starter kit and shows the patient what’s in the box and how to download the “PreventScripts RPM” App. STEP STEP Patient Risk Assesment START HERE Pre‐visit 2 – 3 minutes for patient 4 MA/LPN: 2 – 4 minutes Avg reimbursement $18 Sign UP Patient BY 3Office Visit 1–2 minutes to discuss the program with eligible patients. 2Results Sent to EHR/ Patient Chart Clinic: Average reimbursement $12 per Providers: Less than 1 minute to review.
- 14. Digitizing Prevention Best Practices
- 15. How To Accomplish Our Goals? Assess Engage Facilitate Intervene
- 16. Goal #1: Assess • Assess patients by collecting, scoring, and sending patients’ risk report to their chart • Collect • Screen every patient 18-65 during their normal visits • Patient-facing web page • Sent along with pre-registration software morning of visit • Score • Clinical decision tree to score and stratify patients • Database and algorithm to score surveys and turn into insights • Send • Send secure actionable report as a clinical decision support tool to patient chart utilizing direct message into the EHR • Utilize a Health Information Service Provider, or HISP, is an accredited network service operator that enables nationwide clinical data exchange using Direct Secure Messaging
- 17. Goal #1: Assess • Assess patients by collecting, scoring, and sending patients’ risk report to their chart • Demographics • Height and Weight • Motivation/Readiness • PROMIS Global 10 Physical and Mental Health Survey • PROMIS Self-Efficacy Survey • ADA Pre-Diabetes Survey
- 18. Goal #1: Assess Assess patients by collecting, scoring, and sending patients’ risk report to their chart Patient Education STEP STEP Patient Risk Assesment START HERE Pre‐visit 2 – 3 minutes for patient BY 2
- 19. Goal #2: ENGAGE patients by color coding risk STEP STEP Patient Risk Assesment START HERE Pre‐visit 2 – 3 minutes for patient BY 2Resu Clinic: Av reimburs $12 per
- 20. Goal #3: Facilitate • Facilitate patient-provider prevention conversation during any visit • Report offers recommendations to providers for patient interventions • Report offers talking points for each intervention recommended Patient Name: Alex Rupert DOB: Jan. 26, 1996 Provider: Olivia Hutcheson Date of Report: 22nd July 2022 PATIENT ASSESSMENT RESULTS ADA/CDC Prediabetes Risk Test* 3 PROMIS Short Form v1.0 – General Self- Efficacy 4a* 52.2 PROMIS ADULT short form - global - version 1.2* 43.5 42.3 Motivation Level Medium motivation BMI 34.31 Patient-reported Chronic Condition Status No * validated survey instruments BILLING REMINDERS Survey 1 ADA Risk: CPT code: 96160 Survey 2 PROMIS Self-Efficacy: CPT Code: 96160 Survey 3 PROMIS Global Health Short Form: CPCode: 96160 RECOMMENDATIONS + INSTRUCTIONS We recommend the following pathway for this patient. Below you will find instructions for this pathway. For more information on these recommendations, click here: preventscripts.com Patient Not Eligible Prevention Emails Assess Chronic Condition PreventScripts Prevention Remote Monitoring PreventScripts Preventive Counseling PreventScripts Tobacco Cessation INSTRUCTIONS FOR PATIENT ENROLLMENT This patient is a good candidate for Remote Patient Monitoring. PreventScripts will work with your patient to start reducing risks and improving overall health and wellbeing, on their own schedule. The clinic will help to support the patien pr 1 At time of visit, identify and code ONE chronic diagnosis for eligibility. Possible chronic disease diagnosis could be: hypercholesterolemia, hyperlipidemia, obesity, overweight, metabolic syndrome, stage one hypertension, etc. 2 Inform Patient of Program: (possible talking point ideas) EP STEP ent Risk sment HERE visit es for patient BY 3 2Results Sent to EHR/ Patient Chart Clinic: Average reimbursement $12 per Providers: Less than 1 minute to review.
- 21. Goal #4: Intervene • Intervene and enroll eligible patients into our RPM program Patient Name:Bridget Thomasson DOB: 1974-07-11 Provider: Mandy Childers Date of Report: 9th February 2023. REMOTE MONITORING RESULTS Starting BMI: 45 BIOMETRIC DATA ENGAGEMENT DATA times opened app: 76 times opened app last month: 29 total times stepped on scale since enrollment: 72 BLOOD PRESS BLOOD SUGAR w last update now last update now 145/89 0 Health Biometrics STEPS VEGETABLES w last update now last update now Health Behaviors Welcome Box Delivered Avg reimbursement $55/patient/month ducation 5 t Program Smoking Cessation Patient education to generate more cessation visits (up to $125/year) ADD‐ONS Patient Name: Alex Rupert DOB: Jan. 26, 1996 Provider: Olivia Hutcheson Date of Report: 22nd July 2022 PATIENT ASSESSMENT RESULTS ADA/CDC Prediabetes Risk Test* 3 PROMIS Short Form v1.0 – General Self- Efficacy 4a* 52.2 PROMIS ADULT short form - global - version 1.2* 43.5 42.3 Motivation Level Medium motivation BMI 34.31 Patient-reported Chronic Condition Status No * validated survey instruments BILLING REMINDERS Survey 1 ADA Risk: CPT code: 96160 Survey 2 PROMIS Self-Efficacy: CPT Code: 96160 Survey 3 PROMIS Global Health Short Form: CPCode: 96160 RECOMMENDATIONS + INSTRUCTIONS We recommend the following pathway for this patient. Below you will find instructions for this pathway. For more information on these recommendations, click here: preventscripts.com Patient Not Eligible Prevention Emails Assess Chronic Condition PreventScripts Prevention Remote Monitoring PreventScripts Preventive Counseling PreventScripts Tobacco Cessation INSTRUCTIONS FOR PATIENT ENROLLMENT This patient is a good candidate for Remote Patient Monitoring. PreventScripts will work with your patient to start reducing risks and improving overall health and wellbeing, on their own schedule. The clinic will help to support the patient by monitoring progress via the app, and checking in with the patient monthly. PreventScripts will help the patient take small steps toward healthy choices over time. 1 At time of visit, identify and code ONE chronic diagnosis for eligibility. Possible chronic disease diagnosis could be: hypercholesterolemia, hyperlipidemia, obesity, overweight, metabolic syndrome, stage one hypertension, etc. 2 Inform Patient of Program: (possible talking point ideas) 3 Patient Setup: MA/Nurse brings in a sample starter kit and shows the patient what’s in the box and how to download the “PreventScripts RPM” App. STEP k nt 4 MA/LPN: 2 – 4 minutes Avg reimbursement $18 Sign UP Patient BY 3Office Visit 1–2 minutes to discuss the program with eligible patients. 2Results Sent to EHR/ Patient Chart Clinic: Average reimbursement $12 per Providers: Less than 1 minute to review.
- 22. Goal #4: Intervene Eat your vegetables first. You'll fill up on the good stuff and not have too much room for the less-than-healthy stuff. PreventTip of The Day Week FOUR Day ONE YOUR GOAL: EAT MORE VEGETABLES
- 23. Workflow Challenges We Encountered 1. Providers struggled to enroll patients in the RPM program 2. Providers struggled to execute RPM monthly visits 3. Provider Staffing 4. Patients within the BMI range of 26 – 29 often lacked chronic disease diagnosis or metabolic syndrome diagnosis
- 24. Workflow Challenges: Innovative Solutions • Staffed Behavior Change Expert: Mandy • Provider Engagement: Added monthly provider emails with enrollment details by provider- benchmarking feature and QI payments for providers • Patient Engagement Features: Extended PreventTips, Added Content, Recipes, weekly surveys • Waist Circumference to Kit: Accelerated Clinic MetX Diagnosis for BMI 26 – 29 patients WITHOUT Obesity Diagnosis
- 25. The Impact Assess Population Health Stratification Data 5028 PreventScripts Assessments PreventScripts RPM Eligible PreventScripts Chronic Disease Identified 1147 1394
- 26. The Impact Assess Population Health Stratification Data 150 Tobacco Use Identified Patients Identified As Low Risk Preventive Counseling Eligible 1649 688
- 27. The Impact Analyze Patient Engagement Use Data 67 Patients Enrolled In RPM “MyPlans” Selected By Patients 106
- 28. The Impact PreventTips Patient Engagement 100% PreventTips Engagement Report Feeling Motivated By PreventTips 77%
- 29. The Impact Analyze Patient Engagement Use Data 69 Net Promoter Score MARS Survey of Behavioral Intent 5/5
- 30. The Impact Analyze Patient Health Outcomes Data 32% Patients have lost 5% or more of bodyweight Patients have lost 1 – 4% of bodyweight Patients have neither gained nor lost weight 47% 20%
- 31. The Impact Analyze Patient Health Outcomes Data 12% Systolic Blood Pressure Reduction Diastolic Blood Pressure Reduction 13%
- 32. The Impact Analyze patient health outcomes data:
- 34. Lessons Learned • Provider “buy in” and engagement with program is critical to success • Staffing is key to digital health implementation • Benchmarking providers within the group was useful
- 35. Opportunities To Optimize Program • Auto-enrollment of patients into programs to minimize provider friction • Single sign-on of clinical dashboard with program-specific data for monitoring patients • Collect waist circumference in app as important indicator of metabolic syndrome • Financial dashboard for demonstrating program usage and reimbursement to incentivize provider use • Validated Surveys for teenage patients aged 13 to 17
- 36. Areas For Future Research • NIH SBIR NINR pilot study to further explore health outcomes • NSF SBIR to build 5A conversational assistant (AI) “Preventee” • AHRQ Digital Health at Point of Care grant to better study product implementation and patient use enhancements
- 37. Questions?