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Digital mHealth Platform Expands Population Health in California

The new digital mHealth platform emphasizes patient coaching and data-driven insights to increase engagement, lower costs, and improve health outcomes of at-risk and underserved populations.

By Nathan Boroyan

- The Community Health Center Network (CHCN) and Welkin Health have partnered to develop a new digital mHealth platform geared towards improving the long-term health outcomes of at-risk and underserved patient populations.

Digital health platform targets at-risk and underserved patient populations

Selected as one of three national finalists for Health 2.0's Technology for Healthy Communities initiative, the project looks to develop a complex case management platform to support CHCN's Care Neighborhood Program and its Community Health Workers (CHWs) treating the most at risk patients in San Francisco's East Bay.

Welkin's mHealth platform looks to streamline how CHCN health centers communicates with patients by emphasizing patient coaching and data-driven insights to increase engagement, lower costs, and improve long-term health outcomes.

The platform will aggregate data from electronic health records and claims databases to provide CHWs with clinical decision support, higher efficiency and long-term patient improvement tracking.

“The effectiveness of our Care Neighborhood program is rooted in our ability to successfully connect and follow up with patients,” says Rajib Ghosh, CHCN Chief Data and Transformation Officer. "Up to this point, the program’s CHWs have relied on phone calls and in-person visits, all inputted and tracked via a preliminary prototype system, to engage patients."

By opening up channels of communication like text messaging, email and phone calls, the hope is to better identify high risk patients and provide timely interventions. The platform will also allow CHWs to remotely monitor patients with chronic issues, potentially increasing patient medication, diet and exercise adherence.

Remote monitoring has demonstrated the ability to lower costs and reduce hospital visits for at-risk patient populations, such as the elderly or the chronically ill. For example, a recent Capital Blue Cross mHealth study found that a remote monitoring program for heart failure patients saved more than $8000 per patient and cut hospitalizations by more than 30 percent.

According to the study, these reductions show that remote monitoring programs could save the average million-member health plan more than a $1 million a year.

Frequently communicating with healthcare providers is another proven strategy to improve patient health outcomes, and mHealth platforms have made doing so more timely and convenient. Something as simple as text messaging can improve patient health.

One six-month study showed that receiving informative texts helped coronary heart disease patients make important behavioral changes to improve their health. Patients in the study who received texts lowered their body mass index, blood pressure and cholesterol levels.

Text messaging may also be an especially meaningful tool for underserved populations who are traditionally difficult to reach due to the convenience and low-cost of communicating through cell phones

Welkin's platform will be rolled out at three CHCN health Centers in Alameda County. Eventually, the goal is to expand the platform to Care Neighborhood programs to all eight health centers in the network.

The platform can be designed to meet each Care Neighborhood program's specific needs, including personalized CHW workflow and clinic EHR and CHCN claims database integration.

“CHCN serves patients whose needs are complex. These individuals are among those facing the most risk due to social determinants beyond their control,” says Chase Hensel, co-founder and CEO, Welkin Health. “Our platform will create more pathways of communication between CHWs and patients, help to streamline workflow and provide the ability to capture critical data about this population in the hopes of improving the health outcomes in these communities for the long-term.”

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