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Making mHealth Outreach Work for the Patient

A successful post-discharge program needs just the right balance of reminders and information, as officials at San Diego's Sharp Rees Stealy Medical group are discovering.

By Eric Wicklund

- The transition to value-based care and an emphasis on reducing hospital readmissions is prompting health systems to keep the lines of communication open after the patient leaves the hospital or doctor’s office. Some are sending patients home with videos, while others enroll them in a text-message or e-mail program that offers reminders and education.

But how much communication is enough – and when is it too much?

Roughly six months ago, San Diego-based Sharp Healthcare began offering patients of its 22-location Sharp Rees Stealy Medical Group a mobile coaching program. Upon enrollment in the 90-day Welcome Home Program, patients are sent daily text messages from their nurse care manager, reminding them to follow their care plan or offering advice on what symptoms to watch for or wellness tips to follow. They can also access additional automated support or even connect with their care manager by texting certain keywords.

Janet Appel, RN, MSN, the medical group’s director of population health management, says the new program was patterned after two successful text-messaging projects. One targets smoking cessation, and offers daily tips on trying to kick the habit. The other, involving more than 1,000 newly diagnosed diabetics, sends three motivational text messages a day for six months.

With the Welcome Home program, Sharp Rees-Stealy officials quickly realized this much larger and more diverse population would have to be handled differently.

READ MORE: Using mHealth to Vault the Barriers to Value-Based Care

According to Appel, officials realized soon enough that patients were overwhelmed by multiple text messages a day. So the messages were reduced to one a day. And after a few weeks, those messages were scaled back even further. Administrators are now looking at ways to further personalize the messages

“There are many different ways that you can take a program like this and implement it,” Appel says, adding that she was surprised how patients wanted to limit their correspondences with doctors after going home. “We worked with them to figure out what they wanted.”

That’s a philosophy endorsed by the American Hospital Association as well. In a case study of five different hospital outreach programs issued last January, the AHA determined that providers have to carefully balance what a patient wants with what a patient needs – too little, or too vague, and the patient gains no benefit and the program is wasted; too much, and the patient gets annoyed with or tired of the messages and ignores them.

Appel says patients may not think they need additional support after a healthcare visit, but many do. A 2003 study by the UK’s Royal Society of Medicine found that patients forget 40 percent to 80 percent of what a doctor tells them immediately upon leaving the office or hospital. Another study estimated that half of all patients make some sort of mistake with their care plan – the most serious of which can lead the patient right back to the hospital.

Appel says the 90-day program “allows our nurses to engage and support more patients over a longer period of time than does traditional outreach.” By spreading out that communication and having the patient control how he or she wants to access additional care, Sharp Rees-Stealy is giving the patient more control while making sure that guidance system is in place.

READ MORE: Legislators Urge FCC to Open Up TV Airwaves for Telemedicine

The program has a certain monetary benefit to Sharp Health as well. In 2013, the Centers for Medicare and Medicaid Services began reducing reimbursements to providers for readmissions within 30 days for certain diagnoses. The penalties were increased, and more diagnoses added, this year. CMS is estimating that this approach will amount to $428 million in reduced payments this year, while prompting healthcare providers to improve their outreach and eliminate readmissions.

Different providers are taking different approaches to this issue. Boston Children’s Hospital is in the midst of a text- and e-mail-based pilot, called DisCo, that connects with parents of discharged children within 24 hours and asks them to fill out an online survey. The survey’s results are analyzed by nurses, who then determine if follow-up care is needed. At New York’s North Shore-LIJ health system, meanwhile, a pilot program at Lenox Hill Hospital is examining whether patients sent home with a video of their care plan

“Doctors often do a terrible job at educating their patients,” David Langer, chief of neurosurgery at Lenox Hill Hospital and the co-developer of its video outreach program, told the Wall Street Journal.

“We throw papers and throw words at patients,” added Brian Jack, chief of family medicine at Boston Medical Center, in the WSJ article. “It is crazy to think they would understand.”

But giving them these daily or weekly reminders – “tickling them with information” during their daily lives – makes a difference, Appel says.

READ MORE: Florida Hospital, Supermarket Chain Launch Telehealth Partnership

“You hear it in the personal stories they tell us,” she says. “They’re grateful.”

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