Utilizing Interactive Voice Response to Reduce Health Service Utilization, Expand Clinical Capacity, and Improve the Quality of Life for Older, COPD Patients: HealthCare Partners

HealthCare Partners Institute for Applied Research and Education/Health Care Partners Medical Group

Project Summary

HealthCare Partners (HCP) utilized a telephone-based home remote patient monitoring (RPM) technology in order to reduce health utilization and enhance quality of life for elderly patients with chronic disease. Consumers/patients that were targeted in this RPM project were over 65 years of age and had chronic obstructive pulmonary disease (COPD) and other chronic diseases. The 6-month intervention utilized TeleVox’s interactive voice response (IVR) technology with patients answering COPD symptom and wellness questions 1-2 times a week via telephone. Responses were analyzed and live care management phone calls from RNs were conducted as needed. IVR technology supplemented an existing patient-centric COPD program to help identify and reduce disease exacerbations in between regular care management calls and appointments.

HCP's IVR project found that over a 30-day period following the initial hospital stay, the frequency of hospitalizations related to COPD were reduced by 50% compared to the twelve-month period preceding program enrollment. Rehospitalization rates for patients receiving IVR in conjunction with HCP's COPD care management program (4.97%, 9/181) were lower than those for traditional COPD patients (14%) and patients one year prior to enrollment in the IVR program (9.9%, 18/181).

The IVR technology and IVR reports expanded the clinical capacity of RNs to manage 200 patients with 5% triggering follow-up after every IVR survey. The project resulted in reduced costs per patient per month. Savings off-set program implementation expenses by reducing health costs, i.e., decreased admissions/readmissions, bed-days, and ED/UC visits. Project results also indicate that patients were very satisfied with the telehealth system, reporting 1) increased ability to stay in the residence of their choosing, 2) greater engagement in their health, 3) increased satisfaction with staff (i.e., having a formal caregiver watching over them and acting on their symptom survey responses), and 4) ease of use of the technology (telephone). Finally, clinical staff reported high satisfaction with the ease of use of the technology, time saved, improved ability to keep track of patient’s symptoms, and improved ability to intervene before clinical symptoms became urgent.

HealthCare Partners achieved a 1.3:1 ROI in Year 1, indicating that each dollar invested in RPM yielded $1.30 in savings for HCP. Projected ROI for HCP in Year 5 exceeded 18.

WHO WAS INVOLVED?

Innovator: HealthCare Partners Institute for Applied Research and Education, HealthCare Partners Affiliates Medical Group, TeleVox (IVR vendor)

WHAT THEY DID

Problem Addressed: Chronic obstructive pulmonary disease (COPD) is an escalating public health problem and a cause of chronic morbidity and mortality; it contributes to substantial health service use and overall cost of care. COPD is a progressive disease whose toll extends beyond the physical to include feelings of isolation, depression, and often loss of independence. The National Heart, Lung, and Blood Institute estimates that by 2020, COPD will be the third leading cause of death in the United States. Whereas 24 million individuals in the United States are estimated to have COPD, only 12 million are diagnosed and actively managed. Early identification for diagnosis and treatment remains paramount to reduce disease progression and acute exacerbation.

The 4 components of active COPD management include (1) assessment and monitoring, (2) risk factor reduction, (3) management of stable COPD, and (4) exacerbation management. Furthermore, patient education is important to help manage COPD and should include disease awareness, medication administration, lifestyle changes, and disease exacerbation recognition. Early exacerbation recognition can reduce hospital admissions, bed days, and emergency department (ED) visits, thus improving patient quality of life and decreasing cost of care.

While the rate of cigarette smoking is currently decreasing in the United States, the prevalence of COPD continues to increase as a result of the ‘‘Virginia Slims’’ effect of increased cigarette smoking amongst women in the 1970s. COPD is an incipient disease, occurring 20–30 years after the patient begins smoking. Despite COPD prevalence, there are minimal studies that examine patient quality of life, service utilization, intermediate measures of disease control, and chronic disease guideline adherence. The prevalence of COPD at HCP comprises approximately 21,000 individuals. The economic burden of COPD is considerable, with inpatient hospitalization accounting for approximately half of the per member per month (PMPM) cost. COPD is consistently one of the top 10 diseases at HCP that results in hospital admissions and readmissions.

Patient Population: The patient population in this program was drawn from HCP patients in Southern California whose medical records indicated a diagnosis of COPD. Project staff used HCP data sources to facilitate selection of patients with COPD and to document clinical service utilization. The average patient age was 75 years. Male and female genders were approximately weighted more towards females more than males. Patients were excluded if they or their primary care physician (PCP) declined or opted out, or were no longer an active patient in the HCP health maintenance organization. Individuals were also excluded if they were enrolled in hospice, institutionalized in custodial nursing facilities, unable to participate due to severe dementia or organic brain disorder, on chronic hemodialysis due to end-stage renal disease, or undergoing chemotherapy for active malignancies.

Description of the Program:

HealthCare Partners utilized a telephone-based home monitoring technology in order to reduce health service utilization and enhance quality of life for elderly patients with chronic disease. Consumers/patients that were targeted in this RPM project were over 55 years of age and had chronic obstructive pulmonary disease (COPD) and other chronic diseases.

The 6-month intervention utilized TeleVox’s interactive voice response (IVR) technology with patients answering COPD symptom and wellness questions 1-2 times a week via telephone. Responses were analyzed and live care management phone calls from RNs were conducted as needed. IVR technology supplemented an existing patient-centric COPD program to help identify and reduce disease exacerbations in between regular care management calls and appointments.

The IVR survey calls are based on COPD symptoms corresponding to green, yellow, and red zones. Self-management strategies are emphasized, highlighting symptom recognition and action plans. The action plans are based on the National Jewish Health Research and Science Program COPD self-management plan and consist of various colored zones indicating increasing severity of symptoms. The red zone indicates an emergent situation requiring physician intervention, the yellow zone indicates symptoms of lesser severity that necessitate case manager initiation of the action plan, and the green zone is baseline for the patient and does not require clinical involvement.

Patients complete the IVR survey by entering their disease symptoms based on categories of COPD exacerbations. Patients answer the questions using their telephone keypad and their response is recorded by pressing 1, 2, or 3; these numbers respond to the green, yellow, and red symptom zones. The calls occur at noon, and if no response, there is a “back-up” call at 7:00pm. The frequency of calling is either on Thursday or Monday and Thursday and is based on patient and clinician input. Reports are transmitted to clinicians in an actionable format; total score (9-27 total points); change greater than 2 from previous call, longitudinal trending, and indications of “no answer” or “incomplete survey results” are available to clinicians for evaluation and reaching out to patients within yellow and red zones.

Recruitment: Patients are selected for potential program inclusion from HCP’s COPD registry by clinical staff. Once a patient is identified with COPD and the care manager refers the patient to the program, the telehealth care coordinator activates the TeleVox service by uploading the enrollment information with a begin date, patient’s chosen phone number, and the survey call frequency. Patients can then opt out of the TeleVox service if they wish.

Welcome letters and physician notification of program enrollment: Each new member receives a letter that includes the survey questions and a copy of the COPD Action Plan based on National Jewish Foundation’s guidelines. The physician letter informs the doctor that the patient has enrolled and emphasizes the ability of telehealth to support healthier patient behaviors and better outcomes.

Patient trending reports: The automated emails provided once or twice a week to the care managers allow for efficient monitoring for the most at-risk patients that are prone for an ED or hospital visit.

Discharge from program: Discharge may involve direction from the care managers if the patient has signed on to hospice. The patient may elect to end enrollment due to moving out of area or change of eligibility with the medical group.

RESULTS

Enrollment/Selection Criteria: 181 patients from HCP’s COPD registry ≥55 years old and presenting a COPD diagnosis, stages I, II, or III, were invited to participate in the six-month program. Thirty (30) patients dis-enrolled and/or did not complete the program. Patients were excluded if they or their primary care physician (PCP) declined or opted out or were no longer an active patient in the HCP organization. Individuals were also excluded if they were enrolled in hospice, institutionalized in custodial nursing facilities, unable to participate due to severe dementia or organic brain disorder, on chronic hemodialysis due to end-stage renal disease, or were undergoing chemotherapy for active malignancies.

Program Outcomes: HCP's IVR project found that over a 30-day period following the initial hospital stay, the frequency of hospitalizations related to COPD were reduced by 50% compared to the twelve-month period preceding program enrollment. Rehospitalization rates for patients receiving IVR in conjunction with HCP's COPD care management program (4.97%, 9/181) were lower than those for traditional COPD patients (14%) and patients one year prior to enrollment in the IVR program (9.9%, 18/181).

The IVR technology and IVR reports expanded the clinical capacity of RNs to manage 200 patients with 5% triggering follow-up after every IVR survey. A survey of HCP care managers found that most believed (>90%) the telehealth program enabled them to monitor the patients more efficiently. This clinical survey was based on a patient satisfaction survey that was created by Centura Health at Home.

The project resulted in reduced costs per patient per month. Savings off-set program implementation expenses by reducing health costs, i.e., decreased admissions/readmissions, bed-days, and ED/UC visits. Project results also indicate that patients were very satisfied with the telehealth system, reporting 1) increased ability to stay in the residence of their choosing, 2) greater engagement in their health, 3) increased satisfaction with staff (i.e., having a formal caregiver watching over them and acting upon their symptom survey responses), and 4) ease of use of the technology (telephone). Finally, clinical staff reported high satisfaction with the ease of use of the technology, time saved, improved ability to keep track of patient’s symptoms, and improved ability to intervene before clinical symptoms became urgent.

Results suggest that the patients were extremely pleased with the telehealth system based on their: 1) ability to stay in the home of their choosing, 2) feeling more engaged in their health, 3) having a formal caregiver watching over them and acting on their symptom survey responses, and 4) having technology that is easy to use.

HealthCare Partners achieved an 1.3:1 ROI in Year 1, indicating that each dollar invested in RPM yielded $1.30 in savings for HCP. Projected ROI for HCP in Year 5 exceeded 18.

HOW THEY DID IT

Context of the Innovation: HealthCare Partners Medical Group (HCP) is an accountable care organization that takes global capitation risk in Southern California, Florida, and Nevada. As one of the largest providers of senior health care in Southern California, HCP has staff model clinics and independent physician association (IPA) delivery systems for approximately one million patients. HCP uses a coordinated care model for a culturally diverse patient population with a wide array of socio-economic classes, comorbidities, and ages. Approximately half of HCP’s patients are treated by 750 general practice physicians who are employed in a staff-model health maintenance organization; the remainder are cared for by 1,900 clinicians from regional affiliated IPAs. Previously, ethnic and racial affinity data were not available. However, these data are currently being collected to enhance health equity and further promote culturally sensitive care.

In Southern California, HCP’s service area includes Los Angeles, Pasadena, the San Gabriel Valley, South Bay, Long Beach, the San Fernando and Santa Clarita Valleys, and Orange County. HCP provides health care services to patients enrolled in managed care and fee-for-service plans including commercial insurers, Medicare, and Medi-Cal/Healthy Families. In addition, the HealthCare Partners IPA model enables physicians in the community to affiliate with HealthCare Partners. These regional IPAs consist of more than 500 primary care physicians supported by 1400 specialists. These characteristics ensure that HCP has sufficient size, scale, and broad geographic coverage necessary to absorb the costs and risk associated with development and operation of IVR technology to older, chronically ill patients.

Resources Used and Skills Needed:

Staffing:

  • 1 Telehealth Care Coordinator
  • 1 High risk nurse (extensive experience with CHF, COPD, DM, HTN, CAD, and other chronic conditions).
  • 2 Project management-Directors of Disease Management/Health Enhancement and Applied Research/Education.
  • As the program further expands into year 2 and onward, a 0.5 FTE recruiter will be required to solicit eligible COPD patients from the registry.

Costs:

  • The business/economic model shows start-up costs of $30,000 the first year, and $17.71 annual technology/operating costs/patient. The technology/operating cost decreases to $7.87/patient for annual operating costs/patient in Year 2 and to $4.55/patient in Year 5.

ADOPTION CONSIDERATIONS

Getting Started With This Innovation: Engaging patients to proactively manage their health is a hallmark of patient-driven care and plays a critical role in the design, construction, renovation, and maintenance of the medical neighborhood. The IVR RPM program demonstrated that patients and family members are able to recognize exacerbation symptoms, improve treatment adherence, and decrease hospital and emergency department visits. Moreover, this program helps expand the clinical capacity of staff thereby reducing stress and permitting personnel to focus on the most at-risk older patients.

Sustaining This Innovation:Use of RPM technology for treatment and monitoring of COPD patients has become routine practice in 5 out of the 6 Southern California HCP regions (soon to be all 6 regions), and has been sustained after the conclusion of the CTA grant. As the program expands into Year 2 and beyond, a 0.5 FTE recruiter has been engaged to solicit eligible COPD patients from the HCP patient registry. HCP is also identifying dual-eligible patients with COPD and/or Heart Failure who may benefit from remote monitoring technologies thereby impacting greater numbers of patients.

HCP was one of 32 organizations Awarded Pioneer ACO Model funds in December 2011. Incentives (financial and other) associated with Pioneer ACO status are important to sustaining the use of RPM technology at HCP. Results of the CTA RPM projects (and others) suggest that use of RPM technology for patient monitoring results in tighter management of chronic conditions, lower health care utilization, improved health outcomes, improved patient functioning, and lower cost of care. All of these are important outcomes for any ACO.

Other Considerations and Lessons:

Build off of successful care management programs and technologies. Building off of successful care management programs leverages existing provider and staff relationships while minimizing change management needed to augment established workflows. These program attributes not only increase provider and staff engagement and project support, but also improve the introduction, acceptance, and long-term sustainability within an organization. HCP achieved successful RPM program implementation by building off of their well-established COPD management programs. HCP also had a working relationship with their IVR RPM vendor prior to their RPM project, building off of existing relationships and contracts.

Align telehealth strategic goals with organizational vision and mission. The organization’s leadership needs to clearly define and articulate the goals and expectations for the success of the RPM program, selecting quality and financial outcome targets and goals that align with organizational goals and incentives. HCP defined program success in terms of the avoidance of 30-day readmissions, reducing unnecessary medical utilization, and increased patient satisfaction and activation.

Enroll patients into a RPM program on an opt-out basis. HCP determined that in order to be successful, a RPM program should employ an "opt-out" participant enrollment strategy instead of an "opt-in" enrollment strategy. Opt-out enrollment provided a larger pool of eligible patients and facilitated the enrollment process because physicians must actively de-select eligible patients.