Improving Self-Management and Clinical Outcomes for Congestive Heart Failure Patients by Utilizing Telescale Technology
The CalOptima mHealth CHF) Program utilizes telescale technology to help Dual Eligible patients manage their congestive heart failure (CHF). The program focuses on increasing members’ awareness of CHF symptoms and promotes self-management in order to improve clinical outcomes and prevent emergency department visits and preventable rehospitalizations. The 3-6 month program includes daily weight monitoring using a telescale, follow-up with out of range data or missed weigh-ins, weekly check-in calls, with a focus on improving patient education around CHF management.
CalOptima’s mHealth CHF Program has been successful in reducing body weight, increasing awareness of CHF symptoms, improving self-care skills, increasing patient satisfaction, and improving member/physician communication. While reductions in hospitalizations, hospital days, emergency department visits, were not statistically significant, there are clear trends in decreased health care utilization. CalOptima will sustain the mHealth CHF Program for its OneCare managed care members (dual eligible) and is in the process of incorporating this program into the California Dual Eligibles Coordinated Care Demonstration. Under the demonstration, CalOptima will provide or coordinate all health care services for dual eligibles beginning in 2013.
WHAT THEY DID
Problem Addressed: The growing prevalence of CHF, coupled with poor management of patient conditions, has resulted in tremendous burdens of illness and costs to patients and the health care system. Dual eligibles, typically elderly or non-elderly disabled patients, are the poorest, sickest, and costliest of all Medicaid beneficiaries – representing 15% of Medicaid enrollees and 39% of program spending in 2007 – with the majority of the costs going to pay for long-term services and supports not covered by Medicare. Dual eligibles are also costly to Medicare, accounting for 16 percent of the program’s enrollees and more than onequarter (27 percent) of program spending in 2006.
Patient monitoring technology has the potential to enhance self-care and awareness of heart failure, and reduce re-hospitalizations and ED visits. The CalOptima mHealth CHF Program assessed the impact of monitoring technology on dual eligibles’ patient experience, clinical outcomes, and service utilization in the treatment and management of patients with CHF.
Patient Population: Dually eligible for Medicare and Medi-Cal patients residing in Orange County, CA. Among the 54 members that participated, the average age was 74 years, and nearly 60% were female.
Description of the Program: CalOptima’s mHealth CHF Program incorporates strategies for improved self-management and adherence to treatment plans, such as:
- Daily weight monitoring
- Consideration of other health conditions/co-morbidities, lifestyle issues, health behaviors, and psychosocial issues
- Providing information to caregivers, as permissible
- Encouraging physician/member communication
Workforce needed for member recruitment: Five experienced registered nurses with strong backgrounds in chronic disease management, and one medical assistant, were involved in the recruitment process.
Device Deployment and Training: The technology was explained and an appointment was set for delivery of the equipment (i.e., telescale). A Disease Management nurse delivered the scales to the members’ homes, set up and tested the equipment, and trained the member and/or patient’s family on its use to assure successful participation.
Monitoring: Patients were monitored daily and follow-up phone calls were made to any member who exhibited out of range results or behavior.
Ongoing day to day operations:
- Daily monitoring of members
- Weekly courtesy calls
- Follow-up calls for any emergency department visits or hospitalizations
- Review biometric data alerts (i.e., symptoms, weight or both) and call patients affected
- Notify primary care provider if patient gains more than five pounds in a week or more than two pounds in a day
- Notify primary care provider if patient had significant symptoms
- Notify contracted health network’s case manager as indicated (examples include non-compliance with medications or program)
- Refer patient to case management, as needed
- Call patient if they have not weighed themselves in three days, to encourage compliance
Discharge from program: Participants may stay in the program as long as they want but are disenrolled if they develop end stage renal disease (ESRD), become noncompliant with weighing, move out of the area, are admitted to a facility for what appears to be a long-term stay, or if they request to come off the program.
Enrollment/Selection Criteria: To identify potential participants for the program, CalOptima used its existing data to identify members who met the following criteria:
- Have Medicare and Medi-Cal (dual eligible)
- Have pharmacy claims for one or more heart medications
- Do not have any of the following exclusion criteria:
- chronic liver disease: 571.0 – 571.9
- congenital heart disease
- address field indicates member is homeless, resides in a
- long term care facility or is incarcerated
- Member resides outside Orange County
Staff also contacted case managers at CalOptima’s contracted primary medical groups to request patient referrals; screened members in CalOptima’s case management program to determine if they met participation criteria; and identified members recently discharged from the hospital.
Potential participants were then contacted by mail. Of 704 members contacted by mail, 109 returned the participation form indicating interest. About 175 were contacted by phone, seven of whom agreed to participate. The nurses made three attempts to contact each member.
Total initial enrollment was 54 members. Of these members, 22 disenrolled and 32 completed the intervention or remain active in the program.
Program Outcomes: CalOptima’s mHealth telescale program has been successful in reducing body weight (p=0.007), increasing awareness of CHF symptoms, improving self-care skills, increasing patient satisfaction, and improving member/physician communication. Reductions in hospitalizations, hospital days and emergency department visits were not statistically significant. However, there are clear trends in decreased health care utilization. The number of months that members participated in the study ranged from 3.12 months to 5.95 months (average participationof 4.44 months).
HOW THEY DID IT
CalOptima is a public agency that was formed in 1993 by a dedicated coalition of local elected officials, hospitals, physicians, and community advocates. CalOptima’s mission is to provide members with access to quality health care services delivered in a cost-effective and compassionate manner. As a County Organized Health System (COHS), CalOptima is authorized by state and federal law to administer Medi-Cal (Medicaid) benefits in Orange County, California and holds a contract with the California Department of Health Care Services (DHCS) to administer covered Medi-Cal services. Currently, CalOptima serves more than 424,000 Orange County residents, the majority of whom are Medi-Cal members (91%).
CalOptima has provided health care services to seniors and persons with disabilities (SPDs) for more than 16 years. In 2005, CalOptima became licensed by the Centers for Medicare & Medicaid Services (CMS) to serve dual eligible SPDs by creating a Medicare Advantage (MA) Special Needs Plan, known as OneCare (HMO SNP). OneCare earned a 4-star designation in the Medicare Star Quality Rating System for 2012 and currently serves more than 13,000 members, or 17% of CalOptima’s dual eligible members. The remaining nearly 62,000 duals in the county receive Medicare services from different MA plans, or are a Medicare fee-for-service (FFS) member, with CalOptima coordinating the Medi-Cal wraparound benefits.
Planning and Development Process:
Provider Training and Policies and Procedures Development: The disease management nurses met with the telescale vendor for training on how to operate the wireless scale in the members’ home and collect the data once the information transmits from the equipment to the hub. The Manager of Disease Management developed program policies and procedures and created reporting processes between participants, physicians and other clinical staff.
Patient and Caregiver Training and Education: The Manager of Disease Management developed a program that included training and education for OneCare members and/or their caregiver. Eligible members received a welcome letter that explained how the member was identified as being eligible for the pilot (i.e., claims identification and encounter data, pharmacy claims, a direct referral from a physician or family member, or self-referral). CalOptima established the program as an opt-out proc the program.
Disease management nurses sent a follow-up letter that included disease-specific education to all newly-identified eligible participants. The letter described the services that the CHF pilot program makes available to help the participant manage their CHF and contact information for the program’s disease management nurses.
The disease management nurses used a screening tool to test the likelihood of success and effectiveness of various methods of data transmission, communication, information flow, engagement, readiness for change, and home set-up between the OneCare member and CalOptima. Members were contacted by letter and phone regarding the purpose of the program, how to use the wireless weight scale, and when to contact the disease management nurses and physician office. The nurses confirmed when the OneCare members were ready for participation in the program.
Providers & Health Networks: Provider offices were notified by mail about the program and were asked to refer their OneCare CHF patients to the program. As members enrolled in the program, providers were mailed a list of their participating patients, along with a document of frequently asked questions (FAQs) about the program, and CalOptima’s contact information. CalOptima’s contracted health networks were contacted via email from the Manager of Disease Management about the program and were asked for member referrals.
ADOPTION CONSIDERATIONS AND LESSONS LEARNED
Getting Started with This Program: For CalOptima, being able to leverage the expertise of existing staff was critical to launching this program and helped to contain costs. Consider utilizing readiness assessments and vendor requests for proposals to determine patient eligibility and technology requirements, respectively.
Sustaining and Scaling Use of the Technology: CalOptima will sustain the mHealth telescale program for OneCare members. In March 2012, Orange County was selected as one of four pilot sites for California’s Dual Eligibles Coordinated Care Demonstration. Under the demonstration, CalOptima will provide or coordinate all health care services for dual eligibles beginning in 2013. CalOptima believes that telescale monitoring technology is highly complementary of the demonstration’s goal of coordinated, member-centered care.
Partner with Vendor to Align Patient Needs with the Technology. Conduct a thorough review of technology requirements using a robust request for proposal. Determine patient language needs and technology language capabilities, review technology communications (e.g., verbal commands and volume control) and physical capabilities of older adults to use the technology (many patients required assistance climbing on and off the scale).
Insure Equipment is Viable with Patient Population. Confirm equipment is available in targeted threshold languages to avoid communication challenges with participants. Test for operational issues, such as appropriate volume control and privacy protections.
Patient Selection Criteria Critical for Success. Patient selection inclusion and exclusion criteria has to be very specific and strictly adhered to for effectiveness. Many patients that were very sick had additional case management needs, often requiring a higher level of care than the monitoring program provides.
Plan for Increased Patient Technology Training as Needed. Patients are introduced and instructed on how to use the telescale during the first home visit. Some patients required more training and struggled using the technology throughout the program. Consider additional training as needed on a patient-by-patient basis, where repeat visits might be required to train older adults on using the technology.