Behavior Change

Archive for Behavior Change

Measure What You Manage, With Caveats: Thoughts on Surgeon Ratings

When I worked at Microsoft, we managed by the scorecard. The scorecard was meant to provide key indicators of the business health. If something wasn’t on the scorecard, it didn’t get focus from the worldwide sales and marketing groups, and if a product or initiative didn’t get this focus it would die. The scorecard had tremendous power and was a rallying and focal point for a sometimes unwieldy global organization. So powerful was the scorecard that if any errors were made in how something was tracked, it could drive exactly the wrong behavior.

One year, a metric was introduced to measure sales of a new product, in relation to an existing product. The thought was that the new product was a good “upsell” from the existing product so tracking one in relation to the other was a logical measurement. The intention of the metric was to show the new product growing as it “attached” to the existing product. The metric was calculated as:

Product target calculation

 

The sales teams behaved rationally and stopped selling the existing product, because if they sold the existing product, they had to sell even more of the new product to meet their target since the denominator of the equation kept increasing. They met their targets and got their bonuses, but their behavior was exactly the opposite of what the product teams and the company wanted which was for both businesses to grow or at least for the existing product to stay steady while the new one grew.

Last week, ProPublica caused a flurry by releasing a report of complication data for US surgeons. Using their database you can look up any surgeon and find how their patients fared on average for complications after surgery.

As with any measure, it is fraught with controversy about both the accuracy of the data or whether we are measuring the right things. On the surface complication data seems like it’s a good way to track surgeons, and it is if the complications are caused by surgeon error. The problem is that complications are caused by lots of things including patient behavior (for example not caring for a wound properly or taking too many narcotics and falling down after surgery) or by the patient situation, for example, age or co-morbidities. Looking at complication data alone, as Dr. Jennifer Gunter points out eloquently in her blog post, does not give the whole picture. Dr. Gunter’s mother had two surgeries, one that would be recorded as “no complications” and one full of complications. From the raw data, the first surgery looks like a success with a 7-day hospital stay, and the 2nd a failure with a 90-day hospital stay and many complications. (Note that the 2nd surgery could be counted as a “readmission” which would be counted against the hospital.) Regardless, in this situation data alone does not tell the whole story.

In addition to not telling the whole story, looking at complication data alone can drive the wrong behavior, which is surgeons only taking on the “easy” cases, those who are younger, in perfect health, and have no other diseases, for example diabetes. There are many things that patients can do before surgery to ensure successful outcomes like quitting smoking or losing weight, there are things they can’t do, like get rid of a chronic disease or suddenly shed 10 years. Judging surgeons on only complications can encourage them to “cherry-pick” patients so that they have low complications and high scores. In turn these surgeons will be sought out by the “best” patients, and we could end up with a bifurcated system where the “worst” surgeons (looking only at complications) operate on the hardest cases.

There’s a saying that you can’t manage what you can’t measure. It’s important as well to consider what you are measuring, the behavior that you intend to drive, and the long-term implications of it . Healthcare is making small steps to become more data and outcome-driven and we need to encourage and commend that. At the same time, let’s make sure we are looking at the right metrics.

Posted in: Behavior Change, Healthcare Policy, Healthcare Research, Healthcare transformation, Outcomes

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Reducing Readmissions and Costs for Total Joint Replacement

Last week CMS announced a major new initiative for Total Joint Replacement, aimed at both reducing and reconciling costs. Total joint replacements are predicted to increase at a rate of 30% to 2020. Demographics are the major driver: people are getting joint replacements at a younger age, and may have more than one in their lifetime. On the one hand, more active baby boomers have put greater strain on their joints by running marathons, and on the other an overweight population is putting more strain on their joints just by walking around.

Since the demand is increasing, and the costs fluctuate wildly, up to 100% by Medicare’s estimates, the opportunities to look for costs savings and to reward based on outcomes is key. Like other bundled payment recommendations, Medicare is looking at the 90-day readmission rates and also using a carrot and stick reimbursement approach.

“Depending on the hospital’s quality and cost performance during the episode, the hospital may receive an additional payment or be required to repay Medicare for a portion of the episode costs.”

While private payers often follow Medicare, this is one area where Medicare cites that it is following a trend that has already been piloted in private scenarios, most notably with self-insured employers contracting directly with healthcare systems on fixed-price knee and hip replacements, like the deals Walmart and Lowe’s have struck directly with hospitals.

Screen Shot 2015-07-12 at 4.00.51 PMThe American Hospital Association is also ahead of the curve on this trend, and they published some recommendations in a 2013 report entitled “Moving Towards Bundled Payment.” In it, they also noted the wide fluctuations in pricing between health systems for total joint replacement, and also that 33% of the costs of a total-joint replacement come from post-acute care.

Screen Shot 2015-07-12 at 4.01.13 PM
Our research has shown that a large driver of these costs is discharge setting related. While the majority of patients do better when discharged to home, they were being discharged to skilled nursing instead as a “belt and suspenders” type of back up. Discharging to the right setting, can improve patient experience and lower costs. However discharge to home requires the right type of patient tools. Patients need to have great educational materials, the ability to track their progress, and the ability to get remote help if they need it. This is something we’re passionate about at Wellpepper, and we are working with a number of leading health systems that are moving to bundled payments to help them digitize the pre and post surgical instructions and collect patient reported outcomes. We’d like to be part of the solution for both patients and providers as we move to these new models of care and reimbursement.

The Medicare proposal is open for public comment for the next 60 days. It’s over 400 pages long, so you may want to print a copy and take it for a little light beach reading.

 

Posted in: Adherence, Aging, Behavior Change, Health Regulations, Healthcare Policy, Healthcare transformation, Outcomes

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Personal or Population Health? Big Data or Small Data?

Seattle Health Innovator's meetupJune’s Seattle Health Innovator’s Meetup topic was on Innovations in Population Health Management. Interestingly much of the discussion from panelists circled back to the individual patient. It seems that much of this was because the great promise of big data analytics in healthcare and automation and economies of scale through electronic medical records have not been realized. The audience consisted of entrepreneurs building solutions in this area, and innovative and entrepreneurial people within health systems.

The event, at the sleek new Cambia Grove healthcare meeting space, was kicked off by Dr. Wellesley Chapman, Medical Director Innovation and Development at Group Health. Dr Chapman set the stage by defining population health in a highly inspirational manner by referring to The Gates Foundation mission that everyone deserves to live a healthy and productive life. Narrowing in a bit more Dr. Chapman talked about the influences of good health on a population. Interestingly, although population health is largely thought of as a health system problem, the formal medical system only has a 20% influence on the health of a population and a person. Socio-economic factors have a much bigger influence, things like building walkable cities that encourage activity and community, access to healthful foods, and education. Unfortunately with healthcare representing 18% of the US GDP, there is a misallocation of funds to the clean up of problems versus infrastructure that will affect the well-being of the whole population. However, even though care delivery is a small part of the overall picture and influencers of health, Dr. Chapman enthusiastically encouraged the audience to do what they could to affect change.

The meet up continued with a panel discussion moderated by former Group Health VP of Marketing and now patient engagement consultant, Randy Wise and featuring:

When considering a population health strategy, key factors the panel felt were important were lead time to implement, expected outcomes, costs to patient and payer, and the overall patient experience. Patients are concerned about the quality of their lives, and this needs to be addressed at the primary care level, however, most health systems do not have a primary care strategy. Primary care is reactive rather than preventative, and reactive care is not usually focused on patient goals. Since the health of a population is so varied, at the primary care level, panelist thought “everything could be considered population health” making it difficult to pinpoint specific solutions for care.

When asked about whether big data was improving population health, panelists were negative to neutral, citing Excel spreadsheets used to review data, and the opportunity to know a lot more about patients. However this again came back to the specific saying that the intervention is all about the relationship between patient and provider and asking whether we are enabling patients to follow through with recommendations. (At Wellpepper, we would say there’s a great opportunity to improve here based on many of the care plans and instructions we’ve seen.)

Seattle Health Innovator's MeetupDr. Levine from Iora talked about his experiences training residents in listening skills and the payoff. Compared to a common approach of telling the patient they have limited time and to focus on the top issue, Dr. Levine advocated listening first, ask the patient to recount all their concerns, make a commitment to truly listen and hold the information the patient provided, and then follow up on the most pressing issues. Although the residents were skeptical, this approach yielded significantly faster follow-up as key information wasn’t being uncovered at a later date.

Events like this provide a great opportunity for those enthusiastic about changing healthcare to exchange ideas, and especially for entrepreneurs to learn practical advice from those in the trenches delivering care and trying new models. The big takeaways are that the promise of big data in healthcare is yet to be realized, and because of that population health tools may not be as effective as they could be. While the focus on patient personalization, customization, and meeting the needs of the individual are key, we need to figure out new ways to scale to solve this great problems in health.

Posted in: Behavior Change, chronic disease, Healthcare Disruption, Healthcare motivation, Healthcare Research, Healthcare Technology, Healthcare transformation, M-health, Seattle

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Session Picks for 2015 American Telemedicine Meeting

We can’t promise to get to all these sessions and blog about them for you, but here are a few that caught our attention at the American Telemedicine Association Annual meeting coming up in Los Angeles next week.

Monday May 4th

Establishing a Program to Reduce Readmissions and Costs in the Ambulatory Setting: A California Success Story

Telehealth is proven to decrease costs without sacrificing quality for many scenarios.

Learning Opportunities from Large Scale Telemedicine Initiatives

An interesting mix of private and public sector initiatives across disciplines including pediatrics and psychiatry.

Improving Commitment, Quality, and Outcomes

We love outcomes, and this session also feature’s Seattle’s own Carena.

It’s a Small World After All: Approaches in Neonatal ICU Care

Cute title, serious results with examples across pediatric care.

A New Model for Remote Diabetes Care Best Practices

One of the biggest issues facing our healthcare system so new models welcome!

Expanding Telehealth to Improve Hospital-wide Readmission Rates

Readmissions and care transitions, so important.

Mainstream Medicine Moves into Direct to Consumer Health

Mercy, a Catholic Health System from St. Louis, is a quiet leader in telehealth. Find out why they dedicated an entire new building to for their telehealth practice. Plus a case study from Cleveland Clinic. Whew, that’s a lot of great content.

Tuesday May 5th

Utilizing Interactive Voice Response (IVR) and Telemonitoring to Reduce Hospital Admissions and Readmissions for Heart Failure Patients

Heart failure is a patient group where readmissions can be prevented with better communications, which telemedicine and remote monitoring can provide.

A Large Provider Focuses on Consumers: The Experience at Kaiser Permanente

With large deductibles, patients are increasingly making decisions as consumers.

Implementing Successful Clinical Specialty Programs: Burns, Infectious Diseases, and Genetics

Telemedicine helps scale specialists, especially from centers of excellence and to rural areas.

Using Community Health Models to Enhance Patient Performance and Outcomes

Another great benefit of telemedicine is to empower community health workers through remote support from specialists.

Posted in: Behavior Change, Health Regulations, Healthcare Technology, Healthcare transformation, M-health, Telemedicine

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Reducing Avoidable Readmissions: Measuring and Influencing Change

To wrap up the 2-day “Reducing Avoidable Readmissions Course” from the Institute for Healthcare Improvement, was a session on measuring results. The session, while helping to provide measures and objects was as focused on how to manage change in an organization, with the understanding that within healthcare organizations this can often be akin to turning a cruise ship.

One presenter, describing a successful partnership between a hospital and skilled nursing facility to improve transitions in care mentioned that it took over 3 years to implement the program. She expressed frustration that often people’s roles changed in this period but seemed to accept that this length of time was pretty typical, and considering it was an inter-organizational transformation that is probably true, and possibly fast.

When planning to make changes within your organization, here are some great ideas for influencing change and getting it to stick.

  • Set realistic goals. For example, when trying “Teach Back” ask physicians and nurses to try teach back with their last patient every day. This will give them the experience without unrealistic expectations and if the new method takes a bit longer at first doing it with the last patient will not disrupt the schedule.
  • Use the lean principles of the 5 Whys to get to the root of why something is broken.
  • Make sure that new processes do not increase workload and have perceived value, using the “highly adoptable” formula from Chris Hayes.
Source: Christ Hayes, www.highlyadoptableQI.com

Source: Christ Hayes, www.highlyadoptableQI.com

  • Involve frontline staff in process design. They will be the ones who need to implement it so make them part of the solution.
  • Determine what you will measure before implementing so you can gage success.
  • Test changes under a variety of conditions before trying to replicate across an organization. That way, you will be prepared for any potential adoption blockers.
  • Prepare for and manage relapses. People may revert to older processes if the new ones fail. Plan for this, and see it as a learning opportunity rather than a failure.
  • Make the change about improving patient care. Even though the goal may also include reducing readmissions, lowering costs, and increasing predictability, these are topics that are hard to rally people around. Remember why you and your colleagues entered healthcare: to help people. Appeal to the highest goal of improving patient’s experience and health.

Posted in: Behavior Change, Healthcare transformation, Outcomes

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Using “Teach Back” To Decrease Patient Readmissions

Marshall McLuhan, the late Canadian philosopher, famously said both “the medium is the message” and “the medium is the massage” meaning that the delivery mechanism of information provides insight into the meaning and can also shape the meaning.

In a recent course I attended from the Institute for Healthcare Improvement on “Preventing Avoidable Readmissions” there was a lot of focus on missed messages whether between healthcare professionals or from healthcare professionals and patients. Some of these messages were missed because of the delivery mechanism, and one session in particular focused on a concept called “teach back” which was designed to ensure that the message of discharge instructions actually landed with patients.

Source: IHI.org

Source: IHI.org

Throughout the course, the same refrain was heard that improving communications between healthcare providers and to patients were key to improving health outcomes. Examples of poor or rushed communications were provided across the course and included:

  • Patients in the emergency department not knowing why they were actually admitted
  • Conflicting discharge instructions from different hospital departments
  • Rushed conversations with patients

As well, patients often interpret information differently than intended. For example, when patients are discharged they hear “better” rather than “recovering.” As well the messages often don’t land because patients are thinking ahead to the implications of the information, for example, when told of impending necessity for surgery they are thinking about needing to take time of work, or who will walk the dog.

In our work at Wellpepper, we have interviewed many patients about why they don’t adhere to treatment plan instructions, and what most of them tell us is that when hearing the instructions in the first place they felt like they understood but when they got home they realized that they didn’t. Think about this with respect to how these messages are often delivered: patient have limited time with healthcare professionals, they are often intimidated and don’t want to ask questions, and then frequently the handouts they are sent home with don’t correspond to what they thought they heard.

Thinking about how instructions are delivered to patients can help tremendously with patient understanding and follow up. The IHI course presented some practical strategies both for delivering the information and for testing patient comprehension wrapped in some specific strategies referred to as “Teach Back.”

Healthcare professionals learn many things in their studies, but information design, learning styles, and comprehension are not necessarily part of that. Understanding that people learn in different ways, that patients are often distracted by bigger life issues when you are trying to teach them, and that a patient’s ability to demonstrate what you taught them better indicates they can go home and replicate are all tools to improve patient comprehension and adherence. As well, often it is not just the patient who needs this information but also the patient’s caregiver.

The basic principles of Teach Back include:

  • Making sure that information is easy to understand. For example avoiding medical jargon, written for a 5th grade reading level, and including only the most important information.
  • Delivering the information in a way that shows the patient you care, and that the information is important. For example, taking the time to walk through the information, sitting down and looking at the patient, and using a warm and caring tone of voice.
  • Testing for understanding. Ask the patient to explain what you taught them in their own word and if appropriate to demonstrate what you taught them.

We loved this particular session as it’s in keeping with our findings that patients want to adhere to programs provided you provide them with the right tools. As well, we have been recommending a teach-back style when recording video tasks with Wellpepper. First explain the task to the patient, whether that’s physical therapy, wound care, or using an inhaler. Next have the patient demonstrate to you that they can do it. When the patient is able to show you they can do it without extra help or prompting, record the patient and make this part of the patient instructions that you send home with them.

Teach back and informational design concepts may seem like they are taking healthcare outside of a traditional realm. They may also seem like they take more time. In the short term that might be true, but in the long run you will need to spend less time with these patients as they will be self-activated, which needs to be the goal of any readmissions prevention program.

Posted in: Behavior Change, Healthcare motivation, Healthcare Policy, Healthcare transformation, Outcomes

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There’s No Silver Bullet: Reducing Avoidable Readmissions

Last week I had the opportunity to attend the Institute for Healthcare Improvement’s two-day training on “Reducing Avoidable Readmissions” training here in Seattle.

Reducing Avoidable ReadmissionsI’ve got some good news and some bad news. The bad news first according to this leading organization in healthcare quality improvement, there is no silver bullet. The good news is that there are a number of small practical steps to improve insight, quality, and patient experience.

This blog post provides an overview of the intensive 2-day training, and I’ll follow up with deep dives on a few sessions. Really, there’s enough content for a few weeks of blog posts, so we’ll use this forum to point out some best practices, and capture some of the best insights from the training. As with any training, so much of the value comes from the other participants, so we recommend checking out a training yourself in person. What was amazing about this course is that it brought together healthcare professionals who might not have had the opportunity to meet otherwise, and these different perspectives resulted in actionable takeaways for participants when returning home. Participants ranged from hospital CEOs and other C-level executives, to care coordinators across large and small health systems, primary care, hospitals and health systems, skilled nursing and in rural and urban settings.

Changing Healthcare ParadigmsRegardless of participant, it became clear that information did not flow well between these different healthcare settings, and that each specialty or care location had very little insight into what happened in the other setting. Just bringing these diverse participants together helped them see what could be done to improve patient handoffs and communication across the care continuum. A number of participants expressed how helpful it was to understand the process and constraints that others were seeing. Primary care physicians seemed to be the most handicapped as they had no way of knowing if their patients were admitted to hospital at all.

Sadly, for someone in the digital health field, another key theme that ran across the two days was how many participants felt that their medical records were preventing them from doing a better job on readmissions. The reason for this was two-fold: information did not flow between settings, and it was often too difficult to capture key information about the patient and access it at point of care. Medication reconciliation was cited as the holy grail of patient management but most participants didn’t believe it would ever be possible to get a clear solution to this problem.

Communication with patients was another key theme of the course, both in improving how patient discharge instructions and patient understanding of those instructions were delivered and in asking the patient for feedback. Again, it was a common sense approach rather than a “silver bullet.” Multiple presenters said “The reason your patient readmitted is in the hospital bed” or more simply, “ask the patient why they readmitted.”

Another key focus of the course was on change management within the organization. First understanding and then preventing readmissions requires change within the healthcare organization. Presenters had all led or participated in multi-year change journeys within their organizations and had both battle scars and key strategies for how to motivate and change within a large organization. One most basic tip was “don’t talk about readmissions, fines, or penalties” instead they suggested rallying teams around the benefits to the patients.

Topics that we’ll explore in more detail from the course here on the blog include:

  • Teach back and communicating with patients
  • Care transitions and discharge setting
  • Measuring change

Posted in: Behavior Change, Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare transformation

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Healthcare Reform and the Affordable Care Act: One Year Later

APTA CSM 2015 Recap: Healthcare Reform and the Affordable Care Act: One Year Later

Speaker(s):

Edward Dobrzykowski, PT, DPT, ATC, MHS

Janice Kuperstein, PhD

Karen Ogle, PT, DPT

Charles Workman, PT, MPT, MBA

CSM StepsThe consensus from the speakers in this session was that the changes are real, they require work on the part of healthcare providers, and that physical therapists have a great opportunity to participate. There was definitely a greater sense of urgency on this topic than in previous years at CSM, and speakers made sure the audience knew that:

“While we’re all worried about G-codes, new players like Walmart, Walgreen’s, and Google are creating entirely new models of care.”

“Patient satisfaction is not enough, we need to look at outcomes”

“Reducing length of stay is not going to be the only way to reduce costs.”

Some of the major themes of the Affordable Care Act that speakers believed impact physical therapy include:

  • Realignment of care models from management of chronic disease to preventative medicine
  • Conservative interventions preferred over surgery due to costs and outcomes
  • New payment models and reduction in visits
  • Direct access to physical therapy
  • Standardization of service
  • Accountability for services delivered
  • Outcomes measurement

All of these were seen to provide both challenges and opportunities to the profession. Similar to other sessions, opportunities in improving outcomes and decreasing costs of post acute care, and in improving discharge, and care transitions to reduce readmissions were seen as key areas where physical therapy could have a big impact, however, physical therapists needed to participate more in the process.

Presenters pointed out that homecare workers and occupational therapists are already working in health coaching positions for population health management, but physical therapists were not really serving in these roles. Given that many studies show that discharge to home is best for the patient, and also lowers costs, this is seen as a missed opportunity for physical therapists.

Full moon over Indianapolis

Full moon over Indianapolis

In order to effect change, moving to more accountability and measurement is important, for example predictor tools to score patient on risk of readmit and standardized outcome tools. By moving to these measures and recording outcomes, physical therapists will be better able to participate as part of new payment models, like bundled payments.

Considering that for the patient, function is usually the most important outcome, and physical therapists are experts in delivering a return to function, the core value equation could be applied directly to physical therapy to deliver better outcomes at lower costs.

Value = Quality x Patient satisfaction

Attendees were encouraged to ask questions during the session and feedback ranged from a hospital-based physical therapist participating in a bundled total joint replacement scenario, where the hospital was receiving 3% back from CMS due to delivering positive outcomes at a lower cost than stipulated to those in smaller or private practice wondering whether there was room for them to participate in these types of payments with hospitals, or whether they would be shut-out. This was a common theme at the conference as private practice owners questioned whether controlling costs and outcomes would mean that hospitals would bring outpatient physical therapy in-house.

Similar to other sessions, suggested that the two keys to delivering on new value-based payment models required better care collaboration among multi-disciplinary teams and standardized outcome reporting.

“Merely aligning financial incentives between providers of acute and post-acute care will not improve quality and reduce costs for episodes of care. True coordination of care is required to ensure the best possible outcomes.” Ackerly DC and Grabowski DC. Post-Acute Reform- Beyond The ACA. NEJM 2014;370(8):689-691

For outcome reporting, the question was asked if patient-reported outcomes were the new gold standard. If patient satisfaction and functional outcomes are key in the value equation, then they are.

To conclude presenters reminded participants what they can do to participate in this new world, which reflects the larger clinical, demographic, and social trends.

  • Develop strategies and tactics around population health management
  • Optimize efficiency in each practice segment
  • Build collaboration “upstream” and “downstream”
  • Position for more integration

The session did a great job of showing that the change is real, the opportunities are there, but also making attendees understand that the time is now. Our overall impression of the conference this year is that physical therapists have a great opportunity to be on the front-lines of some of this change but that they may need to move faster than in the past. Exciting times to be in patient-centered care!

Posted in: Behavior Change, Health Regulations, Healthcare transformation, Outcomes, Physical Therapy, Rehabilitation Business

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Developing Exercise Self-Efficacy for Chronic Disease Patients

APTA CSM 2015 Recap: Use of Mobile Health Technology to Facilitate Long-Term Engagement in Exercise in Persons with Chronic Neurological Conditions

Speaker: Robert Motl, PhD

Managing chronic neurological diseases like Multiple Sclerosis and Parkinson’s is not easy, and made even more difficult by conflicting research on how to treat issues. For many years it was unclear whether exercise was good or bad for people with Multiple Sclerosis: some thought that exercise increased the inflammation that is a hallmark of the disease. Recent studies have shown the opposite however and this talk was focused on how an Internet-based intervention could improve exercise self-efficacy.

Exercise, in addition to providing increased mobility, has been shown to actually decrease depression and fatigue for these patients, contradicting past beliefs. Unfortunately, many physicians don’t discuss exercise with these patients, and to go from a sedentary lifestyle to one that includes activity, especially for someone with a chronic neurological issue requires support and supervision.

The problem is widespread as only an estimated 20% of MS patients in the US are engaging in levels of physical activity that will have a positive impact, and studies show a linear decrease in activity from initial diagnosis over the course of the disease with a systematic decline in physical activity every 6 months.

Bandura's Social Cognitive Theory, Source Ahmed Asim

Bandura’s Social Cognitive Theory, Source Ahmed Asim

When researcher Robert Motl discovered through a Microsoft-sponsored survey that people with MS were more likely than average to have Internet access (96% had access actually) he decided this would be a great way to educate on the benefits of exercise and attempt to encourage self-sufficiency. He designed an Internet-portal and telemedicine based intervention using Bandura’s techniques of social cognitive theory to effect behavior change.

People learn by observing and by doing and confidence is key for self-efficacy. To accomplish this through an online intervention the website featured personal stories and videos from people who had MS talking about how exercise made a difference for them. People need role models for behavior change and it’s important that those models are similar. The impact of these videos was that people were able to think “If they can do it, so can I.”

Patients were also able to set goals and self-monitor them and communicate in chat rooms with other people with similar situations. After the first year, the website was removed, which may seem strange, but it was done to test whether people would continue with the intervention, which they did. At this point the only support they received 1:1 video chat with a physical therapist to help them check-in and maintain goals.

The main takeaways from this session are that with the right tools and support, which do not have to be expensive, people can change a behavior and maintain self-efficacy. At Wellpepper, we have definitely seen this and hope that more studies like this enable better care through technology and through outside the clinic support.

Note that the other half of this talk explored a yet unpublished study that Boston University is doing with Wellpepper. You can get a sneak preview here, and we’ll be publishing more on this in the future.

Posted in: Adherence, Behavior Change, chronic disease, Healthcare motivation, Outcomes

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Translating Evidence-Based Interventions to Practice: Falls Prevention and Otago

APTA CSM 2015 Session Recap: Falls Prevention: Otago Program and Behavior Change

Presenters:

Mary Altpeter, PhD

Tiffany Shubert, PhD

Clinical Support for Otago

Clinical Support for Otago

The fact that a session entitled “Falls Prevention: Otago Program and Behavior Change “ ended up in the Health Administration /Policy track at APTA CSM 2015 reinforces that we have a long way to go on translating outcomes-based research into care plans. Otago is a proven and effective set of preventative exercises and care for community-dwelling yet frail adults which improves balance and prevents falls risk. It was developed in New Zealand, at the University of Otago over 14 years ago, and prescribes a set of balance and strength exercises that the patient completes independently over 12 months.

Recommended physical therapy visits to access, teach, monitor, and kick-start patient adherence are to occur over 6-8 weeks and after that patients are encouraged to self-manage, and herein lies the reason that this session is in health policy and administration: this is longer than most insurance covers, and there are not currently enough incentives for remote patient monitoring. However, according to presenter Tiffany Schubert, Otago shows an ROI of $1.25 of every dollar invested as it prevents patients from falling which results deterioration to the patient and further burden on the health system.

Barriers to implementing Otago in the US stem largely from reimbursement and the current incident-based payment model that does not facilitate managing patients over a long period of time. As a result, Otago expert and presenter Tiffany Schubert presented an abridged version that might be easier to fit into current payment models.

Delivering Otago: Calendar view

Delivering Otago: Calendar view

However she is also on a crusade to collect outcomes data for Otago in the US so that these barriers can be overcome as the barriers are not just reimbursement. Clinicians have preconceived notions that patients won’t adhere to plans. Tiffany challenges these misconceptions by asking “are you sure or is it your patients just don’t understand.” We’ve definitely seen this with patients we’ve interviewed: they do want to be adherent to their plans but they find out when they get home that they forgot or are confused. Otago and systems like it work well when there is remote support for the patient.

Clinical Barriers to Implementation

Clinical Barriers to Implementing Otago

Given that Otago requires a high-level of patient self-efficacy, understanding factors that impact behavior change is key in driving long-term outcomes and adherence. Hence, the second half of this presentation, from Mary Altpeter focused on strategies to help patients develop self-management skills to complete the independent part of the program. One of the big misconceptions, that we hear frequently from healthcare providers (and definitely from many of the sensor and tracker vendors), is that knowledge is sufficient to effect change. It’s not, many other factors weigh in including readiness to change and social influences. Understanding more about the patient’s own journey and the patient’s barriers and readiness to change can make a big difference in this area. Also understanding the patient’s goals is crucial and personalizing their risk of not changing their behavior.

Breaking behavior change down into stages can really help move the patient along a path. In this session, Altpeter outlined a 5 stage model to affect patient behavior.

6-Stage Behavior Change Model

6-Stage Behavior Change Model

Understanding that while your assessment may show that the patient is at risk for falls, the patient may not have internalized this. First step is to plant the seed of doubt while the patient is in what is called the “Pre-Contemplation” stage. You can do this by personalizing the risk.

In a falls scenario, patients are not actually worried about falls risk. This sounds counter intuitive, but patient goals are usually not functional goals they are life goals. (We can attest to this from the goals patients set in Wellpepper.) So, the patient may be worried about losing their driver’s license which might happen if they had limited mobility. This is moving to patient-centered goals from clinical goals which personalizes the risk. Find out what the patient might be afraid of losing and this can start to plant the seed of doubt that they might be at risk for falls.

During the Contemplation phase the healthcare professional can help the patient break down what it might look like to be able to embark on a program. What might be their barriers or sticking points to do so? When might they do it? This isn’t about making a plan it’s about facilitating the patient in thinking that a plan might be possible.

The next phase Preparation, occurs when the patient has demonstrated that he or she is ready to change, and this is where we can examine the nuts and bolts, breaking down what may seem like a daunting task (adhering to a program for 12 years), into something manageable. Here is where you help the come up with plans to overcome the barriers you identified. One key barrier is often fear of relapse: that is that when a patient stops doing the plan, they can’t get back on the wagon, so to speak. Making it okay to “start over” is a great way to encourage patients.

During the preparation phase you may also want to help the patient break down the program into smaller goals and manageable chunks so they can see progress during the program. Also help the patient identify rewards that will help drive their adherence. These are both important steps when helping with a large and often intangible goal.

Action is putting the plan into place. Here your main role is to support the patient, help them continue to overcome barriers, and be a cheerleader to keep them going in the case of a relapse.

The final stage is Maintenance (which includes dealing with Relapse). Pointing out the patient progress, possibly by completing another falls assessment and showing the difference is a great way to reinforce that the program worked and it’s worth continuing. Also ask the patient to remember what fears they had before the program and whether they feel that now. Simply shining a light on their own experience can help a lot here.

With an aging population, and rising health costs, translating valuable and proven research like the information in this session into clinical practice is key. Given that the average time from research to implementation is 17 years, and that Otago was invented 14 years ago, we can only hope to see widespread adoption by 2018. That’s also in-line with CMS’s new requirements for 50% of Medicare spend being for new value and outcome-based models. It’s time right?

Posted in: Adherence, Aging, Behavior Change, Exercise Physiology, Healthcare Disruption, Healthcare transformation, Physical Therapy, Rehabilitation Business

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Wellpepper’s Top Healthcare Blog Posts of 2014

We had quite an amazing year at Wellpepper and are really looking forward to great things in 2015. We’re looking forward to more changes and disruption in mobile health and telehealth, as well as new business models, billing codes, and proof of the efficacy and effectiveness of mobile health.

As we look forward, we thought we’d spend a few minutes to recap our most popular blog posts of 2014. In order of popularity they are:

Misfit Shine

Jewelry? Hmm.

A Tale of Two Sensors: Misfit Shine vs FitBit Zip

Not surprisingly given the hype around sensors in 2014, our post comparing how the two stacked up was our most popular blog post.

The Future of Mobile Health is Like a Warm Marshmallow

We read somewhere that your favorite tweet is not destined to be your most popular. This blog post has a warm space in our heart as it was a surprise to see mobile health as mainstream as a heartwarming Disney film.

Forging Ahead With Telehealth: A Roadmap for Physical Therapists

Our conference recaps are always popular, and this one was especially popular as all healthcare professionals are champing at the bit for billing codes that reflect the innovative new ways they want to practice.

Healthcare Is Part Of Our Supply Chain: The Boeing Company

Boeing is really pushing the payers and providers to deliver cost-effective outcome-driven care, so we are chuffed to see this one at the top of the list. Which other employers are going to take the mantle for 2015?

Post or Perish: Disseminating Scientific Research and the Kardashian Index

This recap of a talk on social media and popularity as important to scientific research made our top 5, and while the advice was great, and the debate on popularity vs credibility is important, we suspect it may have something to do with the mention of the “K” word.

Posted in: Behavior Change, Healthcare transformation, Lean Healthcare, M-health, Rehabilitation Business, Telemedicine

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The Future of Mobile Healthcare is Like a Warm Marshmallow

As we look towards a new year, we thought it was time for a few predictions:

  • Patient satisfaction will be the most important focus of the Triple Aim
  • Patient reported outcomes will be combined with full-body scanning for key signs
  • Emotional health will be as important as physical health, and mobile health companions will focus on both
  • The standard 10-point pain measurement scale will still be in active use
  • Mobile healthcare will move on its own, and even fly

Big Hero 6 logoHow do we know this? Big Hero 6: Disney’s treatise on the future of healthcare delivered by robots. Okay, maybe it’s about the bond between brothers and how ordinary brilliant scientists can become superheroes but given that one of the main characters, Baymax is a personal health companion, we believe Disney is also trying to tell us something about the future of healthcare.

Baymax is a huggable robot and personal health companion who can scan, diagnose, and treat humans and cannot be ‘turned off” until his patient is “fully satisfied with his or her care.” Baymax takes the patient satisfaction pillar of Triple Aim to the extreme. He can also do kung-fu, packs a mean punch, and can fly.

Baymax: I fail to see how flying makes me a better healthcare companion.

Hiro Hamada: I fail to see, how you fail to see that it’s awesome!

Baymax is activated when he hears someone say “ow” and uses a standard 10-point pain scale to first identify problems. Given his ability to review vital signs by scanning, we have to assume he’s asking this question for the emotional benefit of patient rather than a real data point.

Baymax: Hello. I am Baymax, your personal healthcare companion. I heard the sound of distress, what is the problem? On a scale of 1 to 10, how would you rate your pain?

Baymax Big Hero 6

Like a futuristic country doctor, Baymax understands that a patient’s health and well-being is affected by his or her emotions. At one point he tells his young charge:

Baymax: “It is all right to cry, crying is a natural response to pain.”

While he is only activated in response to injury, once Baymax is caring for a patient, he anticipates future issues, and is aware of what’s happening before the patient.

Baymax: “You have sustained no injuries. However, your hormone and neurotransmitter levels indicate that you are experiencing mood swings, common in adolescence. Diagnosis: puberty.”

He is also prepared for health emergencies.

Baymax: “My hands are equipped with defibrillators. Clear!”

Unfortunately, in this situation, the patient was using a figure of speech about having a heart attack, and this is one central problem with this future mobile health: Baymax is naïve and doesn’t understand human emotion. As well, in his desire to help he asks his young patient if certain activities will make him feel better even though they are potentially ill-advised. Baymax 2.0 will need to have some situational learning skills and not confuse patient satisfaction with the “customer is always right” motto.

However, like a real healthcare provider, Baxmax has taken an oath not to hurt humans and he fuBaymax hug Big Hero 6lfils this to the best of his ability, even when the humans try to get him to do otherwise.

So what is Disney trying to tell us about the future of mobile health? Based on the example of Baymax, we’d say in the future it needs to be:

  • With you when you need it
  • Focused on the needs of the patient
  • Summoned by the patient
  • Comprehensive
  • Focused on patient satisfaction
  • Huggable

The last one can’t be underestimated. One of the great appeals of Baymax besides his childlike naivety, is that he looks like a giant marshmallow. Mobile health needs to be patient-friendly and approachable. People don’t like to be reminded that they are sick and medical apps with medical names too often do this. For us at Wellpepper, we have a dog as our logo for this reason. We want to be approachable, friendly, and supportive to patients. We’re going to be with them on their mobile devices so they’d better want to have us there with them, just as Hiro has Baymax.

Happy Holidays from all of us at Wellpepper! All the best for 2015.

Posted in: Behavior Change, Healthcare Technology, Healthcare transformation, M-health

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Texting to Better Health

This post is guest authored by freelance journalist Fiona Hughes.

Can text messaging improve patient health outcomes? Judging from presentations made during a seminar at the sixth annual mHealth Summit held in Washington D.C. Dec 7-10, the answer to that question is a resounding YES.

In a seminar entitled “Evidence, Challenges and Successes in Text Messaging Programs,” three speakers discussed their unique experiences using text messaging (SMS) programs to improve health outcomes for patients. Key to any success, all three noted, was patient engagement to empower patients to cultivate and sustain positive lifestyle behaviors.

Wellpepper's Secure Text Messaging

Wellpepper’s Secure Text Messaging

But why use SMS? The answer is obvious. Almost everyone owns a cell phone. In fact, 90% of American adults own a cell phone, according to the Pew Research Center.

Seminar speaker Vanessa Mason, a strategist with ZeroDivide.Org, provided even more compelling statistics: 81% of cell phone users text, 97% of texts are read, 78% of cell phone owners make less than $30,000 a year. These stats may explain why SMS is rapidly becoming a means to reach out to diverse populations because of the low cost and ubiquitous nature of mobile devices. Other studies have shown that for low income populations a mobile device is their only way of accessing the Internet.

Dr. Stephen Agboola, a research fellow at the Boston-based Centre for Connected Health, presented his findings from a 2-arm randomized controlled trial called Text to Move, which sent personalized text messages to improve physical activity (PA) among patients with Type 2 diabetes. According to Dr. Agboola, PA is one of the more difficult behaviours to change among Type 2 diabetics.

Patients in the intervention group were sent 60 messages a month for six months (one in the morning, one in the evening) of practical educational and motivational information tailored to a 4th grade level (e.g. sample morning message: As of 08:27 AM, you were active for 45 minutes – 75% of your goal. Reply HELP for help…)

Dr. Agboola, who has expanded the trial to four more health centres associated with Massachusetts General Hospital, noted that the low cost and design of the messages makes it possible for the program to be easily scaled across a diverse patient population regardless of age, educational, economic or ethnic background and sustained over a longer period of time.

Results of the Text to Move included 3-pound weight loss in the intervention group, a significant decrease in HbA1c, an increase in average daily step counts and 78% program engagement.

Dr. Agboola’s conclusion: “Text messaging can be used to improve patient outcomes.”

***

In his brief presentation, business and research analyst Troy Keyser of the Centre for Connected Health compared various techniques in participant recruitment in texting health intervention in a clinical setting.

He cited the example of Quit Now, a free service to help people live tobacco free. Techniques used to get patients to enroll included postcards left in the clinic (1.6% conversion rate); An opt-in text (200 messages were sent, 7 patients enrolled for a 3.5% conversion rate); and finally a provider-led approach (126 patients were asked to enroll by their physician, 126 enrolled for a 100% conversion rate).

***

ZeroDivide’s Vanessa Mason expanded further on enrollment methods and offered a how-to-guide for text messaging (recruitment, operational needs, technological specifications, content development, evaluation). Some key points included:

  • Assess target audience
  • Involve patients in message content
  • Segment messaging as necessary
  • Evaluate patient expectations, needs and skills
  • Assess self-management goals
  • Encourage peer support for participation
  • Reinforce positive behaviours to support health goals
  • Mason’s full report “Texting for Better Care Project” can be viewed at zerodivide.org. It examines text messaging interventions for health care delivery in the safety net for underserved populations.

Mason shared the story of ZeroDivide’s work with church congregations in Atlanta, Cleveland, Columbus and Dallas that are using SMS to improve health outcomes for Africa-American women. According to the Pew Research Centre, Latinos, African-Americans and people between the ages of 18 and 49 are more likely than other demographic groups to access health information on their mobile devices.

The two grassroots programs — Mobilize-4-Fitness and Text4Wellness — use culturally appropriate SMS to provide information about physical activity, nutrition and wellness. The initiatives specifically target female congregants between the ages of 19 and 55.

“Given that many African-American women see being part of a faith-based community as a bedrock to their social lives, this is a great opportunity to leverage the assets that are already in their church, including fellow congregants and the health ministers, to achieve better health outcomes,” Mason writes.

Final results of these programs will be published in May 2015.

One issue, important to all health organizations that want to use texting with patients for clinical purposes, PHI protection, was skirted by the panelists. One said that no PHI was sent back and forth, however, this is doubtful if a patient is sending their outcomes. SMS holds great promise but information must be sent in a secure manner.

As the digital revolution shakes up the healthcare system and changes the way medicine is practiced, it’s not hard to imagine SMS becoming a standard tool for physicians to engage patients to help them manage their care. But it’s important to be mindful of the digital divide affecting underserved communities, especially in the U.S. healthcare system, which — as ZeroDivide noted in a recent report on eHealth in underserved populations — is known for its “persistent disparities in quality of and access to care.”

 

Posted in: Behavior Change, Healthcare Disruption, Healthcare motivation, Healthcare Technology, Healthcare transformation, M-health

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The Connected Patient Is Here

After either a realistic or pessimistic Day 1 keynote, depending on whether you’re a glass half full or half empty kind of person, Day 2 at the MHealth Summit started with a difficult topic but a much more inspiring message and continued with presentations stressing that patients are already connected and engaged. A bonus for those of you who are counting (XX in Health, Halle Tecco), is that ¾ keynote speakers on this day were women.

Confronting Mental Illness Online

First up was Jen Hyatt (@jennyhyatt) CEO and co-founder of Big White Wall, and online community for mental health. Big White Wall provides an online community for people who are mentally distressed and sometimes suicidal. Jen relayed a heart-breaking story of a possibly preventable suicide, if the person had just had an anonymous place to share what he was feeling. Big White Wall provides a community of people who are trying to self-manage their mental distress with support from clinical process and staff. It does so confidentially and anonymously. Anonymity is a key part of how Big White Wall works. People are more comfortable sharing when they know they won’t be judged and sometimes talking to a machine rather than a person can provide that, to illustrate, Hyatt shared the story of the young autistic boy who made friends with Siri. Hyatt has compared the accuracy of the data behind Big White Wall to predict depression and suicide risk to that of standardized tests, and says that interactions on Big White Wall provide enough information to be as accurate as the tests. Considering the difficulty of getting people to take these tests, and especially those who might not be seeking help for mental illness, this holds great promise for the power of patient (or people) generated data.

Serving the New Connected Patient

Source: MHealth Summit

The connected patient is already here, and she’s a millennial says Janet Schijns, Vice President of Global Verticals and Channel Marketing at Verizon. Schijns used a recent ER visit by her daughter, a college student to elaborate how patients are outpacing hospitals when it comes to digital care. Schijns daughter sprained her ankle badly, while waiting for a nurse to return with discharge instructions, she had already found and watched a video on how to navigate the world on crutches, ordered groceries online so she wouldn’t have go out, and researched how she would be able to get around campus. Schijns posits that healthcare organizations are spending dollars in the wrong areas online because they don’t really understand what patients are looking for. She talked about how patients are creating their own content through community sites like Patients Like Me and filling in gaps in the information the healthcare system is providing.

 Email Is Our Killer Application

Christine Paige, Senior Vice President of Marketing and Internet Services from Kaiser Permanente helped all m-health entrepreneurs in the audience breathe a sigh of relief when she said that Kaiser was not going to get into the m-health app business and instead focus on working with companies that help them improve the patient provider relationship. Paige called email Kaiser’s killer app for two reasons, one is that patients are not able to absorb key information when they’re in the clinic, especially if they’ve had a difficult or surprising diagnosis and second because they want convenience and a connection to their physicians. Kaiser’s patients who engage online are healthier, and only 1/4 emails results in a doctor’s office visit.

While personalized medicine is a hot topic these days, Paige warned against personalization trumping patient privacy and the risk of personalized recommendations being wrong. That is, patients using technology trust their physician with the information, but not necessarily if an application starts intervening and providing recommendations based on that data.

While the day 2 keynote was optimistic about the promise of m-health, it was definitely cautiously optimistic. Patients and providers are still feeling their way through the role of technology in communication and automating care.

Posted in: Behavior Change, Healthcare Disruption, Healthcare motivation, Healthcare Technology, Healthcare transformation, M-health, Telemedicine

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Using Homecare For Positive Change in Healthcare

The week before last, I was fortunate to be invited to attend the Collaborative for Integrated Home Care Aid Innovation Symposium: a group of committed individuals and organizations that passionate about improving healthcare through home care. The goal of the summit, organized by the SEIU union for healthcare workers was to apply the “Triple Aim” principles to home care. With the realization that our current systems cannot support the increase in chronic disease and the aging population, the group was looking for innovative solutions through people, process, and technology, that could provide preventative care and follow-up care in a community setting.

The State of Washington

Washington State CareBill Moss, Assistant Secretary for Aging and Long-Term Support, kicked off the day with a sobering look at the statistics for Washington State. While the number of people in nursing homes has declined by 7,000 since 1993, and more people are cared for in their homes, which provides a better quality of life, the complexity of health issues affecting the population has dramatically increased. In addition to being the preference of patients, at-home care is less expensive. If today we had as many people in long-term care facilities as 1993, it would cost the state an extra $200 M annually, so that’s good news.

Recognizing this benefit, but also understanding the increasing complexity of patients, provides a starting point for improving and supporting the role of home care workers to support more people aging at home. While return-on-investment studies are few and far between, the general understanding of participants is that keeping people out of long-term care facilities can provide financial subsidies to people in long-term care. For example, for the annual cost of one person in a nursing home, $17,500, three patients can be cared for in their homes.Medications Taken By Clients in Washington State

Clinical Care Needs for Washington StateTo support these home care workers and their patients, new training needs to be developed to address some of the top health risks and preventative medicine including nutritional needs, fall risk, and mobility support. By helping people improve their health, we can save money and also improve quality of life.

Continuing on the data wallow, Lili Hay a researcher with Milliman, an independent consulting and actuarial firm, shared a deep dive into the situation in Washington and the complexity of patients that require home care, for example 40% of Medicare patients take 5 or more medications and most have more than one issue.

The Penn Center for Community Health Workers

Next up, Casey Chanton, a social worker and project manager at the Penn Center for Community Health Workers in Philadelphia talked about a unique program for training community leaders as health workers. In dealing with patients from low-income, high-health risk neighborhoods, physicians and patients had both expressed frustration with the gap between what physicians prescribed and the reality of patient’s lives. Physicians might tell a patient to eat a low sodium diet while the patient would be getting most of their meals from a food bank and have little or no control over what they ate. Both felt helpless to bridge the gap. Enter the community health worker. The program trained natural leaders from within these high-risk communities. These leaders visit patients in their homes and help them get the support they needed within the constraints of their own lives.

Not surprisingly, most of the issues were not medical but related to their living situations, income, and access to services. The best recruits to be community health workers were people who listened more than they talked and were non-judgmental. They helped patients set goals that were attainable by using patient-centered goal setting coupled with achievable steps.

Results of the program are impressive and really speak for themselves:

You can learn more about the center and the program here: http://chw.upenn.edu/

Panels on Technology Innovation and Practice Solutions

The next two sessions were panels, one on technology innovation and the second on practice options. There was too much good information for me to summarize everything, so I’ll stick to the major themes.

  • Post-acute care costs are the fastest rising and most variable care costs, so finding a way to manage them is key.
  • Technology is not the solution, people and process are the solution, but technology can help.
  • People of all ages and socio-economic backgrounds can be use technology (although possibly not EMR interfaces—this isn’t a reflection on the people 😉 )
  • If we could start from scratch designing a health system, we would never have designed the siloed-system we have today.
  • Issues of care coordination are causing post-acute care to be the fastest rising cost in healthcare today, even though readmissions are falling
  • Homecare needs to be structured around outcomes not having homecare workers check off task lists
  • Even if the payment models aren’t there yet, we need to take best practices and move forward.
  • Even if all the research isn’t in, we need to take best practices and move forward.
  • Even if healthcare administration isn’t ready for it, we need to take best practices and move forward.

During the panels and Q&A we heard from a few of the homecare workers in the audience about the impact they’ve had on people’s lives because they do what’s right and not what’s required. Particularly striking was the story from a woman who talked about caring for one of her patients who needed to go into a nursing home temporarily after surgery. The nursing home was understaffed so the homecare worker visited her patient there multiple times a day to make sure he was being turned in his bed. She did this because she cared about her patient and she wanted to make sure when he was released back into her care he wasn’t in worse condition than when he entered the nursing home. Rather than consider the negative aspects of this anecdote, let’s look at the amazing resource that exists in home care workers who spend more time with patients than their medical professionals and sometimes their families. That was the point of the day: what can we do to help scale this valuable resource and empower them to help patients even more.

Posted in: Aging, Behavior Change, Healthcare Disruption, Healthcare motivation, Healthcare Technology, Healthcare transformation, M-health, Managing Chronic Disease

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Should Patients set SMART or MEANING(ful) Goals?

Goal setting provides incentive, improves adherence, and helps measure progress. Right? Maybe. Presenters in the session “Goal Setting in Rehabilitation: Theory, Practice, Evidence” at the annual American Congress of Rehabilitation Medicine conference in Toronto were consistent in their believe that goal setting is important for rehabilitation but also pointed out a lack of evidence and a distinct lack of consistency in application. It seems that goal setting theory in healthcare has been largely borrowed from business and sports, and while it makes sense that goal setting should help patients, there is not a lot of decisive evidence and there is a lot of debate on how goals should be set.

Does goal setting work?

A survey of the clinical research on goal-setting in rehabilitation showed that goal setting didn’t improve physical function, however it did improve patient self-efficacy. Evidence was inconclusive on whether goal setting affected motivation, adherence, or engagement. However, the overall analysis showed a statistically significant difference in favor of goal setting. The issue is how goals are set and could setting them differently improve care.

How are goals set?

Currently the usual care condition for setting goals is having healthcare professionals set them instead of patients. The problem with this is that the goals may be SMART, but they are not meaningful for the patients. There is often a mismatch between patient and physician goals: physician goals are often functional goals and patient goals are quality of life or aspirational goals. Since goal seems to have a bigger impact on intrinsic factors, like efficacy and possibly also satisfaction, it seems that patient-directed goals would be more effective.

The following are “SMART goals” adapted to apply in rehabilitation. However, the speakers adapted them slightly to apply more directly to rehabilitation. (Assignable rather than achievable.)

Specific, measurable, assignable, realistic, time bound
 
 

How should goals be set?

Goals that help a patient connect with their care plan are preferred, for example, goals that fit the following criteria.

MEANING goal setting

 

While presenter Kath McPherson from the Auckland Institute of Technology argued that patient goals could be vague and also asked why goals had to be realistic: wasn’t it better that the patient continued to hope and work towards something, William M. M. Levack the concept of helping patients set “fiduciary” goals. That is, guide the patients goals based on the situation more initially and less as the patient gained autonomy. To illustrate this he used the example of Mr Roberts a blind diabetic amputee who had a goal of going home to live. If Mr. Roberts’ goal were the only thing taken into consideration, it would ignore the realistic factors that might not make this possible, for example, his wife’s ability to care for him. As such, a better approach for goal setting for Mr. Roberts was to consider a number of factors including:

  • The values and preferences of the patient
  • Clinical judgment of the healthcare professional
  • Time and resources required for the goal
  • Likely consequences of pursuing the goal

For Mr. Roberts, this approach would look like this:

value pluralism in goal setting

The takeaway from these sessions was the necessity to link the clinicians small functional goals with the patients big aspirational goals. Functional goals are necessary and will measure progress but aspirational goals are what drives patient self efficacy which is so important for recovery.

 

We think a lot about goal setting and patient reported outcomes at Wellpepper. Patient reported outcomes are great tools to show progress and also validate clinical efficacy but they must be linked to patient’s goals for real impact. We’re working on some interesting ways to do this through our technology and are excited to be able to share this with the rehabilitation medicine community.

Posted in: Adherence, Behavior Change, Healthcare motivation, Healthcare transformation, Occupational Therapy, Rehabilitation Business

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Pushing, Pulling, Nudging and Tipping Healthcare Evidence Into Practice: Highlights from ACRM

We’re just back from 2 weeks on the road visiting Wellpepper customers and also attending the Annual Congress of Rehabilitation Medicine conference in Toronto where our research partners at Boston University presented the preliminary results from a study they’ve been working on. We’re so pleased and impressed with the results, but if you weren’t at the Congress, you’ll need to wait until November when we can share final results with you.

In the meantime, you can follow our recaps from some of the sessions we were fortunate to attend atIMG_0325 the conference. While the conference was heavily research-based (subtitled, “Progress in Rehabilitation Researchers), most researchers were affliated with teaching hospitals so that research could be put into practice. Also striking about this event, compared to many other healthcare conferences, is the team-based care and interdisciplinary nature of the presentations. Most presentations features care or research teams that included professionals with varying backgrounds including physicians, surgeons, dieticians, registered nurses, physical therapists, and occupational therapists. Another striking difference was that while everyone was striving toward repeatable outcomes, rehabilitation medicine requires a level of personalization that is specific to each patient’s ability.

Keynote: Pushing, Pulling, Nudging and Tipping Evidence Into Practice: Experience From the Frontline Implementing Best Practices in Rehabilitation

Dr. Mark Bayley from University Health Networks, and the University of Toronto kicked off the ACRM conference with a challenge to researchers to shorten the distance between research and implementation using techniques from other disciplines. His talk highlighted the challenges and provided solutions in a snappy and entertaining manner.

The Problem with Information Dissemination

To illustrate the problem, Dr. Bayley launched the talk by describing with the 386 year path from when Vasco da Gama observed scurvy in his ship’s crew to the implementation of vitamin C (or citrus juice in particular) as a protocol in the British navy. Although da Gama’s crew recovered from scurvy when given citrus fruit in India, the connection somehow was not made, and there’s a long history of sailors dying from scurvy, until the first ‘clinical trial’ when James Lind ran a 6-armed comparative study at sea and proved that citrus or vitamin C cured scurvy. Another 40 years passed before the British Navy adopted citrus as a standard.

Lest anyone in the audience start to feel smug about advances from scientific discovery to implementation today, Dr. Bayley revealed that it currently takes discoveries and new methods 17 years to get from research to implementation. He then spent the rest of the talk providing concrete suggestions that researchers could use to try to change this.

Researchers are often very focused on publishing, it’s how they are evaluated. However, publishing information and hoping that someone reviews it and sees the value is not enough to drive change into clinical practice. To put this into perspective, Dr. Bayley quizzed the audience on how many articles a healthcare professional would have to read each year to stay on top of all the research. The answer: 7300 or 20 articles each day. Compare this to the 1 hour of reading per week that most practicing healthcare professionals can manage, and you’ll see very clearly why best practices derived through research are often lost and not implemented. With only 1 hour per week for reading, is it any wonder most healthcare professionals get their information from their peers?

Barriers to Implementing New Methods from Research

As well, it’s not enough to provide recommendations but researchers must provide guidelines for how they should be implemented and understand the types of organizational barriers to implementation.

Barriers can include:

  • Individual perceptions
  • Complexity of solution
  • People who will need to adopt the new practice
  • Where the new practice will need to be implemented

Other things to consider are who will deliver the care, what stage of recovery the patient is in, the amount of time available with the patient, and the expected outcomes. Rehabilitation medicine adds an additional level of complexity to writing general implementation guidelines as each stage of recovery is different and requires it’s own care path, and the level of specificity for each is high.
Personal Barriers

When considering the people who will implement the guidelines from the research, many factors will impact their openness and ability to implement, including:

  • Knowledge: Does the person understand the research?
  • Skills: Does the research require the healthcare professional to learn new skills?
  • Social role: Does the healthcare professionals role within the healthcare system give them the authority or autonomy to implement the solution?
  • Beliefs: Do their beliefs in their capabilities or in the consequences of implementing the solution interfere with a successful outcome?
  • Motivation: Are they properly motivated or incentivized to implement the solution? For example, does the way they are compensated cause issues with implementation?
  • Emotion: Are their any emotional beliefs that will interfere with implementation, for example: “this is different than what I learned in school”?

Organizational Barriers

In addition to barriers that may arise through the people who are implementing research, there are many possible organizational barriers to implementation. These include:

  • Practice: How does the new method fit in with what is currently practiced?
  • Resources: Are the right people and skills available to implement?
  • Legal: Are their legal or regulatory issues that could block implementation?
  • Cost: Is it too expensive to implement? Are financial incentives aligned? (Of course the biggest issue here is always “Is it billable?”
  • Physical layout: Does the implementation require a change in the physical layout of the care center?
  • Time: Do staff have adequate time to understand the new procedure? Does the new procedure take longer than the time available?
  • Staff turnover: Can this new practice be maintained if staff change?
  • Equipment: Does it require new equipment to be purchased? Is it in the budget? Is it difficult to learn?
  • Communications: Does the practice require new ways of communicating between disciplines, within teams, and between patients and providers?

So should we give up?

To contrast the almost 400 years to recognize the treatment of scurvy, Dr. Bayley provided the example of how the use of general anesthetic spread thousands of miles from the UK to France and Germany in only a few months, and to widespread adoption within 2 years. Although the knowledge of properties of gases like either goes back further, the main adoption was relatively quick between demonstrations in 1844 and widespread adoption in 1846. The fast adoption stemmed from two factors: it was better for the patient and easier for the surgeon to operate on a patient that wasn’t squirming around.

What makes an invention or a new process sticky is that it’s good for providers and good for patients. (We would add to that in the US, it needs to be good for payers.)

Dr. Bayley then went on to provide some practical and possibly new advice for the best ways to effect change starting with things that don’t work within healthcare settings.

Methods that won’t effect change

  • Pamphlets
  • Total quality measures
  • Lectures

Methods that will effect some change

  • Patient driven or mediated
  • Conferences

Methods that will effect real change

  • Reminder systems (like hand washing)
  • Mass media for patients but will also impact providers
  • Financial incentives
  • Interdisciplinary collaboration

More practically, finding champions and interdisciplinary teams to implement changes, figuring out how the change relates to financial incentives, either the fear of losing money or the opportunity to gain money, and finding opinon leaders to publicize the changeDoctor-Recommeds-ProduceFinally Dr. Bayley introduced the theory of nudges and benevolent paternalism, or the idea that if you can make it easier for someone to do the desired behavior than the usual behavior they will. To illustrate this point, he showed a picture of an escalator and stairs, with an outline of a slim figure pointing to the stairs and a pudgy figure pointing to the escalator. Not quite as cheeky was a UK campaign that had pictures of local family physicians next to the fresh ruit and vegetable aisle asking people to eat more healthily which caused a 20% increase in produce sales.

This was a great talk to start the conference as it provided concrete advice for the presenters of all the great innovations over the next few days to get their advances into clinical practice in a period shorter than the current 17 years, because heaven knows our health system needs the nudge.

Posted in: Behavior Change, Healthcare Disruption, Healthcare motivation, Healthcare transformation, Rehabilitation Business

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