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Falls Challenge

How might we enable older adults to live their best possible life by preventing falls? We have entered a challenge with AARP and IDEO to bring our proven falls solutions to the masses. Along side our partners at Harvard and Boston University, we believe that using mobile technology to enhance and scale a proven falls prevention program will lead to better life by increasing access to care and decreasing costs.

The challenge started with over 220 submissions and recently weeded down to the top 40. We’re thrilled to have made the first cut. Our method is proven and we invite you to participate in the next round to refine our idea and help achieve greater impact.

Click here to check out our entry!

 

 

Posted in: Aging, Clinical Research, Healthcare Technology, Outcomes, Physical Therapy, Research, Uncategorized

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Home Sweet Home

Our goal at Wellpepper has always been to make sure patients have a top-notch experience with our Partners. What better experience can patients have than being in the comfort of their own home while rehabilitating from a joint replacement? An article was recently published in the New York Times that really hits home for us. Not only is in-home therapy more cost-effective than inpatient rehabilitation, but it significantly decreases the risk for adverse events.

More and more studies are showing that patients are generally happier and actually prefer being at home during their recovery from a joint replacement. A study published earlier this year in Australia found that inpatient rehabilitation did not provide an increase in mobility when compared to patients participating in a monitored home-based program.

Don’t get me wrong, inpatient rehabilitation is extremely valuable to have. In fact, we are starting to see more patients interact with their Wellpepper digital treatment plans in an inpatient setting and then continuing once discharged home.

Rehabilitation is not a one size fits all solution and much depends on a patient’s general health and attitude. The ability to be flexible and innovative in providing treatment is crucial when evaluating a patient’s needs for rehabilitation. With Wellpepper digital treatment plans, we enable health systems to bring the expertise and personalization of inpatient rehabilitation to their patient’s mobile devices, so that they may recover from their surgery in the comfort of their own homes.

Posted in: Behavior Change, Healthcare motivation, Healthcare Technology, patient engagement, Patient Satisfaction, Physical Therapy

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Stroke Rehabilitation is the Poster Child for the Need for Collaborative Care

APTA CSM 2015 Recap: Anne Shumway-Cook Lecture: Transforming Physical Therapy Practice for Healthcare Reform

Speaker: Pamela Duncan, PhD

Interdisciplinary teams and patient-centered care are key to the future of healthcare, and physical therapists attending this keynote of the Neurology track at APTA CSM 2015 in Indianapolis were encouraged to embrace this change. Bemoaning the lag time from research to clinical practice, Pam Duncan suggested that researchers find ways to work with interdisciplinary teams of biomechantical engineers and even private companies to bring innovation to patients faster. She started with the inspiring example of Carol Richards who received the Order of Canada for her work with the interdisciplinary team on the Stroke Network Canada, aimed at decreasing the impact of stroke across Canada.

Source @mdaware on Twitter

Source @mdaware on Twitter

Duncan then told a story to explain her passion for changing post-acute stroke care, involving a personal experience that changed the course of her career. Duncan’s mother suffered a stroke and while Duncan was trying to provide comfort in her mother’s last days, a traveling physical therapist arrived in the hospital room with a goal of getting her mother to get her mother to stand, which was apparently the clinical protocol she was assigned to do. Duncan protested and later spoke to the owner of the physical therapy company that had contracted to the hospital. He shrugged and asked her why she cared since Medicare would pay for the visit. Incensed at the waste of time and money but more furious at the way this care completely disregarded the patient’s best interests, Duncan put aside her plans for opening a private practice and focused research to improve post-acute care for stroke patients.

Translating Research to Evidence and the Humble Researcher

With the same vehemence, Duncan described how she believed that over 180 publications she’d made on the topic had done little to advance stroke care, largely due to the difficulty of translating clinical research into practice, and asked the researchers in the audience to change this by developing interdisciplinary teams, questioning all their assumptions, and thinking about the patient holistically, not just from their own discipline.

She asked researchers to be “humble researchers” referencing a column by the New York Times columnist David Brooks and not just set out to prove what they want to be true. Duncan used an example in her own research which disputed a popular belief on stroke recovery and showed that home-based exercise was more effective than treadmill-based. Duncan described herself as still having arrows in her back from that publication.

Best Practices for Stroke Recovery

After lighting a fire for the audience to think about things differently  by saying

“Take off your neuro-plasticity hat and think about patients holistically.”

Duncan continued with specific examples on how to change care. First was to understand the overall situation. 10-30% of stroke patients face permanent disability, something that is not always clear when they are released from hospital within 3-5 days of the incident. She gave an example of a patient who was discharged with care instructions and prescriptions yet when she got home she couldn’t follow them: she discovered the stroke had affected her ability to do basic calculations.

“If you asked if I had discharge instructions I would have said yes, I heard what the nurse said and I showed her I could inject my drugs, and my math deficit wasn’t diagnosed until I got home. I did the things I needed do to get discharged but wasn’t really able to cope.”

This is a clear example of how our current system fails us. It does not support the patient outside the clinic, and yet it’s so much less expensive and more comfortable for the patient to be released to home. Looking at the costs it’s clear that we need to improve home health options.

Post stroke care costs:

  • Acute inpatient care: $8,000
  • Skilled Nursing Facility: $41,000
  • Inpatient Rehab: $14,000
  • Home health: $6,000
  • Long-term care: $62,000

As Duncan put it, “Home health is a dirty word in Washington” yet this where the patient should be. She called stroke the poster child for the discontinuity of care in healthcare as 73% of post stroke readmissions are for other issues not related specifically to the heart. Duncan sees hope though, and called bundled payments the best thing to happen to stroke recovery as providers will have to collaborate across the care continuum.

She sees the benefits as:

  • Coordinated high quality care with seamless transitions
  • One primary metric for integrated care
  • Excellence based on outcomes

The message to physical therapists is that they are uniquely suited to these multi-disciplinary teams focused on patient outcomes. For patients, outcomes are measured by function. For CMS, value is measured by those functional outcomes divided by the cost and physical therapists can deliver on both.

This session was a great kick-off to the conference, which had an overall tone of embracing the changes coming in healthcare and the role of physical therapists in it. As a company providing continuity of care through digital treatment plans and connections with healthcare providers outside the clinic we were inspired to see so many people embracing this change.

Posted in: Aging, Health Regulations, Healthcare Disruption, Healthcare transformation, Physical Therapy

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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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Support for Telemedicine in Rehabilitation

Recognized barriers to telemedicine in rehabilitation, for example, the need for hands on intervention, a lack of billing codes, and not enough studies on cost-effectiveness, did not damper the enthusiasm for the potential of the field and the inevitability of future interventions at American Congress of Rehabilitation Medicine annual conference in Toronto. Presenters in numerous sessions demonstrated the many benefits of tele-rehabilitation for patients, providers, healthcare systems and payers.

Two sessions we attended, “Use Of Telemedicine In Spinal Cord Injury And Pressure Sore. A Pilot Project “ and “Tele-rehabilitation: A New Frontier In Geriatric Rehabilitation” debunked many of the common myths of telemedicine including:

  • Concerns about patient privacy
  • Ability of seniors to use telemedicine
  • Diminished care quality

Instead what they showed was:

  • Patients were more than willing to invite the video into their homes
  • Seniors and people with severe disabilities can use technology with the right support
  • Care quality can be improved by telemedicine

However, even with solid data presented in all of these sessions, presenters joked that telemedicine still largely suffers from a disease called “pilotitis”, that is never progressing past the pilot stage and a proliferation of pilots.

The Use of Telemedicine In Spinal Cord Injury And Pressure Sore: A Pilot Project

Norwegian Health SystemThis session showcased another great example of an interdisciplinary team, common at this conference. This team was from Norway, as they called it “land of trolls and polar bears.” Norway has a total area of 385,252 square kilometres and a population of 5,109,059 people (2014). 84% of the population has smart phones. Like most countries other than the US, they also have socialized medicine. Telemedicine was first introduced in Norway in 1980, so the fact that this project was still a pilot points to some of that “pilotitis.”

The driver for this particular project was two-fold: improve patient care by enabling patients to stay in their home, extend the reach of specialists to rural areas. Both are common reasons for telemedicine, and also can help lower healthcare costs in this case by decreasing transportation of the patient to a medical center located a few hours away. This particular intervention focused on helping Paraplegic patients manage pressure ulcers. Due to both cost and patient preference, patients with spinal cord injuries are being released earlier from hospital. However the risk of developing a pressure ulcer is greater and local healthcare support often does not have the expertise needed.

In this case, a team from the hospital would check in with the patient via video conference through a web camera at the patient site. Now, here’s where we debunk the myth of patient privacy. The patient in this case was so happy with the remote support and care he received that he agreed to have the recording of his sessions shown at the conference. For those unfamiliar, pressure ulcers occur in intimate locations like the buttocks. The team did a great job of showing how they manage to capture high-quality video over speeds as low as 256k and keep the privacy of the patient protected by positioning the camera only on the ulcer with no identifyiable patient visuals. (The video presented in the session was not for the faint of heart though.)

Patient benefits

Telemed costs

 

 

 

 

 

 

 

 

Benefits that the team saw were:

  • Cost-savings from decreased hospital stay
  • Decreasing travel exhaustion for the patient
  • Supporting the nurses in the community and helping them improve skills
  • Time-saving as the patient was always ready at the exact appointment time
  • Continuity of care, although interestingly, summer vacations caused some discontinuity and showed that this is not ensured simply by having Telemed.

Some best practices they identified included making sure that all introductions were completed for context, safety, and dignity before starting the examination, excluding personally identifiable information from sensitive video, and working with an interdisciplinary team to deliver results.

 

Tele-rehabilitation: A New Frontier In Geriatric Rehabilitation”

This session reinforced the need for telemedicine to support patients in their own homes. Dr. Helen Hoenig from Veterans Affairs described the gap between what the patient was able to do in the hospital and what they were able to do at home. For example, one veteran was released from the hospital proficient at using a walker but had no way of getting into his house because of the large number of steps. Having the veteran capture photo and video and send it for review (a method known as “store and forward” or “asynchronous telehealth”), enables staff at the hospital to provide advice and programs that are more applicable to the veteran’s real home situation.

Another example was of a patient who was given a shower chair and taught to use it during occupational therapy sessions at the hospital. When he returned home, it was obvious that the chair didn’t fit in the shower, and needed to be replaced with a bench. During the next video telemedicine session, the veteran practiced getting in and out of the shower using the shower bench while the occupational therapist coached remotely. (Unlike our Norwegian example, this person was fully clothed on the video.)

Veterans Affairs spends up to $6000 per person on home renovations for disabled veterans who need it. Having occupational therapists who are able to see the home remotely and help the veteran navigate it, as well as provide suggestions for modifications can help maximize the benefit of spending this money.

Our favorite part of this session was the presentation by Nancy Latham from Boston University who shared preliminary results from their study using Wellpepper and FitBit to keep activity levels high for people with Parkinson’s. People with Parkinson’s often see a dramatic decline in activity levels. However, the healthcare system has little or no support for long-term exercise needs. This randomized control trial had one group receiving the usual care condition which was an in-person visit and exercise prescription. The m-health group received an in-person visit but their exercise program was assigned using Wellpepper for their program with custom video, reminders, and messaging with a physical therapist. They were also given a FitBit. The results are extremely positive for exercise adherence, self-efficacy, patient satisfaction, and most importantly outcomes, judged using the 6-minute walk test. Stay tuned for early 2015 when we’ll have the final results to share with you. If you’d like to see the preliminary results, contact us.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Technology, M-health, Rehabilitation Business, Telemedicine

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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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