Population health strategies have the benefit of advanced remote monitoring and telemedicine capabilities than in decades past, but to create a truly successful telehealth program you have to keep an open mind.
That is the message that Banner Health, an integrated, nonprofit health system based in Phoenix, Arizona, has taken to heart from its ongoing ambulatory care program for patients with chronic and complex diseases which is powered by Philip’s telemedicine platform.
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The program – named Intensive Ambulatory Care or Banner iCare — launched June 1, 2014, and the goal was to provide better care and reduce costs for the most complex patients – those with two or more chronic conditions — who happen to account for the highest cost in terms of healthcare dollars spent on their care.
Many population health programs focus on one chronic disease or another, but Dr. Hargobind Khurana, senior medical director of health management at Banner Health, said Banner’s approach was different.
“The idea was to say that there are complex, chronic patients who don’t have one chronic disease but have multiple chronic diseases and they have a hard time managing these diseases …these patients keep coming to the ED. They are in and out of the hospital,” he said in a recent interview. “Our goal was to be more broad than just one or two chronic diseases, so we focused on this aspect and said let’s find the high-utilizers who end up [repeatedly] in the hospital, in the ED.”
Claims data helped to identify them.
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Once participants are chosen and they elect to be part of the program, they are given traditional home health monitoring tools, including blood pressure cuffs and weight scales. Patients also receive Samsung Galaxy tablets to participate in video consults with caregivers that would serve as extra support in helping to meet health goals.
But the population health strategy isn’t just high-tech. It is high-touch too.
“There’s a large team central team that’s dedicated for this work – health coaches that go to the patient’s home, there’s a social worker, there’s a pharmacist there are tele-nurses and there’s a physician who kind of helps coordinate their care,” Khurana explained.
But there was a problem.
When the program launched, not enough patients who Banner felt could benefit were choosing to participate. The reason was simple: they didn’t want to switch their primary care providers as the program protocol required.
“We went in with this program thinking that what we would do is we would identify these patients and we’ll become their entire care team, so basically we would go to these patients and say, ‘We will become your primary care physician and we would also be the care team that would help with the telehealth platform,'” Khurana said. “Part of the lesson learned there was that patients were hesitant in the idea of leaving their PCP and entering a new entity.”
So Banner iCare pivoted.
“So we changed that model about a year into it and told them, ‘You don’t have to leave your PCP. We will be an add-on to your care team. So you will have your PCP and you will work with them but we will be supporting your care as an addition to your PCP,’ ” he recalled. “That really helped the patients feel more comfortable joining my team, andI think that was a good learning.”
Changing the model based on feedback shows that in year two Banner Health was willing to take on the additional complication of keeping PCP’s apprised of any intervention they did to help the PCP’s patients. All without overwhelming the primary care doctor with raw data that was being transmitted through Philips’ telehealth platform.
Currently, about 500 patients are being cared for using the Banner iCare program and to date more than 1,000 have utilized the program. Khurana said people drop off when they move, change health plans, or die, adding that very few people leave the program because they didn’t like it.
Banner has seen some savings too.
The Banner iCare program has reduced the total cost of care per beneficiary by 27% per year. It has also reduced hospitalizations by 45%.
The program is ongoing, and Khurana believes that while they have hit upon an effective program, all the answers aren’t available yet.
For Philips, which codeveloped the program with Banner, there have been some important lessons too.
“We learned and showed that telehealth technologies can have a big impact on the care for patients dealing with multiple chronic conditions,” said Jeroen Tas, CEO of Philips Connected Care and Informatics, in an email. “We also learned that the process of integrating telehealth and other connected health solutions is a delicate one. It will only be successful if existing care pathways are redesigned. Change management and education are needed too as telehealth enables a more integrated and multidisciplinary care team approach than the traditional doctor-patient interaction.”
That traditional assumptions must be questioned was something that Banner Health also learned through the iCare program. And those assumptions center around who is a high-cost patient.
“You can’t use retrospective costs or utilization data and assume that it would be the same in the future because it doesn’t account for the regression to the mean,” Khurana said, adding that just because some patients “had a bad year doesn’t mean that they are going to keep having bad years, year after year after year.”
In other words, the entire thinking about who is going to be an expensive patient in the future requiring coordinated care needs to be overhauled.
“We have to be smarter in building and developing more intelligent algorithms to identify patients who would be future high utilizers,” he said. “That will be the next focus of population health – to have better predictive analytics.”
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