Dr. Mary Cramer spoke at the Pediatric Nursing & Healthcare 3rd International Conference on September 21 about a pilot study using GoMo Health's Personal Concierge.

1. 3rd International Pediatric Nursing & Healthcare Conference
Exploring Innovations and Latest Advancements in Pediatric Nursing and Healthcare
Vancouver,Canada
September21-22,2018

2. Mary E. Cramer
PhD, RN, FAAN
Professor Emeritus
University of Nebraska MedicalCenter
College of Nursing
Courtesy Faculty
College of Public Health
Omaha, Nebraska
USA
I have no financial conflict of interests with GoMo Health™ or
Blue Cross Blue Shield Nebraska.

3. Acknowledgements
This study was supported by a grant from Blue Cross Blue
Shield Nebraska, Fund for Health Quality.
This project was also supported by the National Institute of
General Medical Sciences, 1U54GM115458‐01. The content is
solely the responsibility of the authors and does not
necessarily represent the official views of the NIH

4. Objectives
1. Community Based Participatory Research (CBPR) as Innovation
to Population Health Problems
◦ “Community engagement” to solve the population problem of preterm birth
2. Concierge Mobile Technology and Community Health Workers
as innovative, evidence-based intervention
◦ 2014 Pilot Study to reduce rural population problem of preterm births
3. Mobile Technology updates since 2014
* Source: March of Dimes 2017 Prematurity Campaign: Five Main Activities. https://www.marchofdimes.org/mission/prematurity-
campaign.aspx

5. Articles
CBPR
Cramer ME; Lazoritz S; Shaffer K; Palm D; Ford
A. (2017). “Community advisory board
members’ perspectives regarding
opportunities and challenges of research
collaboration.” Western Journal Of Nursing
Research[West J Nurs Res], ISSN: 1552-8456,
2017 Mar 01, pp. 193945917697229;
Publisher: Sage Publications;PMID: 28367677
MOBILE TECHNOLOGY INTERVENTION
Cramer ME; Mollard EK; Ford AL; Kupzyk KA;
Wilson F. (September 2018). “The feasibility
and promise of mobile technology with
community health worker reinforcement to
reduce rural preterm birth.” Public Health
Nursing Journal. DOI: 10.1111/phn12543.
Publisher: Wiley Publications.

6. POPULATION HEALTH PROBLEM:
Preterm Births

7. Preterm Birthrates 2016
SOURCE: https://wData used in this report card come from the National Center for Health Statistics (NCHS) natality files, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital
Statistics Cooperative Program ww.marchofdimes.org/materials/premature-birth-report-card-united-states.pdf

8. U.S. HEALTH SYSTEM**
• $50 billion per year
• >50% births paid by Medicaid
PRIVATE INSURERS &
PATIENTS
• Hospitalization costs 10x higher
than normal births
• Top 5 most expensive reasons
for hospitalizations
INFANTS
1. Acute cardiac, respiratory,
neurological issues at birth
2. Life-long issues with vision,
hearing, speech, learning, or
behavior
PARENTS*
1. Unpaid work and job loss
2. Social isolation and emotional
distress
3. Debt and financial ruin
Economic
Social
*SOURCE: Ashwini Lakshmana, Meghana Agni, Tracy Lieu, Eric Fleegler, Michele Kipke,Philippe S. Friedlich, Marie C. McCormick and Mandy B. Belfort. The impact of preterm birth <37 weeks on parents and families: a cross-
sectional study in the 2 years after discharge from the neonatal intensive care unit. Health and Quality of Life Outcomes201715:38 https://doi.org/10.1186/s12955-017-0602-3
** https://www.cnsnews.com/news/article/terence-p.../24-states-50-babies-born-medicaid
Preterm Toll

9. *Births that occurred to mothers who reported
receiving prenatal care only in the third trimester of
their pregnancy, or reported receiving no prenatal care.
Race/Ethnicity
Asian 8.5%, White 9%,
Hispanic 9%, Native
American 10.4%, Black
13.3%
Source:
https://www.marchofdimes.org/m
aterials/premature-birth-report-
card-united-states.pdf
Smoking
10% of U.S. women
reported smoking during
the last 3 months of
pregnancy.
Source:
https://www.cdc.gov/reproductive
health/maternalinfanthealth/tobac
cousepregnancy/index.htm
Obesity
36% of U.S. pregnant
women are obese
Source:
https://www.marchofdimes.org/pr
egnancy/being-overweight-during-
pregnancy.aspx
Inadequate
Prenatal
Care*
10% of U.S. women
Source:
https://datacenter.kidscount.org/d
ata/tables/9078-births-to-women-
receiving-late-or-no-prenatal-care-
by-race-and-
ethnicity?loc=1&loct=2#detailed/1/
any/false/573,869,36,868,867,133,
38,35,18/10,11,9,12,1,13/18064,18
065
Preterm Correlates

10. Research
conducted in
Academic Medical
Centers 
Evidence
Based
Medicine
Clinical
Practice
In communities
where patients are
cared for
“Translational Research
Gap” between
Academia and
Community
Population
Health
Problems
PersistWhy have we not improved preterm births?

11. Basic Science
•Animal studies
•Preclinical studies
Human Clinical Research
•Controlled Observation
•Clinical trials
Population Health
• Lower IMR
• Reduced LBW
TRANSLATIONAL RESEARCH
9/25/2018
Only 50%
providers use
evidence based
medicine
Clinical Practices
• Health providers using
Evidence-based Medicine
ACADEMIC MEDICAL CENTERS COMMUNITIES
17 years

12. Community-
Based
Participatory
Research
A solution
that speeds
uptake of
EBM
9/25/2018

13. CBPR
…systematic inquiry, with
the collaboration of those
affected by the issue, for
purposes of education
and taking action or
effecting change.
CDC,2013;
Cohenetal.,2002,p.144
The Community
•Patients
•Providers
•Leaders
The Population
Health
Problem:
Rural Preterm
Births
9/25/2018
Academic Research
Team
Community Stakeholders
Physicians
Nurses
Hospitals
Clinics
Social Service Agencies
Churches
Schools
Businesses
Patients

14. 9/25/2018
Degreeofcommunityinvolvement
Full Collaboration (CBPR)
•Define study question and priority
•Develop the grant proposal
•Implement the research project
•Analyze results
•Disseminate findings
Some Collaboration
•Assist with recruitment and data collection
•Provide feedback on findings
•Community partner has narrow set of
responsibilities
Little Collaboration
•Assists only in discrete steps of the
study such as recruitment
Source: Principles of Community Engagement, 2nd Edition. CTSA June 2011, Figure 1.1, p. 8.

15. CBPR Research Questions
1. Do the EBM interventions to reduce preterm births work in
our rural setting, with our patients, with our providers?
2. Can we modify the EBM interventions to reduce preterm to
make it more workable for us in rural Nebraska?
3. If we try this EBM intervention, will it improve our patient
outcomes?
Let’s test them using research!
9/25/2018

16. Healthcare Providers
Patients and Communities
Researchers
9/25/2018
• Healthcare quality
• Enhanced community capacity to solve health
problems
• Bridges academic – community gaps
• Improves population health
• Improved research design and recruitment
• Validates intervention
• Puts problems in cultural perspective
• Makes findings more relevant
• Uptake of EBM by clinicians
CBPR ADVANTAGES

17. ◦ Centers for Disease Control and
Prevention (CDC)
◦ National Institute of Environmental
Health Sciences
◦ National Institute of Health (NIH)
 Supporting institutes:
NCI, NHLBI, NIAAA, NICHD, NIDA, NIDCD,
NIDCR, NIEHS, NIMH, NIMHD, NINR, OBSSR,
and ORWH.
9/25/2018
Federal Investment

18. Mothers Receiving
Inadequate
Prenatal Care
LBW and VLBW
Rate per 1,000
live births
Hispanic
Population
Rural
Counties
14% - 30% 70 – 129 Attracted by
agro-industries
State 16% 71.1 325% increase in
state. 89% are
under the age of
45
Nebraska Far and Remote (FAR) Regions
RURAL PRETERM POPULATION PROBLEM
(NEBRASKA)

19. PHASE 1: CBPR
FUNDING
$16K from Nebraska State Health Department
GOALS
1. Form the Central Nebraska Prenatal Advisory
Board
2. Train for research
3. Enlist full collaboration
PHASE 2: RESEARCH
FUNDING
$225,000 from BCBS Nebraska
GOALS
1. Implement research study
2. Analyze results with CAB
3. Disseminate results
4. NIH funding
The Project

20. Community Co-Chairs
• Dr. Ken Shaffer, local pediatrician and Medical Director CHI Health—Kearney and CO-I
• Dr. Stephen Lazoritz, Medical Director of Nebraska’s Medicaid managed care and CO-I
Academic Research Team
• Mary Cramer, Principal Investigator
• Amy Ford, Women Health NP and Project Coordinator
• Fernando Wilson, Health Economist
• Kevin Kupzyk, Biostatistician
Consultants
• Mary Larsen, Nebraska March of Dimes Education Director
• UNMC Institutional Review Board Coordinator
35 Community Members from:
• Five rural medical clinics
• Three regional hospitals
• Two pregnancy testing sites
• Four social service agencies
• Two Hispanic churches
• Public schools
• Two patients

21. ORGANIZATIONAL ASPECTS
◦ LEADERSHIP
◦ STRUCTURE
◦ MONTHLY MEETINGS
◦ AGENDA
◦ TRAININGS ON
◦ Informed Consent
◦ Role of institutional review boards
◦ Ethics of research
◦ Role in CBPR
◦ CONSENSUS BUILDING
◦ Context of their rural preterm births
◦ Selection of intervention
CAB ROLE
Before Grant submission
 Advice on design, recruitment, implementation,
dissemination, garnering community support
After Grant Funding
 Recruitment and retention
 Feedback on research progress
 Assistance solving issues of implementation
 Interpreting findings
 Addressing conflicts that may arise
 Adherence to research protocols

22. Community Awareness & Involvement

23. The Study

24. EBM Intervention Selected
CELL PHONES
OWNERSHIP
◦ 91% own cell phones
◦ 88% of women; 93% of men
◦ 85% of rural residents ; 92% of urban
◦ 88% of Hispanics
◦ 86% of those earning <$30,000/yr
TEXTING
◦ 75% text message
◦ Among 18-35 yr olds, 109 texts/day
◦ 31% prefer text over voice
EVIDENCE
◦ Text4baby shows improved maternal confidence
◦ Well-received venue of health information in US
COMMUNITY HEALTH WORKERS
POLITICALLY EXPEDIENT
◦ Legislative Interim Study on CHW (2014)
◦ Define role in underserved areas of state
◦ Drive to extend outreach of preventive care
NEW TRAINING PROGRAMS IN NEBRASKA
◦ Northeast Community College
◦ Central Community College
◦ NDHHS Health Navigator Course
EVIDENCE
◦ Effective in international programs
◦ Well-received in US
9/25/2018

25. PRIMARY STUDY
AIM
Assess the feasibility of an
EBM intervention using
concierge smartphone
(*PRENATAL TECHNOLOGY
PLATFORM) combined with
Community Health Worker
reinforcement among rural
pregnant women.
*GoMo Health™

26. • Usual Medical Care
• EBM InterventionINTERVENTION
GROUP
n = 50
• Usual Medical Care
• Informational Packets
CONTROL
GROUP
n = 50
AIM 1:
Intervention
Feasibility
Measures
• Satisfaction
(CSQ-8™)
• Enrollment
• Data Collection
• Fidelity
9/25/2018
AIM 2:
Preliminary
Outcome Data
on Intervention
Promise
Measures
• Birth outcomes
• Patient
Activation
(PAM™)
• Medical
Adherence
AIM 3:
Financial
Implications of
Intervention
Measures
• Return on
Investment
(ROI)
Quasi-Experimental Design

27. Methods
Criteria
• Inclusion
• Rural residence
• Plans to deliver at one of
our partner hospitals
• <20 weeks gestation
• Medical provider
• English/Spanish speaking
• Exclusion
• More than ususal medical
care
• Previous history of preterm
Procedures
• Clinic Referrals (N = 114)
• CHW home visits
• Enrollment (N = 98)
for consent,
orientation,
smartphone, baseline
data
• Conclusion for
smartphone and data
Duration
• Program extended from
enrollment through 36
weeks
• 15 months total study
time

28. 28
Information Packet
 Community Resources
 Prenatal book
 Brochures
 Linkage to Text4baby
Community Health Worker
 Two home visits – enrollment
and conclusion at 36 weeks
Control Group

29. 29
Stratified by;
 Risk behaviors
 Trimester
 Language
Use of Smart Phone
Prenatal Technology Platform™
Individualized texting, mobile
websites that delivered evidence-
based prenatal health information
and instructional videos
 Weekly “Wellness” messages
 Weekly “Risk intervention” messages
 Medical appointment reminders
Community Health Worker
 Weekly SMS chats
 Telephone follow-up over a HIPAA
compliant platform
 Referral assistance for transportation,
childcare
Intervention Group

30. 30
Reminders
Wellness
Risk
Behaviors

31. Followed by our
bilingual CHW
Sent individualized &
personalized messages

32. 32
GoMoHealth
SecureChat™
Patient View
Care Navigator View
GoMo Chat dashboard
OK, Wednesday
morning will work fine.
That’s great! We’ll see
you in the office on
Wednesday morning at
11:00 am. Please bring a
sample.
Live 2-Way Text Chat Between CHW & Patient

33. Analytic Strategy
Control vs Intervention Group
Differences
◦ Chi‐square (χ2)
◦ demographics, risk factors, insurance, ER
use,
◦ Likelihood ratio tests (LRT)
◦ LBW vs normal weight, and Preterm vs full
term
◦ T-Tests
◦ pre-pregnancy BMI, weight gain during
pregnancy, age
◦ Mann-Whitney U (non-normal
distributions)
◦ birth weight, gestation
Descriptive Stats and Trends
◦ Due to small sample size and pilot
nature of study results were not
significant at 5% level; therefore, we
used descriptive stats and trends

34. Respondent Demographics
Race/Ethnicity
• 96% white race
• 49% Hispanic
ethnicity
• 33% spoke Spanish
Risk Behaviors
• 4 smoked (IG)
• 1 used alcohol (IG)
• 2/3 overweight and 1/3
obese
• Pre-pregnancy BMIs for
both groups identical
Social Factors
• Most were married with
spouse
• Highly educated (some
college+)
• Most were employed
• Most had insurance

35. AIM 1: Feasibility Findings
Efficiency
Slow recruitment
Low-risk population
Parental consents were
barrier
Attrition
N = 77/98 (n = 41/52 intervention [79%]; n =
36/46 control [78%]).
Mobile population and missing birth data
Non-completers were more likely to be
uninsured, on government insurance, smoke, and
be Hispanic
SATISFACTION
Intervention participants scored
higher on the CSQ‐8 (M = 3.59, SD
= 0.3) than controls
(M = 3.22, SD = 0.7).
Enjoyed personalization of
program and regular contact with
CHW
Fidelity
High level of engagement based
on # chats, hyperlink hits, CHW
phone calls
Engagement higher among
English speaking
Enactment
Study phones were impediment
Placebo effect  Controls
Study bias  Clinic partners
confounding study

36. Aim 2: Promise of Intervention for Primary
Outcome Results
Gestation
> full-term deliveries in
Intervention Group (98%
vs 94%)
Longer gestation in
Intervention Group (39.43
vs 39.13)
Birthweight
Intervention Group 97.5%
vs 97.3%
Patient Activation
Intervention Group had greater increase in
PAM scores
Significant improvements on:
“I am confident that I can tell whether I
need to go to the doctor or whether I can
take care of a health problem myself”
“I am confident I can figure out solutions
when new problems arise with my health.”

37. Return on Investment (Aim 3)
Question: Can the EBM intervention be cost-effective and produce saving for the intervention
group as compared to the control group?
Data Collected:
◦ Participants’ use of hospital services (inpatient and ER)
◦ Dates of admission and discharge
◦ Age
◦ Primary payment source
◦ Payment amounts
◦ Total hospital charges
◦ Primary clinical diagnosis
Analysis from perspective of the health care provider

38. ROI Costs Calculation
1. Mobile technology intervention based on GoMo costs = $3.00 Per member per month cost
2. CHW intervention costs = 0.3 FTE x average wage plus benefits ($18.75/hr) and 2 weeks
training costs ($1,500) plus $213.75/ participant for direct outreach  $37.50 per
intervention participant
3. Smartphone loan = $20/month per participant
4. Based on these data, we developed two plausible scenarios (see next slide)

39. Financial Impact Results
OPTION INTERVENTION DESCRIPTION INTERVENTION COST
PER PARTICIPANT
RETURN ON
INVESTMENT (%)
A Mobile Technology Service only $27.00 1,859 %
B Mobile Technology Service
CHW
Training
CHW program
management
$251.25 90%
39

40. Discussion
Feasible Intervention
Cost-effective
Intervention
Intervention shows
promise of improving
preterm births
Intervention shows
promise of improving
patient activation for
enhanced self-care
Intervention was
highly acceptable

41. Conclusions and Recommendations
CBPR can lead to
quicker uptake of
tailored EBM
interventions– but also
study bias
Need larger scale study
with higher risk
population likely to
benefit from the
intervention
Four-group design
could parse effects of
mobile technology and
CHW
Future study should use
subjects own
smartphone as
convenience and to
track relocations
Future study requires
blinded participation
from clinic partners to
avoid bias
Future study requires 2-
3 year timeframe

42. MOBILE TECHNOLOGY UPDATES

43. Innovations in Peri/Post Natal Health Management
“Personal Healthcare Concierge”
New Interactive Health Management Solutions, empower patients,
insurers and providers to deliver/receive better, more individualized, any-
time anywhere interactive, health care; local resources, education, health
reminders and intervention – a true Concierge-Level of Care.
Preterm Birth Reduction Program - Approach
43

44. Post-Partum Programs – Birth to 3 Years Old

45. Multi-Prong Engagement Strategies & Tactics;
1. “Automated-Continuous” Patient Health Management
(Non-downloadable App; anyone with mobile phone, and/or email
can use)
2. 2-way Live, Interactive Patient Management Tools
Preterm Birth Reduction Program - Components
45

46. Program Topic-Specific Deep Dives & Intervention
Fast, easy online access to local health
care resources & 24/7 live help & triage

47. 1. Automated Prenatal Health Management: 8-months
2. Automated Discharge Management: In-patient
3. Automated-Post-Partum Management: Birth – 3rd Grade
New digital tools for live real-time engagement via; PC, Tablet, Smartphone
(CHWs, Social Workers, Case Managers, Nurses, Aids, Health Administrators)
• Tele-video: online appointments (PC, tablet or smartphone-to-
smartphone)
• Alexa (Audio-bot): internet based interaction
• API: Live device-monitoring interface(s)
Mother/Child Health Management Programs - Components

48. Live, Fully Integrated Prenatal/Post-Partum Live Health Monitoring

49. 49
Patient Engagement Components
• Care Messages™ (1-way, 2-way interactive)
• GoMo Chat™ (2-way)
• Care Companion™ (Interactive Web)
• Care Web Pages
• GoMo Device Monitoring
• Caren™ (Voice via Alexa Bot)
© 2018 GOLD GROUP ENTERPRISES, INC. CONFIDENTIAL AND PROPRIETARY

50. Fully Integrated Prenatal/Post-Partum Live Health Monitoring with
Providers

51. Fully Integrated Prenatal, Inpatient, Post-Partum & Med-Specific
programs
Example: Pharmacological-specific Fertility Programs

52. In-Patient (Non-Emergency) Service Automation
Bedside Concierge™ is an automated inpatient program designed to reduce Nurse workload and
patient improve service delivery.

53. 53
The Discharge Concierge™, an inpatient
App designed to connect prenatal to
post-partum programs, while simplifying
and automating the complex discharge
process, for mandatory form submission,
prior to discharge.
In-Patient Post-Partum Discharge Automation