Leveraging Innovative Way to Connect with Patients at Covenant Care Practices- Our experience using a mobile pre-visit assessment, Clinical Decision Support, and remote Monitoring Tools to engage and improve health outcomes in "Rising Risk" patients
This document provides information about PreventScripts, a digital care pathway program for preventing and treating metabolic syndrome. It includes the names and contact information of the co-founders, their mission to simplify healthy living for patients, and a quote about capturing patients before they become sick. It also includes sample patient reports that show biometric data, prevention plans, engagement data, recommendations and instructions for the PreventScripts program.
This document discusses a cancer support program and insurance solutions. The program aims to empower consumers by providing innovative solutions to their problems, delivering real value, and making data-driven decisions. The program focuses on various elements of the cancer continuum including prevention, early detection, treatment, and recovery management. It provides personalized cancer coaching, symptom tracking, daily cancer management activities over 12 weeks, and daily educational content to help patients manage their condition and improve clinical outcomes.
Stanford UniversityDiabetes Health Literacy Project 030614David Donohue
This document proposes a mobile health program to improve health outcomes for diabetes patients with low health literacy. It would customize diabetes education and communication based on patients' health literacy levels and survey data. It aims to increase patient knowledge, disease ownership, and engagement through longitudinal tracking of behavior, resulting in an estimated 8% reduction in healthcare costs. The program would use interactive tools, data analysis, and personalized interventions delivered by SMS, email, IVR and other channels to match patients' literacy and needs.
Accessing Diabetes Education Through TelehealthTAOklahoma
M. Dianne Brown, MS, RDN, LD, CDE
OU Physicians Diabetes Life Clinic at the Harold Hamm Diabetes Center
Cynthia Scheideman-Miller, MHSA
Heartland Telehealth Resource Center
Oklahoma Telemedicine Conference 2014: Telehealth Transition
October 16, 2014
This document discusses quality improvement efforts around breast and colorectal cancer screening at CommunityHealth, a nonprofit health center providing free healthcare to low-income, uninsured residents in Chicago. For breast cancer screening, opportunities for improvement include developing patient reminder systems, better use of EMR tools to flag overdue patients, and providing more education. For colorectal cancer screening, a tiered approach using fecal immunochemical tests for average-risk patients and colonoscopies for high-risk patients was implemented. Additional strategies to boost screening rates include intensive provider and staff education and targeted patient outreach. Success will be measured by benchmarking screening rates over time.
Journal Communications implemented a value-based benefit design to improve health outcomes and control costs. They promoted high-quality, low-cost providers and reduced barriers to preventive care. They also managed chronic diseases through a pharmacy compliance program offering coaching and incentives. Wellness programs were integrated, using data to connect participants with the right resources and motivate healthy behaviors. Through engagement and prevention, they achieved better health outcomes while lowering healthcare spending.
This presentation will walk the viewer through the following key moments:
Slide 2 – About Ochsner
Slide 3 – Book of business
Slide 4 – Key differentiators
Slides 5/6 – The problems we’re solving
Slides 7/8 – Care team and collaboration
Slides 9/10 – Results, outcomes and ROI
Slides 11/12 – Employer experience and ideal client profile
Slides 13/14 – Employee engagement
More than just condition monitoring:
Ochsner Digital Medicine is remote clinical management, including clinicians and pharmacists on the care team to adjust medications accordingly.
Full clinical management - including medication management and ordering labs. The only program delivering at national scale that is backed by a not-for-profit, Center of Excellence health system. The only program that augments the member's PCP care via seamless data integration with Epic electronic health record.
This document provides information about PreventScripts, a digital care pathway program for preventing and treating metabolic syndrome. It includes the names and contact information of the co-founders, their mission to simplify healthy living for patients, and a quote about capturing patients before they become sick. It also includes sample patient reports that show biometric data, prevention plans, engagement data, recommendations and instructions for the PreventScripts program.
This document discusses a cancer support program and insurance solutions. The program aims to empower consumers by providing innovative solutions to their problems, delivering real value, and making data-driven decisions. The program focuses on various elements of the cancer continuum including prevention, early detection, treatment, and recovery management. It provides personalized cancer coaching, symptom tracking, daily cancer management activities over 12 weeks, and daily educational content to help patients manage their condition and improve clinical outcomes.
Stanford UniversityDiabetes Health Literacy Project 030614David Donohue
This document proposes a mobile health program to improve health outcomes for diabetes patients with low health literacy. It would customize diabetes education and communication based on patients' health literacy levels and survey data. It aims to increase patient knowledge, disease ownership, and engagement through longitudinal tracking of behavior, resulting in an estimated 8% reduction in healthcare costs. The program would use interactive tools, data analysis, and personalized interventions delivered by SMS, email, IVR and other channels to match patients' literacy and needs.
Accessing Diabetes Education Through TelehealthTAOklahoma
M. Dianne Brown, MS, RDN, LD, CDE
OU Physicians Diabetes Life Clinic at the Harold Hamm Diabetes Center
Cynthia Scheideman-Miller, MHSA
Heartland Telehealth Resource Center
Oklahoma Telemedicine Conference 2014: Telehealth Transition
October 16, 2014
This document discusses quality improvement efforts around breast and colorectal cancer screening at CommunityHealth, a nonprofit health center providing free healthcare to low-income, uninsured residents in Chicago. For breast cancer screening, opportunities for improvement include developing patient reminder systems, better use of EMR tools to flag overdue patients, and providing more education. For colorectal cancer screening, a tiered approach using fecal immunochemical tests for average-risk patients and colonoscopies for high-risk patients was implemented. Additional strategies to boost screening rates include intensive provider and staff education and targeted patient outreach. Success will be measured by benchmarking screening rates over time.
Journal Communications implemented a value-based benefit design to improve health outcomes and control costs. They promoted high-quality, low-cost providers and reduced barriers to preventive care. They also managed chronic diseases through a pharmacy compliance program offering coaching and incentives. Wellness programs were integrated, using data to connect participants with the right resources and motivate healthy behaviors. Through engagement and prevention, they achieved better health outcomes while lowering healthcare spending.
This presentation will walk the viewer through the following key moments:
Slide 2 – About Ochsner
Slide 3 – Book of business
Slide 4 – Key differentiators
Slides 5/6 – The problems we’re solving
Slides 7/8 – Care team and collaboration
Slides 9/10 – Results, outcomes and ROI
Slides 11/12 – Employer experience and ideal client profile
Slides 13/14 – Employee engagement
More than just condition monitoring:
Ochsner Digital Medicine is remote clinical management, including clinicians and pharmacists on the care team to adjust medications accordingly.
Full clinical management - including medication management and ordering labs. The only program delivering at national scale that is backed by a not-for-profit, Center of Excellence health system. The only program that augments the member's PCP care via seamless data integration with Epic electronic health record.
Dr. Kristi Henderson - Remote Patient MonitoringSamantha Haas
This document discusses remote patient monitoring and how it can help control healthcare costs, improve outcomes, avoid readmissions, and modify patient behavior. It describes how remote patient monitoring can help address challenges like healthcare workforce shortages, hospital financial issues, and poor population health status. Remote patient monitoring brings healthcare teams to patients using technologies like telehealth, remote monitoring devices, and coordinated care to help with issues like chronic disease management, transitional care after hospital discharge, and personalized health and wellness programs. The document provides examples of remote patient monitoring programs in Mississippi that have led to outcomes like cost avoidance, improved care coordination and quality, and decreased hospital readmissions and emergency room visits.
In this webinar, you will learn:
How we approach intervention campaigns: a framework
The science of behavior change and how it can be applied to increase the probability of desired outcomes
How Altarum’s ACE Measure can help predict consumer behaviors and design successful intervention campaigns
Speakers:
Ryan Rossier, Medullan
Chris Duke, Altarum
Josh Klapow, ChipRewards
Routine HIV Testing in the Community Health CenterMPCA
Routine HIV screening in primary care settings can help identify undiagnosed cases of HIV infection earlier. Late HIV testing leads to poorer health outcomes compared to earlier diagnosis. The CDC now recommends opt-out routine HIV screening for patients ages 13-64 in primary care. A model developed by health centers successfully integrated routine HIV screening and achieved high testing rates, identifying new HIV cases and linking patients to care.
Acute hospitals end of life care best practiceNHSRobBenson
Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain. Including details of the AMBER care bundle. Presentation from Anita Hayes and colleagues from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011
This document discusses a comprehensive approach to diabetes self-management support using mobile technology. It outlines how mHealth interventions can educate and empower both patients and providers. A range of mHealth tools are proposed, including text messaging programs, smartphone apps, online education, telemonitoring, and video conferencing with specialists. These tools aim to enhance self-management, provide ongoing support, and help integrate care across community and clinical settings. An mHealth system is envisioned that combines population health data, shared care plans, and a suite of tailored digital tools to improve diabetes control.
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This document summarizes the key aspects of a health management program. It discusses how the program addresses various health risks and conditions across the care continuum from wellness to disease management. It provides data on common health risks and costs associated with them. The program utilizes nurses and health coaches to provide various services including wellness coaching, decision support, health coaching during pregnancy, case management, and disease management. It aims to help individuals better manage their health conditions and make healthcare decisions. Data is also presented on outcomes of the program, including improvements in clinical indicators, utilization, costs and member satisfaction.
The National Diabetes Prevention Program aims to prevent type 2 diabetes through lifestyle change programs. It is based on evidence from the Diabetes Prevention Program research study showing that modest weight loss and increased physical activity through a structured lifestyle intervention can reduce risk of developing diabetes by 58%. The National DPP coordinates efforts across sectors to recognize and support diabetes prevention programs delivering this evidence-based approach. Quality assurance and a growing network of over 500 recognized sites nationwide are key to achieving the large-scale implementation needed to effectively address the diabetes epidemic in the United States.
ClickMedix is a connected mHealth platform that enables healthcare organizations to serve more patients better, faster, and at lower costs. It has been deployed in 16 countries through over 90 sites addressing different diseases. ClickMedix provides case studies on scaling tele-dermatology, community-based care for low-income populations, and managing diabetic patients collaboratively with multiple specialists. The platform aims to improve access to care through task-shifting to nurses and community health workers while lowering costs.
Uncover Successful Strategies for Analytics-Driven Alignment Sudeep Debnath
This document discusses strategies for using data analytics to improve physician alignment with quality and value-based care goals. It notes the changing roles of providers and patients with new payment models focusing on quality and value over volume. Analytics can help prioritize measures, identify gaps in care, and target high-risk patients and providers. The document outlines several approaches including empowering office staff, personalized engagement, and automated outreach. It presents a case study showing a data-driven program successfully engaged providers and improved performance on several quality measures.
Kamal Jethwani, MD, MPH
Corporate Manager - Research and Innovation
Partners Healthcare Center for Connected Health
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This document summarizes the benefits of highly organized primary care and medical homes. It discusses how organizing primary care into teams that focus on population health, care coordination, planned care for chronic conditions, and quality improvement can improve health outcomes, reduce costs, and enhance the patient experience. The document provides examples from Cambridge Health Alliance that show improved quality metrics, decreased hospital and emergency room use, and reduced costs after implementing a primary care reform model centered around medical homes and accountable care.
Since its original inception, Clinician Group has continually expanded its battery of assessment solutions and added new features (such as benchmarking and a comparison modules). With Clinician Group, our assessment solutions have become a preeminent provider of psychological, Annual Wellness Visits and Neurocognitive Assessment programs with services expanding to therapists, general practitioners, researchers and a host of other medical professionals.
The My Mind Lab assessment provides a multi-dimensional behavioral health screening for depression, bipolar disorder, anxiety, PTSD, and substance use in a quick and easy to administer test. The assessment increases quality of patient care, enhances a practice's image, and incorporates digitized health records while helping to increase revenue. It can be used by medical practices, hospitals, managed care organizations, and other providers to better identify and treat underlying mental health issues, track patient progress, and submit claims under CPT code 96103 for reimbursement. The assessment takes on average less than 10 minutes for patients to complete and provides immediate scoring and reporting to help physicians.
The document introduces My Mind Lab, an assessment tool from Clinician Group that provides a brief behavioral health screening. It screens for depression, bipolar disorder, anxiety, PTSD, and substance use in one test. The assessment takes under 10 minutes and provides immediate results to help physicians identify underlying psychological issues contributing to physical health problems. Using My Mind Lab allows physicians to bill for the screening under CPT code 96103 and establishes an additional revenue stream. It benefits patients through early detection and personalized treatment, while saving physicians time and improving care.
- The document discusses the requirements and incentives for physicians to achieve Meaningful Use of electronic health records as part of the government's stimulus program.
- Physicians must meet objectives in three stages involving electronic prescribing, clinical quality reporting, and advanced clinical processes to receive incentive payments of up to $44,000 from Medicare or $63,750 from Medi-Cal.
- Achieving Meaningful Use requires efforts from physicians, medical assistants, and office staff according to defined roles and responsibilities for data capture, review, and reporting.
The document outlines a quality improvement project conducted by a team at an Accountable Care Organization to improve hypertension control rates in their patient population. It describes forming a multidisciplinary team, analyzing the root causes of uncontrolled hypertension through tools like cause-and-effect diagrams, and implementing a Plan-Do-Study-Act cycle to test engaging patients in self-management education during visits. The team's goal is to increase the percentage of hypertensive patients with controlled blood pressure below 140/90 mmHg through standardized communication of management strategies.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
Dr. Kristi Henderson - Remote Patient MonitoringSamantha Haas
This document discusses remote patient monitoring and how it can help control healthcare costs, improve outcomes, avoid readmissions, and modify patient behavior. It describes how remote patient monitoring can help address challenges like healthcare workforce shortages, hospital financial issues, and poor population health status. Remote patient monitoring brings healthcare teams to patients using technologies like telehealth, remote monitoring devices, and coordinated care to help with issues like chronic disease management, transitional care after hospital discharge, and personalized health and wellness programs. The document provides examples of remote patient monitoring programs in Mississippi that have led to outcomes like cost avoidance, improved care coordination and quality, and decreased hospital readmissions and emergency room visits.
In this webinar, you will learn:
How we approach intervention campaigns: a framework
The science of behavior change and how it can be applied to increase the probability of desired outcomes
How Altarum’s ACE Measure can help predict consumer behaviors and design successful intervention campaigns
Speakers:
Ryan Rossier, Medullan
Chris Duke, Altarum
Josh Klapow, ChipRewards
Routine HIV Testing in the Community Health CenterMPCA
Routine HIV screening in primary care settings can help identify undiagnosed cases of HIV infection earlier. Late HIV testing leads to poorer health outcomes compared to earlier diagnosis. The CDC now recommends opt-out routine HIV screening for patients ages 13-64 in primary care. A model developed by health centers successfully integrated routine HIV screening and achieved high testing rates, identifying new HIV cases and linking patients to care.
Acute hospitals end of life care best practiceNHSRobBenson
Delivering reliable best practice in an acute hospital setting for patients whose recovery is uncertain. Including details of the AMBER care bundle. Presentation from Anita Hayes and colleagues from England's National End of Life Care Programme as part of the Department of Health's QIPP end of life care workstream seminar series at Healthcare Innovation Expo 2011
This document discusses a comprehensive approach to diabetes self-management support using mobile technology. It outlines how mHealth interventions can educate and empower both patients and providers. A range of mHealth tools are proposed, including text messaging programs, smartphone apps, online education, telemonitoring, and video conferencing with specialists. These tools aim to enhance self-management, provide ongoing support, and help integrate care across community and clinical settings. An mHealth system is envisioned that combines population health data, shared care plans, and a suite of tailored digital tools to improve diabetes control.
This document summarizes the key aspects of a health management program. It discusses how the program addresses various health risks and conditions across the care continuum from wellness to disease management. It provides data on common health risks and costs associated with them. The program utilizes nurses and health coaches to provide various services including wellness coaching, decision support, health coaching during pregnancy, case management, and disease management. It aims to help individuals better manage their health conditions and make improvements in clinical outcomes and costs through personalized support and education.
This document summarizes the key aspects of a health management program. It discusses how the program addresses various health risks and conditions across the care continuum from wellness to disease management. It provides data on common health risks and costs associated with them. The program utilizes nurses and health coaches to provide various services including wellness coaching, decision support, health coaching during pregnancy, case management, and disease management. It aims to help individuals better manage their health conditions and make healthcare decisions. Data is also presented on outcomes of the program, including improvements in clinical indicators, utilization, costs and member satisfaction.
The National Diabetes Prevention Program aims to prevent type 2 diabetes through lifestyle change programs. It is based on evidence from the Diabetes Prevention Program research study showing that modest weight loss and increased physical activity through a structured lifestyle intervention can reduce risk of developing diabetes by 58%. The National DPP coordinates efforts across sectors to recognize and support diabetes prevention programs delivering this evidence-based approach. Quality assurance and a growing network of over 500 recognized sites nationwide are key to achieving the large-scale implementation needed to effectively address the diabetes epidemic in the United States.
ClickMedix is a connected mHealth platform that enables healthcare organizations to serve more patients better, faster, and at lower costs. It has been deployed in 16 countries through over 90 sites addressing different diseases. ClickMedix provides case studies on scaling tele-dermatology, community-based care for low-income populations, and managing diabetic patients collaboratively with multiple specialists. The platform aims to improve access to care through task-shifting to nurses and community health workers while lowering costs.
Uncover Successful Strategies for Analytics-Driven Alignment Sudeep Debnath
This document discusses strategies for using data analytics to improve physician alignment with quality and value-based care goals. It notes the changing roles of providers and patients with new payment models focusing on quality and value over volume. Analytics can help prioritize measures, identify gaps in care, and target high-risk patients and providers. The document outlines several approaches including empowering office staff, personalized engagement, and automated outreach. It presents a case study showing a data-driven program successfully engaged providers and improved performance on several quality measures.
Kamal Jethwani, MD, MPH
Corporate Manager - Research and Innovation
Partners Healthcare Center for Connected Health
iHT² CMIO Symposium Beverly Hills – Opening Keynote: Kamal Jethwani, MD, MPH, Corporate Manager – Research and Innovation, Partners Healthcare Center for Connected Health
This document summarizes the benefits of highly organized primary care and medical homes. It discusses how organizing primary care into teams that focus on population health, care coordination, planned care for chronic conditions, and quality improvement can improve health outcomes, reduce costs, and enhance the patient experience. The document provides examples from Cambridge Health Alliance that show improved quality metrics, decreased hospital and emergency room use, and reduced costs after implementing a primary care reform model centered around medical homes and accountable care.
Since its original inception, Clinician Group has continually expanded its battery of assessment solutions and added new features (such as benchmarking and a comparison modules). With Clinician Group, our assessment solutions have become a preeminent provider of psychological, Annual Wellness Visits and Neurocognitive Assessment programs with services expanding to therapists, general practitioners, researchers and a host of other medical professionals.
The My Mind Lab assessment provides a multi-dimensional behavioral health screening for depression, bipolar disorder, anxiety, PTSD, and substance use in a quick and easy to administer test. The assessment increases quality of patient care, enhances a practice's image, and incorporates digitized health records while helping to increase revenue. It can be used by medical practices, hospitals, managed care organizations, and other providers to better identify and treat underlying mental health issues, track patient progress, and submit claims under CPT code 96103 for reimbursement. The assessment takes on average less than 10 minutes for patients to complete and provides immediate scoring and reporting to help physicians.
The document introduces My Mind Lab, an assessment tool from Clinician Group that provides a brief behavioral health screening. It screens for depression, bipolar disorder, anxiety, PTSD, and substance use in one test. The assessment takes under 10 minutes and provides immediate results to help physicians identify underlying psychological issues contributing to physical health problems. Using My Mind Lab allows physicians to bill for the screening under CPT code 96103 and establishes an additional revenue stream. It benefits patients through early detection and personalized treatment, while saving physicians time and improving care.
- The document discusses the requirements and incentives for physicians to achieve Meaningful Use of electronic health records as part of the government's stimulus program.
- Physicians must meet objectives in three stages involving electronic prescribing, clinical quality reporting, and advanced clinical processes to receive incentive payments of up to $44,000 from Medicare or $63,750 from Medi-Cal.
- Achieving Meaningful Use requires efforts from physicians, medical assistants, and office staff according to defined roles and responsibilities for data capture, review, and reporting.
The document outlines a quality improvement project conducted by a team at an Accountable Care Organization to improve hypertension control rates in their patient population. It describes forming a multidisciplinary team, analyzing the root causes of uncontrolled hypertension through tools like cause-and-effect diagrams, and implementing a Plan-Do-Study-Act cycle to test engaging patients in self-management education during visits. The team's goal is to increase the percentage of hypertensive patients with controlled blood pressure below 140/90 mmHg through standardized communication of management strategies.
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Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
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Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
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KY HIMSS Leveraging Innovative Ways to Connect with Patients at Covenant Care Practices
1. Leveraging Innovative Ways to Connect
with Patients at Covenant Care Practices
Our experience using a mobile pre-visit assessment, clinical
decision support and remote monitoring tools to engage and
improve health outcomes in "Rising Risk" patients
3. Conflict Of Interest Disclosure
• Per PIMS standards, Natalie Davis, MD, Category of Conflict,
and company of conflict, example below:
• Natalie Davis, MD Chief Medical Officer of PreventScripts, Founder
4. Agenda
• Learning Objectives
• Covenant Care Background
• Overview of Digital Health Technologies Used
• Partnership Goals
• Workflow Challenges
• Impact
• Lessons Learned
• Opportunities to Optimize Clinical Integration and Patient Outcomes
5. Learning Objectives
• Assess Population Health Stratification Data from 5,000+ Pre-visit
Patient Self Assessment tool Reports administered through a Web-
based App.
• Analyze Patient Engagement Use Data from Prevention Remote
Monitoring Enrolled Patients with Metabolic Syndrome.
• Analyze Health Outcomes Data from Prevention Remote Monitoring
Enrolled Patients with Metabolic Syndrome.
6. Introducing Covenant Care Practices
•54,415
Outpatient Visits in 2021
•17,018
Total Patients in EHR
•4
Locations in Tennessee
•12
Providers
•43
Employees
11. Goals Of Our Partnership
• Assess patients by collecting, scoring, and sending patients’
risk report to their chart
• Engage patients in their health risks and assess motivation
pre-visit
• Facilitate patient-provider prevention conversation during
any visit
• Intervene with the eligible, motivated patients at-risk of
developing metabolic disease
13. Overview Of Digital Health Tools
Patient Name:Bridget Thomasson
DOB: 1974-07-11
Provider: Mandy Childers
Date of Report: 9th February 2023.
REMOTE MONITORING RESULTS
Starting BMI: 45
BIOMETRIC DATA
most recent blood pressure: not taken
most recent blood sugar 159
average 30 day blood sugar not taken
# blood sugar readings taken in 30 days: N/A
# scale data points (30 days): 9
PREVENTION PLANS STARTED RECENTLY
DATE STARTED
Eat more fruit
2022/10/06
Eat more fruit
2022/09/22
ENGAGEMENT DATA
times opened app: 76
times opened app last month: 29
total times stepped on scale since enrollment: 72
average daily step count:
276
LAST
MONTH
THIS
MONTH
daily average water intake:
0 oz 0 oz
daily average veggie intake:
0.00/8 0.00/8
daily average fruit intake:
0.00/4 0.00/4
7
BLOOD PRESS
BLOOD SUGAR
WEIGHT
last update now last update now last update now
0 lb 145/89
0
Health Biometrics
WATER STEPS VEGETABLES
last update now last update now last update now
0 oz
Health Behaviors
Welcome Box
Delivered
Avg reimbursement
$55/patient/month
Patient Education
5
&Support Program
!"#$% PrevenTips
&''($%
)*+,-$%
Progress SURVEY
Care Team Calls 20 minutes data review / call
Avg reimbursement: $50/patient/month
Monthly Report to EHR/Patient Chart
Results
Smoking Cessation
Preventive Counseling
Patient education to generate
more cessation visits
Up to 20 visits per year per provider
(Avg. reimbursement $30 – $45 / 15 minute visit)
(up to $125/year)
6
ADD‐ONS
Patient Name: Alex Rupert
DOB: Jan. 26, 1996
Provider: Olivia Hutcheson
Date of Report: 22nd July 2022
PATIENT ASSESSMENT RESULTS
ADA/CDC Prediabetes Risk Test* 3
PROMIS Short Form v1.0 – General Self-
Efficacy 4a* 52.2
PROMIS ADULT short form - global -
version 1.2* 43.5 42.3
Motivation Level Medium
motivation
BMI 34.31
Patient-reported Chronic Condition
Status
No
* validated survey instruments
BILLING
REMINDERS
Survey 1
ADA Risk: CPT code: 96160
Survey 2
PROMIS Self-Efficacy: CPT
Code: 96160
Survey 3
PROMIS Global Health Short
Form: CPCode: 96160
RECOMMENDATIONS + INSTRUCTIONS
We recommend the following pathway for this patient. Below you will find instructions for this
pathway. For more information on these recommendations, click here: preventscripts.com
Patient Not Eligible
Prevention Emails
Assess Chronic Condition
PreventScripts Prevention
Remote Monitoring
PreventScripts Preventive
Counseling
PreventScripts Tobacco
Cessation
INSTRUCTIONS FOR PATIENT
ENROLLMENT
This patient is a good candidate for Remote Patient
Monitoring.
PreventScripts will work with your
patient to start reducing risks and
improving overall health and wellbeing,
on their own schedule. The clinic will
help to support the patient by monitoring
progress via the app, and checking in
with the patient monthly. PreventScripts
will help the patient take small steps
toward healthy choices over time.
1 At time of visit, identify and code
ONE chronic diagnosis for eligibility.
Possible chronic disease diagnosis
could be: hypercholesterolemia,
hyperlipidemia, obesity, overweight,
metabolic syndrome, stage one
hypertension, etc.
2 Inform Patient of Program: (possible
talking point ideas)
3 Patient Setup: MA/Nurse brings in a
sample starter kit and shows the
patient what’s in the box and how to
download the “PreventScripts RPM”
App.
STEP STEP
Patient Risk
Assesment
START HERE
Pre‐visit
2 – 3 minutes for patient
4
MA/LPN: 2 – 4 minutes
Avg reimbursement $18
Sign UP
Patient
BY
3Office
Visit
1–2 minutes
to discuss
the program
with eligible
patients.
2Results Sent to EHR/
Patient Chart
Clinic: Average
reimbursement
$12 per
Providers: Less
than 1 minute
to review.
16. Goal #1: Assess
• Assess patients by collecting, scoring, and sending patients’ risk
report to their chart
• Collect
• Screen every patient 18-65 during their normal visits
• Patient-facing web page
• Sent along with pre-registration software morning of visit
• Score
• Clinical decision tree to score and stratify patients
• Database and algorithm to score surveys and turn into insights
• Send
• Send secure actionable report as a clinical decision support tool to patient chart utilizing direct
message into the EHR
• Utilize a Health Information Service Provider, or HISP, is an accredited network service operator that
enables nationwide clinical data exchange using Direct Secure Messaging
17. Goal #1: Assess
• Assess patients by collecting, scoring, and sending patients’ risk
report to their chart
• Demographics
• Height and Weight
• Motivation/Readiness
• PROMIS Global 10 Physical and Mental Health Survey
• PROMIS Self-Efficacy Survey
• ADA Pre-Diabetes Survey
18. Goal #1: Assess
Assess patients by
collecting, scoring,
and sending patients’
risk report to their
chart
Patient Education
STEP STEP
Patient Risk
Assesment
START HERE
Pre‐visit
2 – 3 minutes for patient
BY
2
19. Goal #2: ENGAGE patients by color coding risk
STEP STEP
Patient Risk
Assesment
START HERE
Pre‐visit
2 – 3 minutes for patient
BY
2Resu
Clinic: Av
reimburs
$12 per
20. Goal #3: Facilitate
• Facilitate patient-provider prevention conversation during any
visit
• Report offers recommendations to providers for patient
interventions
• Report offers talking points for each intervention
recommended Patient Name: Alex Rupert
DOB: Jan. 26, 1996
Provider: Olivia Hutcheson
Date of Report: 22nd July 2022
PATIENT ASSESSMENT RESULTS
ADA/CDC Prediabetes Risk Test* 3
PROMIS Short Form v1.0 – General Self-
Efficacy 4a* 52.2
PROMIS ADULT short form - global -
version 1.2*
43.5 42.3
Motivation Level
Medium
motivation
BMI 34.31
Patient-reported Chronic Condition
Status No
* validated survey instruments
BILLING
REMINDERS
Survey 1
ADA Risk: CPT code: 96160
Survey 2
PROMIS Self-Efficacy: CPT
Code: 96160
Survey 3
PROMIS Global Health Short
Form: CPCode: 96160
RECOMMENDATIONS + INSTRUCTIONS
We recommend the following pathway for this patient. Below you will find instructions for this
pathway. For more information on these recommendations, click here: preventscripts.com
Patient Not Eligible
Prevention Emails
Assess Chronic Condition
PreventScripts Prevention
Remote Monitoring
PreventScripts Preventive
Counseling
PreventScripts Tobacco
Cessation
INSTRUCTIONS FOR PATIENT
ENROLLMENT
This patient is a good candidate for Remote Patient
Monitoring.
PreventScripts will work with your
patient to start reducing risks and
improving overall health and wellbeing,
on their own schedule. The clinic will
help to support the patien
pr
1 At time of visit, identify and code
ONE chronic diagnosis for eligibility.
Possible chronic disease diagnosis
could be: hypercholesterolemia,
hyperlipidemia, obesity, overweight,
metabolic syndrome, stage one
hypertension, etc.
2 Inform Patient of Program: (possible
talking point ideas)
EP STEP
ent Risk
sment
HERE
visit
es for patient
BY
3
2Results Sent to EHR/
Patient Chart
Clinic: Average
reimbursement
$12 per
Providers: Less
than 1 minute
to review.
21. Goal #4: Intervene
• Intervene and enroll eligible patients into our RPM program
Patient Name:Bridget Thomasson
DOB: 1974-07-11
Provider: Mandy Childers
Date of Report: 9th February 2023.
REMOTE MONITORING RESULTS
Starting BMI: 45
BIOMETRIC DATA
ENGAGEMENT DATA
times opened app: 76
times opened app last month: 29
total times stepped on scale since enrollment: 72
BLOOD PRESS
BLOOD SUGAR
w last update now last update now
145/89
0
Health Biometrics
STEPS VEGETABLES
w last update now last update now
Health Behaviors
Welcome Box
Delivered
Avg reimbursement
$55/patient/month
ducation
5
t Program
Smoking Cessation
Patient education to generate
more cessation visits
(up to $125/year)
ADD‐ONS
Patient Name: Alex Rupert
DOB: Jan. 26, 1996
Provider: Olivia Hutcheson
Date of Report: 22nd July 2022
PATIENT ASSESSMENT RESULTS
ADA/CDC Prediabetes Risk Test* 3
PROMIS Short Form v1.0 – General Self-
Efficacy 4a* 52.2
PROMIS ADULT short form - global -
version 1.2* 43.5 42.3
Motivation Level
Medium
motivation
BMI 34.31
Patient-reported Chronic Condition
Status No
* validated survey instruments
BILLING
REMINDERS
Survey 1
ADA Risk: CPT code: 96160
Survey 2
PROMIS Self-Efficacy: CPT
Code: 96160
Survey 3
PROMIS Global Health Short
Form: CPCode: 96160
RECOMMENDATIONS + INSTRUCTIONS
We recommend the following pathway for this patient. Below you will find instructions for this
pathway. For more information on these recommendations, click here: preventscripts.com
Patient Not Eligible
Prevention Emails
Assess Chronic Condition
PreventScripts Prevention
Remote Monitoring
PreventScripts Preventive
Counseling
PreventScripts Tobacco
Cessation
INSTRUCTIONS FOR PATIENT
ENROLLMENT
This patient is a good candidate for Remote Patient
Monitoring.
PreventScripts will work with your
patient to start reducing risks and
improving overall health and wellbeing,
on their own schedule. The clinic will
help to support the patient by monitoring
progress via the app, and checking in
with the patient monthly. PreventScripts
will help the patient take small steps
toward healthy choices over time.
1 At time of visit, identify and code
ONE chronic diagnosis for eligibility.
Possible chronic disease diagnosis
could be: hypercholesterolemia,
hyperlipidemia, obesity, overweight,
metabolic syndrome, stage one
hypertension, etc.
2 Inform Patient of Program: (possible
talking point ideas)
3 Patient Setup: MA/Nurse brings in a
sample starter kit and shows the
patient what’s in the box and how to
download the “PreventScripts RPM”
App.
STEP
k
nt
4
MA/LPN: 2 – 4 minutes
Avg reimbursement $18
Sign UP
Patient
BY
3Office
Visit
1–2 minutes
to discuss
the program
with eligible
patients.
2Results Sent to EHR/
Patient Chart
Clinic: Average
reimbursement
$12 per
Providers: Less
than 1 minute
to review.
22. Goal #4: Intervene
Eat your vegetables
first. You'll fill up on the
good stuff and not have
too much room for the
less-than-healthy stuff.
PreventTip of The Day
Week FOUR Day ONE
YOUR GOAL: EAT MORE VEGETABLES
23. Workflow Challenges We Encountered
1. Providers struggled to enroll
patients in the RPM program
2. Providers struggled to execute
RPM monthly visits
3. Provider Staffing
4. Patients within the BMI range of
26 – 29 often lacked chronic
disease diagnosis or metabolic
syndrome diagnosis
24. Workflow Challenges: Innovative Solutions
• Staffed Behavior Change Expert: Mandy
• Provider Engagement: Added monthly provider emails with enrollment
details by provider- benchmarking feature and QI payments for providers
• Patient Engagement Features: Extended PreventTips, Added Content,
Recipes, weekly surveys
• Waist Circumference to Kit: Accelerated Clinic MetX Diagnosis for BMI 26 –
29 patients WITHOUT Obesity Diagnosis
25. The Impact
Assess Population Health Stratification Data
5028
PreventScripts
Assessments
PreventScripts
RPM Eligible
PreventScripts
Chronic Disease
Identified
1147 1394
26. The Impact
Assess Population Health Stratification Data
150
Tobacco Use
Identified
Patients
Identified As
Low Risk
Preventive
Counseling
Eligible
1649 688
27. The Impact
Analyze Patient Engagement Use Data
67
Patients
Enrolled In RPM
“MyPlans”
Selected By
Patients
106
29. The Impact
Analyze Patient Engagement Use Data
69
Net Promoter
Score
MARS Survey of
Behavioral Intent
5/5
30. The Impact
Analyze Patient Health Outcomes Data
32%
Patients have
lost 5% or more
of bodyweight
Patients have
lost 1 – 4% of
bodyweight
Patients have
neither gained
nor lost weight
47% 20%
31. The Impact
Analyze Patient Health Outcomes Data
12%
Systolic Blood
Pressure
Reduction
Diastolic Blood
Pressure
Reduction
13%
34. Lessons Learned
• Provider “buy in” and engagement with program is critical
to success
• Staffing is key to digital health implementation
• Benchmarking providers within the group was useful
35. Opportunities To Optimize Program
• Auto-enrollment of patients into programs to minimize provider
friction
• Single sign-on of clinical dashboard with program-specific data for
monitoring patients
• Collect waist circumference in app as important indicator of
metabolic syndrome
• Financial dashboard for demonstrating program usage and
reimbursement to incentivize provider use
• Validated Surveys for teenage patients aged 13 to 17
36. Areas For Future Research
• NIH SBIR NINR pilot study to further explore health outcomes
• NSF SBIR to build 5A conversational assistant (AI) “Preventee”
• AHRQ Digital Health at Point of Care grant to better study product
implementation and patient use enhancements