Reaching Beyond the Exam Room: How Technology-backed Lifestyle Intervention Is Improving Health Outcomes for Diabetes and Hypertension Management

In 2003, Susan L. Norris, MD, MPH, a researcher at McMaster University, Ohio State University, and the CDC Center for Diabetes Translation, and her colleagues sought an operational definition of chronic disease management. Based on their review of programs in clinical settings, they defined chronic disease management as:

An organized, proactive, multi-component, patient-centered approach to healthcare delivery that involves all members of a defined population who have a specific disease entity (or a subpopulation with specific risk factors). Care is focused on, and integrated across, the entire spectrum of the disease and its complications, the prevention of comorbid conditions, and relevant aspects of the delivery system.¹

This definition certainly describes the approach to addressing chronic disease at that time and in many cases today. For decades, the medical community has designed chronic disease management programs to fit within the clinical patient care setting, whether or not it was convenient for the patient. For individuals who do not need care in a clinical setting, there are numerous chronic disease self-management education programs (CDSMPs). These programs extend beyond the traditional educational, knowledge-centered approach to include knowledge application in real-world situations, self-monitoring, problem solving, utilization of external resources, and application to behavior change in real world situations.² They are typically provided in a community setting to minimize the clinical feel. However, CDSMPs require participants to show up at a specific time and location and adjust their life to the provider rather than meeting them where they are.

What if a lifestyle intervention and management program was designed to address the risk factors associated with the condition, enhance knowledge, and lead to sustainable behavior change in a way that allowed participants to attend when and where it was convenient for them? More importantly, what if the program allowed participants to engage when they were truly “present” and not merely in a state of presenteeism? Now, with the proliferation of mobile technology, such programs exist.

Bringing together innovative technologies and clinically validated curricula expands reach outside of the physician exam room and/or community-based setting into the daily lives of patients. This powerful combination can significantly enhance the prevention of lifestyle-related chronic conditions to improve health outcomes further upstream. The potential of this approach is extensive, with benefits related to prevention of the condition and/or symptom improvement, as well as a reduction in healthcare costs.

Overview and Business Case

Recently, a large private employer and health system in the Midwest identified a significant rise in type 2 diabetes and hypertension in their patient population. This trend was mirrored closer to home, among the health system’s own employees. Although the system offered multiple disease management and prevention programs, including physician referrals for these services, their care-related costs were increasing, productivity was declining, and the overall well-being of their employee population was suffering.

Faced with this data, the health system decided to divert from a traditional chronic disease management approach to a new model. In 2016, it created a partnership with Noom, Inc, a leader in mobile health coaching, to deploy an innovative chronic disease management solution designed to address these issues. The year-long initiative leveraged technology and human coaching to improve practical knowledge of the diagnosed condition and modify lifestyle behaviors, with a goal of decreasing associated risk factors. The initiative maintained positive aspects of traditional and self-management education programs while simultaneously reducing common barriers to engagement. This included high-touch support from a health coach alongside a structured clinically validated program delivered via their employees’ smartphones. This approach also increased the reach and efficiency of the program by reducing the number of required staff resources per participant from 1:15 to 1:42.

Noom’s technology and its structured diabetes and hypertension management programs were utilized for this initiative. The health system’s coaches supported participants in real time, utilizing Noom’s coaching tools which reveal trends, patterns, and individual actions to enable timely intervention. Eligible participants used Noom’s mobile application to log their meals, track physical activity, and monitor biometric readings with integrated glucometer and blood pressure monitors. They also received structured, condition-specific curriculum; group support from a virtual group of peers; and feedback from their coach at moments of greatest impact, such as during a vacation or family celebration.

Employee eligibility was determined using data available in the health system’s EPIC database. Once identified, individuals were made aware of the opportunity to participate via a series of communications and allowed to seamlessly self-enroll via their smartphones. No incentives were given to interested employees. All participants were guided through an initial onboarding period that explained the components of the initiative and the use of Noom’s mobile application, set expectations for coach and participant responsibilities, and gathered baseline participant metrics. The 2 health coaches employed by the health system were also trained by Noom on how to use the Noom platform, including the mobile application functionalities, curriculum delivery in a virtual environment, the use of a coach dashboard, and foundational behavior change techniques.

When the initiative launched, participants received virtual delivery of condition-specific curriculum via their mobile device, virtual human coaching, and a combination of four 1-on-1 in-person meetings, scheduled coach check-in phone calls, and access to daily 2-way messaging via the mobile application. Participants also used the mobile application to log their food and beverage intake, physical activity, blood glucose, and/or blood pressure (as appropriate for their condition); completed in-app motivation and mood surveys at scheduled intervals; and were provided with program satisfaction surveys at 4-week intervals.

Using the Noom mobile application, participants took advantage of a proprietary food database that includes more than 3.7 million unique food-portion pairings to log all their meals. This emphasized awareness and self-monitoring throughout the program. In addition, participants monitored and logged blood pressure and blood glucose, weight, and physical activity, and received ongoing support from a health coach and group of peers.

Eighty-two employees were enrolled in the program, with the majority being female (83%) between 50 and 64 years old (65%). Depending on eligibility, participants were placed in either diabetes management (20%), hypertension management (65%), or comorbid diabetes and hypertension management (15%) programs. A majority of baseline weights fell within the obese (20%) and morbidly obese (48%) classifications based on CDC guidelines and body mass index (BMI) categories. See the Figure and Table for a more detailed summary of baseline characteristics.

After just 14 weeks, participants demonstrated clinically significant outcomes and trajectories. All 82 participants remained engaged in the initiative. Of those who recorded a weight at baseline, 65% recorded weight loss, with an average loss of 3.4% of their body weight. Additionally, 21% of the cohort had already demonstrated transformative weight loss, that is, weight loss greater than 5%.³ Sixty-seven percent of participants with diabetes or comorbid diabetes/hypertension demonstrated controlled blood glucose levels and 22% achieved normal fasting blood glucose levels as defined by the American Diabetes Association.⁴

Individuals with hypertension or comorbid diabetes/hypertension also demonstrated early improvements, 45% of whom reduced their blood pressure below 140/90 mmHg. Coaches reported, anecdotally, that the number of prescribed medications by some patients’ primary care physicians went from 4 to 1 as a result of the lifestyle changes achieved.

Beyond improved health outcomes, the program scored positively among participants. Helpfulness of Coach Calls and Overall Satisfaction scored initial ratings of 4.3 and 4.2, respectively, on a 5-point Likert scale. Ninety-two percent of participants said they would recommend the program to a friend or family member. In addition, participants reported a high level of commitment to the program and increased confidence in making lifestyle changes across the board. They reported that the program was effective in addressing their specific personalized needs. Based on previously reported findings,⁵ program satisfaction often predicts adoption and adherence.

The program will conclude in the third quarter of 2017. While the initiative is ongoing, participant progress has been significant thus far. The implications of such an initiative are paramount to helping prevent and manage potentially chronic conditions at scale. Extending beyond the examination room, institutions such as large health systems, which serve communities of hundreds of thousands of people while employing tens of thousands more, can successfully improve health outcomes and drive lasting behavior change across large populations.

Traditional in-person lifestyle interventions struggle with participation and lack context and visibility into the actions or behaviors of their population in the daily environment. However, by partnering with an innovative company like Noom, one health system was provided with a unique opportunity to meet (and help) their patients in the most convenient place imaginable—right on their mobile phone. Author information: Andreas Michaelides, PhD, is chief psychology officer for Noom, Inc. Ed Pienkosz is the director of Business and Coach Development for Noom, Inc. References

1. Norris SL, Glasgow RE, Engelgau MM, O’Connor PJ, McCulloch D. Chronic disease management: a definition and systematic approach to component interventions. Dis Manag Health Out. 2003;11(8):477-488. doi: 10.2165/00115677-200311080-00001.

2. Lorig KR, Holman HR. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003;26(1):1-7. doi:10.1207/S15324796ABM2601_01.

3. CDC. National Diabetes Statistics Report, 2014: estimates of diabetes and its burden in the United States. CDC website. https://www.cdc.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf. Accessed January 31, 2017.

4. Diagnosing diabetes and learning about prediabetes. American Diabetes Association website. http://www.diabetes.org/diabetes-basics/diagnosis/ Updated November 21, 2016. Accessed January 30, 2017.

5. Michaelides A, Raby C, Wood M, Farr K, Toro-Ramos T. Weight loss efficacy of a novel mobile Diabetes Prevention Program platform with human coaching. BMJ Open Diab Res Care. 2016;4(1):e000264. doi: 10.1136/bmjdrc-2016-000264.

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