How Can Telehealth Promote Care Coordination, Value-Based Outcomes in Cardiovascular Disease?

In the United States, cardiovascular disease (CVD) is the number 1 cause of mortality, with every 1 in 3 deaths attributed to the condition. In managing complex chronic conditions such as CVD, a myriad of factors need to be addressed to ensure that patients are provided with timely and effective care.

One primary concern is communication. Patrick Dunn, program director at the Center for Health Technology and Innovation (CHTI) at the American Heart Association (AHA), notes that too often patients can misrepresent how they are truly feeling, due to fears such as changes in medication, readmission to hospitals, and potentially cognitive dissonance when in the hospital.

“I would say 90% of the time, the first question we would ask the patient is, over the past several months, how's your health been? Over 90% of them will say: good, other than the fact that I had a heart attack 2 weeks ago, everything's been fine,” said Dunn.

So, how can physicians better align care with patient needs, especially when patients may not be vocal of their recent symptoms?

Through a partnership with GoMo Health, AHA will implement the company’s telehealth care coordination solution, known as Concierge Care. Bob Gold, chief executive officer (CEO) of GoMo Health, explained the functions of the platform, in what is today referred to as a digital therapeutic that centers around patient engagement, precision health, and population health.

“At the heart of what we do is we have an evidence-based behavioral science that integrates psychosocial support into a physical remote care plan to motivate and activate people on an individualized basis to be resilient to do the things that will make a difference,” explained Gold.

By incorporating Concierge Care into the hospitals, health plans, and pharmaceutical companies partnered with AHA’s CHTI Innovators Network, CVD care will take a more integrated treatment approach that will address not solely the 15 minutes of a patient/physician meeting, as Gold notes, but a more expansive effort on addressing overall health and lifestyle needs.

In an interview with The American Journal of Managed Care^®, Dunn and Gold both discuss why such a partnership is warranted, how data can be leveraged in the hospital setting and at home, and how behavior-based, patient-centric care can lead to measurable and sustainable population health.

Transcript

AJMC^®: Hello, I'm Matthew Gavidia. Today on MJH Life Sciences’ Medical World News, The American Journal of Managed Care^® is pleased to welcome Patrick Dunn, program director at the Center for Health Technology and Innovation, or CHTI, at AHA, and Bob Gold, CEO of GoMo Health.

Can you both just introduce yourself and tell us a little bit about your work?

Gold: Hi, I'm Bob gold. I'm the founder and chief behavioral technologist at GoMo Health, and my area of expertise is the science of human motivation, activation, resiliency, applied to recrafting clinical care plans.

Dunn: I'm Pat Dunn. I'm the program director for the Center for Health Technology and Innovation at the AHA. My background is in cardiac rehabilitation. I was a clinical exercise physiologist, basically a health educator for the majority of my career. So, I work with Bob and companies like GoMo Health.

Basically, I'm the connecting point between the tech world and the clinical and scientific world—helping the tech platforms to be more aligned with the evidence-based guidelines and the science and with the hope and the goal of improving health outcomes.

AJMC^®: Just to get us started off, Patrick, can you explain the significance of cardiovascular disease in the US? How do current strategies fare in providing a preventive mechanism for these risks?

Dunn: It’s obviously very important in the US and around the world. It is the leading cause of death and disability—it causes a lot of disruption in people's lives, from an economic perspective, but also just from a family and a health perspective. So, it's an enormous burden on us. A lot of effort, a lot of money goes into the diagnosis and treatment of cardiovascular disease.

You mentioned the treatment—the treatments kind of fall into several categories. There are surgical treatments like open heart surgeries, angioplasty, pacemakers. Those are amazing interventions that literally save lives. There's medication management–drugs that can lower your cholesterol, your blood pressure, improve the rhythm of your heart, and also save lives.

What's also important is really the area that Bob works in as well. It's how to motivate and engage people to do what they need to do. You know that last part, the lifestyle part, the self care behaviors and not only taking your medicine, but being physically active, eating right, avoiding dangerous things like smoking or vaping, reducing your stress, and just leading a more healthy and enjoyable life. Those things are critically important, and they're not solved usually with drugs or surgeries. They're solved with people taking more accountability and control of their lives.

If they do that, it can make a tremendous impact. So, while it's challenging, it may sometimes be easier to just take a pill or have a surgery. We really know that we get much more of a bang for our buck, so to speak, out of helping people just lead healthier lifestyles.

AJMC^®: Just to build off that, Bob, in partnering with the AHA’s CHTI Innovators network, your organization will be integrating their digital care plans and education content into your Concierge Care solutions. Can you discuss what is Concierge Care and how it will function through this partnership?

Gold: It’s been wonderful working with Pat’s CHTI and the AHA. They have amassed about 5000 pieces of evidence-based content that we have had access to, and we integrate that into our Concierge Care programs like the one we're talking about here for heart failure. So it's been extremely helpful for us and it also furthers the AHA's mission of getting the right content to the right people at the right time, which is what the GoMo portion of this is.

So, what we do at GoMo Health and our Concierge Care program, it centers around patient engagement, precision health, population health, and in today's term, it may be called the digital therapeutic, but at the heart of what we do is we have an evidence-based behavioral science that integrates psychosocial support into a physical remote care plan to motivate and activate people on an individualized basis to be resilient to do the things that will make a difference like that Pat mentioned—eat better, exercise better, quit smoking, show up at wellness appointments, less anxiety and stress means less panic, less ED [emergency department] visits, readmissions, those types of things.

Interestingly enough, I've been discussing with Pat and have been promoting with various payers, plans, providers, pharmaceutical companies, a deeper level of research and development and behavioral cardiology, because that's what Pat's getting at. You can have wonderful surgeries and technology and equipment, but if people aren't adherent in their lifestyle, it's going to repeat again and that's what you see. So, I think this is providing individuals with activities, resources, suggestions on an individualized basis based on their lifestyle, their preferences, and who they are, has shown to activate them more and produce better outcomes and reduce costs. That's what we've actually accomplished in this integrated Concierge Care program—integrating the AHA’s content with our personalized care delivery to folks.

We've reduced readmissions from 22% to 9% in this cohort. We significantly by half cut down on ED visits, we increased wellness appointments by over 10%, significantly increased patient satisfaction, and 1 fascinating point, in our system, we have a concept of a local and remote caregiver because, especially in cardiovascular caregivers can play an important role, but they always don't know what to do, when to do it, and what's the right thing to do.

The data definitely supports integrating caregiver information into the patient experience—it can dramatically change the outcomes and reduce caregiver fatigue because remember, caregivers get fatigue too and they get frustrated too. So, how do you help them help the patient? So that's our role, and it's the behavioral side of cardiology, right? That's our value in this mix here.

Dunn: Yeah, and just to add to that, what Bob's also talking about—a term we typically use is what's called health literacy. In this context, it's digital health literacy. So, a lot of people think of literacy as just reading level–is the brochure at a fifth grade reading level, but it really goes more than that. Especially in a digital context, did the person actually understand the information, did they understand the numbers associated with it, so they understand blood pressure and why it's important. They know what the number means, that it's high, it's normal, could be better, could be worse; but then, do they know what to do with that information? Okay, so it's really high, what do I do? Do I call my doctor? Do I go to the hospital? Do I ignore it? Do I take another dose of my meds?

Do they know what information to share with their caregiver and their doctor? Frankly, what information to report—"Yeah, I've also been having chest pain, and I've been getting dizzy a lot." Then finally, can they use that information to make good, well-informed decisions? That can be with their doctor like, yep, we're gonna go on this medication, but it can also be unilateral decisions like, yeah, I need to lose a few pounds, I need to be not smoking, those types of things.

So it's what Bob and his group do, frankly, as well as anybody that we've seen, is really incorporate that into their platform. It's not just about an information surge for the person with information that's not relevant, they do an excellent job of really getting to those points that really leads to better health outcomes.

Gold: To further that, what we experienced with cardiologists and cardiac surgeons is actually very similar in many respects to what we do in oncology is a lot of times the physician or nurse will say to the patient who ended up back in the hospital—if you only told me about that symptom, I could have done something about it.

What I explained to the clinicians is, here's why that doesn't happen a lot. These people have so many problems. They don't know where to start. Also, their real life is 99% of the time not when they're in front of you in an office or even in front of a televideo session. So, you have 15 minutes, and how much could you as the clinician ask questions, and how much are they going to tell you? They don't know which one of those things is actually more important than the other. So, maybe they told you more things, but they didn't tell you the one thing on why they ended up in the hospital. So that's number one, and it's too much burden to put on them. Oh, if you only told me—that's not the right answer.

What we do in our digital therapeutic is we're consistently asking questions based on the set of answers. We escalate to nursing or pharmacy or social work or dietetics or ambulatory, and we're pre-empting those issues.

Then the second reason why sometimes they don't say is there's certain stigmas, and people actually sometimes do a white lie because: I don't want to tell the doctor too much, then they're going to switch my med or do this or tell me I got to go back in the hospital, and I don't want that so I'm going to make up that I'm fine.

Part of telehealth these days is not just the application of a message or an app or some form of technology. It's 1 plus 1 is 3—we actually have a specific training program to help nurse navigators and clinicians train them on integrated digital care coordination. So, when you deliver these things, a key thing to get the person to feel that this care team, whether it's a plan or the provider, actually understands me is integrating the human and the digital care coordination in a seamless protocol, but that requires a delivery method and an operational method not just throwing a text message to remind someone to take a med.

So, part of our science on what we deliver in the digital therapeutic is a phased program, which listens, collects information, personalizes the activities that needs to be done by age, gender condition, comorbidity, those things—delivers them in snackable bytes of information or questions. Adjusts and starts to build self trust and self confidence and changes their outlook, that they could actually work through this.

If you can do that, you get 5 to 7 times, period, the level of activation. The issue is a lot of technology delivered, and a lot of the way the human care plans are delivered are great clinically, but the 3 things that you must do to get them to listen to the content is one, you have to get the person to feel that the information applies to me, and there's a science to do that. Second is the person has to believe I can do the tasks. Third is, which helps with the first 2, if you get the person to feel they're influencing the care plan—they're part of the care plan, they're more likely to do the care plan.

Dunn: It really allows that patient clinician interaction to just continue and do it in a much more natural way as opposed to well, how have you been feeling? I've been feeling pretty good.

In my experience in cardiac rehab, which is for people who've just had a heart attack or just had an open heart surgery—in over 30 years, I would say 90% of the time, the first question we would ask the patient is, over the past several months, how's your health been? Over 90% of them will say: good, other than the fact that I had a heart attack 2 weeks ago, everything's been fine!

So, you can call it a little bit of cognitive dissonance if you want, but it’s because they feel good at that specific moment. So, it's critical to be able to capture what's actually going on between those visits. Whether it's a biometric, like a blood pressure, a psychometric, like I'm feeling good—all of those things, because people just can't remember typically what they were feeling like 2 weeks or 2 months ago.

Gold: I think you have to view telehealth, and the fact that you could get dozens of data points and categorize them and use those as a sort of a digital barcode of somebody's life that can lend itself to more decision support when recommending procedures, medication, medications, therapies, or just common sense talking to an individual—that type of thing.

AJMC^®: To touch upon that telehealth aspect that you just brought up Bob, Patrick, can you explain how Concierge Care can be leveraged in the hospital?

Dunn: Well, in the hospital, the good part of being in hospitals is you know about the condition. So, you can target to, if it's somebody with heart failure or if they've had a heart attack, or if they have diabetes. The key then is to be able to extend that, again, into that transitional period when they're going home and they're recovering, and then just the long term—the at-home piece of it.

So, the hospitals the starting point, it's where the patients are. It's kind of the old adage, why do bank robbers rob banks, because that's where the money is. In the case of the hospital, that's where the patients are, so it's a good place to capture them. It’s not necessarily a great place to provide a lot of education. Their minds are focused on sometimes very primary things like, am I going to die? How am I gonna be able to go back to work—those types of things. Even basic things like, can I drive a car? Can I walk up a flight of stairs? Can I eat this piece of pie? They don't have that information and some people will seek it out. Some people will just kind of isolate themselves and not do anything because they're afraid.

Gold: I think where it can help hospitals, to your question, it's pre and post. So, to Pat's point, some of these things, these procedures are emergencies, and there's no prep, but some are scheduled. Now, if you talk to a cardiac surgeon or cardiologist or anyone in that field, it's like, oh, I would like Bob to, if possible, to be scheduled for 2 months later—I'd like him to lose 5 pounds. I would like him to do certain things. Maybe there's a prep week before, maybe I need to get off my blood thinner, whatever all these things are.

That, going into it and maybe even helping with my mental state a little bit going into it, preparing me for it, those things could have a significant difference if you speak to a surgeon. Someone’s psychosocial physical state going into a surgery could have a big difference. So where Concierge Care could be helpful is helping prep these people, as opposed to Pat's point of being used extensively within the 4 walls of the hospital.

Dunn: The other thing to that point is it can also help prepare for the setting outside of the hospital. So, what are some of the social factors, what does it look like at home, which, again, can help the clinician guide that patient if let's say they can't afford their medications or they're living in a food desert or they just have other other factors that are that are impacting their lives, then, you can get a handle on that much quicker than having to react to it later.

Gold: In addition to significantly reducing ED readmits, our medication adherence data is significantly above the industry norm. Now one of the reasons why from the EMR we get your refill schedule, and then we ask you, Matthew, are you planning to refill?

Now if you say yes, we say that's fantastic. If you say no, all of a sudden you get a question with a checklist, why? Then when they check it, we escalate to the right person at the practice, the nurse or pharmacist or whoever's there—they're getting specific information, then they can address it.

In this heart failure program in the last 9 months about we've had 562 escalations to nurse navigation, some revolving around physical issues that could lead to a readmission, swelling of the extremities, bloating, weight gain, lack of taking meds, and interestingly enough, 362 of those or about 350 were all unique individuals. So, some people had multiple escalations.

Dunn: Yeah, and Bob you make a really good point, with the role of the computer and the role of the technology. We're not talking about man versus machine here. We're really talking about human-enabled AI. It's using those repetitive things that somebody who's been trained as a cardiovascular surgeon doesn't need to be answering those types of questions all day long. Let the technology, let the computers compile the information, and then provide it, serve it up to the professionals that have been trained to deal with it in a summarized manner. So, it really can leverage the time and expertise of those highly trained individuals as opposed to them being caught all day in administrative tasks.

AJMC^®: Lastly, are there any concluding thoughts that either of you have that has not yet been addressed? You could go first Bob.

Gold: My summary is the education of both the clinical care team and the patient, engaging in a patient partnered plan that provides resources that they could accomplish and activities in their lived environment. Integrating on an individualized basis practical problems, emotional coping problems, social determinants, and physical challenges into 1 protocol. So, I think where health care is going, and I think CMS is seeing it and the payers have bundled payments, we need to better integrate the mind and the body, the psychosocial and the physical care into 1 coordinated care plan, and not separate. That would be my conclusion that bundling those together, because there's 1 human being, they're not separating their mind and body.

Dunn: Yeah, and I would just add to that. COVID-19 has really kind of put this to the forefront, but we're at a tipping point, both with the intersection of medical management and behavioral management. It's not 1 or the other, it's how they can complement each other. We're also at a tipping point of the use of technology versus the role of the professionals. Again, it's not 1 versus the other. It's how do we leverage and how do we make the best out of both of those.

So, what's exciting is the way the technology is going, and the way the methods, the platforms like GoMo Health, are able to really fit in very nicely into that intersection. Both of lifestyle and medicine, technology and human behavior. I mean, what a wonderful place to be.

AJMC^®: To learn more, visit our website at ajmc.com. I'm Matthew Gavidia. Thanks for joining us!