The Next Frontier of Integrated
Healthcare: Using Data and Txt4Health
Technology to Improve Clients' Physical
and Behavioral Health
Presenters:
Diana McIntosh, Ph.D, APRN, BC, Hamilton County Mental
Health and Recovery Services Board
Roni Christopher, M.Ed., OTR/L, LNHA
The Health Collaborative
Shana Trent, MSW, LSW, The HealthCare Connection
Session # G3b
October 5,
Collaborative Family Healthcare Association 14th Annual Conference
October 4-6, 2012 Austin, Texas U.S.A.
Faculty Disclosure
» We have not had any relevant financial
relationships during the past 12 months.
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Objectives
» Describe effective partnerships that
promote integrated medical and behavioral
health models
» Discuss Txt4Health as a viable technological
intervention to improve healthcare
» List quality improvement strategies and
consumer outcomes
» Identify consumer and provider responses
to Txt4Health
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Learning Assessment
» A learning assessment is required for CE
credit.
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Demonstration Project Partnership
for Integrated Care
» Partners include:
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Hamilton County Mental Health and Recovery Services Board
HealthCare Connection
CCHB
GCB
Talbert House/Centerpoint
Greater Cincinnati Beacon Community
Health Collaborative
HealthBridge
The Health Foundation of Greater Cincinnati
» Target population is adults with diabetes and a severe mental illness
» Partnership will use data and technology for improvement of
behavioral and physical health care
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The Partners
» The HealthCare Connection
» Federally Qualified Health Center (FQHC)
» National Committee for Quality Assurance , Patient Centered
Medical Home recognition
» Seven locations serving 18,000 patients annually
» Mission: Provide quality, culturally sensitive and accessible
primary care focusing on the medically underserved,
underinsured and uninsured in northern Hamilton County
Ohio and surrounding areas
» Oldest FQHC in Ohio. Founded in 1967
www.healthcare-connection.org
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The Partners
» Greater Cincinnati Behavioral Health Services
» A comprehensive mental health agency serving adults
with severe mental illness in the Cincinnati area.
» 300 care professionals serve over 4,000 adults annually
» Rehabilitation services at 10 locations
» Provides psychiatric, nursing, counseling, care
management, residential, vocational, day programs
and others
» SMI clients include the homeless, incarcerated, and
those with many dual disorders.
www.gcbhs.com
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The Partners
» Central Community Health Board of Hamilton County
»A Private, non-profit corporation founded in 1970.
»Provides comprehensive mental health and drug treatment,
alcoholism referral services and HIV prevention services to
Hamilton County residents.
»Mission: Provide the best possible mental illness, substance
abuse and HIV prevention and treatment services
» Services: Case management, psychotherapy, partial
intervention, emergency and long-term residential,
psychiatric , addictions and methadone treatment.
www.cchbinc.com
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The Partners
» Talbert house/Centerpoint Health
» Comprehensive Behavioral Health Care Provider in
Hamilton County (Cincinnati) with five locations
» Mission: Strengthen communities served by
providing the best quality mental health care to
children, adults and families
» Care provided includes outpatient treatment,
counseling, case management, support services,
crisis and prevention services
www.talberthouse.org
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The Partners
» The Health Foundation of Greater
Cincinnati
» Awards grants to non-profit and governmental
organizations for programs and activities that
improve health in Cincinnati and 20
surrounding counties in Kentucky, Indiana and
Ohio
» A leader in promoting integrated healthcare
www.healthfoundation.org
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The Partners
» The Health Collaborative and Greater
Cincinnati Beacon Community
» The Health Collaborative is a multi-stake holder
organization who was sub contracted on the
Beacon grant for Cincinnati
» It is the home of the largest Adult Diabetes
public report in the United States
» It’s role in Beacon: to use HIT (provided by
HealthBridge) married with QI to improve
diabetes outcomes
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Greater Cincinnati Beacon
Community
» One of 17 communities funded by the
Office of the National Coordinator
» One of 3 communities afforded the
opportunity to test Txt4Health technology
» Cincinnati medical systems have begun to
form and build their own integrated
networks including the purchasing of
primary care
» Cincinnati is largely an “EPIC” HIT town
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Adult Diabetes Goals for Cincinnati
Beacon
» Reduce the “D5” by 5% points for a
community of publicly reporting physicians
(450+)
» Reduce each “D5” component measure by 5%
for the same group of publicly reporting
physicians
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LDL>100
BP 140/90
A1c >8
Tobacco cessation self report
Aspirin regimen as appropriate
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Integrating Mental Health
» Beacon project did not define a mental
health intervention
» Cincinnati is a collaborative and innovative
city…
» We found an opportunity to work together
with Mental Health
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Need/Practice Gap & Supporting
Resources
» People in Ohio with Severe Mental Illness (SMI) die
32.2 years earlier than the rest of the population
(Miller, Paschall, Svendsen, 2006)
» Studies show that 60% of patients with SMI die of
preventable health conditions
» Access to primary care is limited/a problem for SMI
clients
» By report a large percentage of SMI clients have
poorly controlled chronic health problems, e.g.,
Diabetes, Hypertension
» Care for SMI clients is fragmented–not coordinated.
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Our Partnership Co-Location Model
Independent, Parallel
Clinical Processes
Behavioral Health Clinic Site
MH
intake
Psychiatrist
Case Manager
Client
Referral
Partnership’s
Client Flow
Supervising PC Physician
MD & APN
PC intake
Support Staff: LPN & MA
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New Partner: Hamilton County
Mental Health and Recovery Services
Board
» Authority under Ohio Revised Code 340 to
lead public behavioral health in Hamilton
County through:
» Planning
» Funding
» Managing
» Evaluating
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Goals for Integrated Project
1.
Improve mutually agreed upon client outcomes.
2.
Increase integration between physical and behavioral health
focusing on adults with diabetes and a severe mental illness
3.
Facilitate NCQA certification for the community mental health
centers.
4.
Foster collaboration among Beacon, behavioral health system
and FQHC
5.
Examine the use of technology, such as Txt4Health, in
improving patient care.
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The Model
» Loose adaptation of the Breakthrough Series
framework from IHI
» Rapid Cycle Change and Improvement Science
methods (Plan Do Study Act)
» Enhance Health Information Technology capabilities
» What we wanted to know:
» Could the mental health providers utilize social media with
their patients?
» Could we impact the ability for mental and physical health
providers to work as an interdisciplinary team?
» Would these patients improve outcomes?
» How would these patients respond to this technology?
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The Mental-Physical Health
Measures
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Blood pressure less than 140/90;
LDL levels less than 100mg;
Hemoglobin A1C below 8%;
Decrease in symptom distress;
Increase in quality of life.
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Use of Texting To Improve Outcomes
» Use of mobile phone text messaging can be
effective in improving health behaviors and
health outcomes
(Cole-Lewis and Kershaw, 2010; Fjeldsoe, et al., 2009; Krishna, et al.,
2009; Wei, et al., 2011; Whittaker et al., 2009;)
» Among a sample of low income households
on Medicaid, 80% of patients report texting
regularly
(pricewaterhousecoopers, 2011)
Cole-Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev. 2010;32:56–69. doi:
10.1093/epirev/mxq004
Fjeldsoe BS, Marshall AL, Miller YD. Behavior change interventions delivered by mobile telephone short-message service. Am J Prev Med.
2009;36:165–73. doi: 10.1016/j.amepre.2008.09.040.
Krishna S, Boren SA, Balas EA. Healthcare via cell phones: a systematic review. Telemed J E Health 2009. 15231–40.40. doi: 10.1093/epirev/mxq004.
Wei J, Hollin I, Kachnowski S. A review of the use of mobile phone text messaging in clinical and healthy behaviour interventions. J Telemed Telecare.
2011;17:41–8. doi: 10.1258/jtt.2010.100322.
Whittaker R, Borland R, Bullen C, Lin RB, McRobbie H, Rodgers A. Mobile phone-based interventions for smoking cessation. Cochrane Database Syst
Rev 2009(4):CD006611.
Pricewaterhousecoopers Health Research Institute, Healthcare Unwired, 2010.
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Technology – Txt 4 Health
» A mobile health information service designed to help
people:
» Understand their risk for type 2 diabetes
» Become more informed about the steps they can take to
lead healthy lives
» In a 14-week text-based program engage with and manage
their own health.
» a private public partnership with American Diabetes
Association, Center for Disease Control, Office of
National Coordination for Health Information, Voxiva,
and Beacon
» The Health Foundation of Greater Cincinnati agreed to
fund cell phones for 4 months for 100 clients as part of
the Txt4Health demonstration project.
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The Mental-Physical Health Chronic
Disease/Diabetes Results (5-6 Month Intervention)
Pre vs Post Averages
140.00
128.90 130.19
120.00
98.90 98.23
100.00
80.30 80.76
80.00
Pre-Data Averages
60.00
Post-Data Averages
40.00
20.00
7.91
8.09
0.00
A1C Average
A1C
Systolic
Diastolic BP
BP
BPAverage Systolic
Average
LDL Average
Diastolic BP
LDL
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Ohio Consumer Outcomes
Clients Exhibiting Improvement (N=60)
Time 1 to Time 2
100.00%
90.00%
80.00%
68.4%
70.00%
60.00%
52.7%
50.00%
40.00%
46.3%
30.00%
20.00%
10.00%
0.00%
Symptom Distress Scale
(SDS)
Quality of Life Scale (QOL)
Change in One or Both
(SDS or QOL)
Information regarding the Ohio Consumer Outcomes system can be found at: http://www.mh.state.oh.us/what-we-do/protect-andmonitor/consumer-outcomes/index.shtml
Ohio Consumer Outcomes
Change in Client Health,
Medication and Physical Health (N=60)
Information regarding the Ohio Consumer Outcomes system can be found at: http://www.mh.state.oh.us/what-we-do/protect-andmonitor/consumer-outcomes/index.shtml
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Pre(N=100) and Post (N=47) Survey
of Clients Using Txt4Health
100
88
90
80
68
70
60
53
55
50
50
Pre-Data
Post-Data
40
31
30
20
10
0
Comfortable Using Texting
Helpful to get Health Messages
Wanted Health Messages more than
Weekly
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Client Anecdotal Data:
Txt4Health messages were helpful
» Remind me to do things
» Remind me to eat right and take my
medicine
» Good reminder to check blood sugars and
take insulin
» Encouragement and support
» Informational
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Client Anecdotal Data:
Txt4Health messages not helpful
» Could not read the text
» Lost phone in one month
» Low service at house, one bar and had
trouble with getting messages
» Rather have someone to talk to me
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Client Anecdotal Data:
Report Changing Behaviors to
improve their health
» Better diet and more exercise
» Make appts and taking meds as prescribed
» Started going to gym and eating healthy
» Walk more and started yoga
» Drink less soda and eat less fast food
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Post Case Manager Surveys (N = 32)
» 91% reported no problems in assisting
clients to register for Txt4Health
» Only 1% used text for appointments
» Only 34% thought text messaging was an
important tool to use with clients
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Mental Health Case Manager
Anecdotal Data: Changing Their
Interventions
» Report doing the following differently:
» more communication with home health nurse,
healthcare provider or PCP
» discussing health issues more in-depth
» asking about blood sugar levels
» encouraging healthy food choices and exercise
» Reminding client about physical health appt.
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What We See in the Data
» No significant improvement in the short
timeframe, but showing promise
» Patients tolerated the phone and idea of
text messages
» Patients wanted to receive health messages
more often
» Providers were not as comfortable using
text messaging
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Conclusions
» No significant change in outcomes at this time in the
project
» Conclusion:
» While the intervention did not show a change in numbers as
expected, it did not show a significant decrease either.
» There are anecdotal stories to support that this intervention
may have be worth continued pursuit.
» The introduction of technology for mental health patients
and providers should be explored further to determine what
factors might contribute to improved outcomes.
» The Mental-Physical health collaboration is essential for
improved patient outcomes and improved professional
development.
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Acknowledgements
» Consumers who participated in the project
» Staff from all partner agencies who
participated and provided data
» Dr. Erik Stewart, Hamilton County Mental
Health and Recovery Services Board
» Janice Bogner, The Health Foundation of
Greater Cincinnati
» Hamilton County Public Health Department
» Sprint
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Acknowledgements Cont.
Beacon Community
»
The Beacon Community Program is funded by the Office of the National
Coordinator (ONC) for Health Information Technology, part of the U.S.
Department of Health and Human Services. Greater Cincinnati is one of the
17 ONC-funded Beacon Communities that are building and strengthening
local health IT infrastructure and testing innovative approaches to make
measurable improvements in quality, cost and population health. Greater
Cincinnati Beacon Collaboration partners supporting this program include
HealthBridge, Cincinnati Children's Hospital Medical Center, the Greater
Cincinnati Health Council, the Health Collaborative, GE, Hamilton County
Public Health, the University of Cincinnati and dozens of area hospitals and
physician practices.
»
Support is provided under cooperative agreement #90BC0016/01 from the Office of the
National Coordinator for Health Information Technology of the U.S. Department of
Health and Human Services.
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Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!
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