Use of Telehealth Modalities to Effect Behavioral Changes Required for Improved Glycemic Control

1. Use of Telehealth Modalities to Effect Behavioral Changes Required for Improved Glycemic Control Presentation to American Diabetes Association 68th Scientific Sessions June 9th, 2008 Susan Lehrer, RN , BSN Director of House Calls Telehealth Program New York City Health & Hospitals Corporation

2. The New York City Health and Hospitals Corporation (HHC) • The largest municipal hospital and health care system in the country • $5.4 billion public benefit corporation that serves 1.3 million New Yorkers and nearly 400,000 who are uninsured. • Serves the city’s poorest patients who are most in need of care for chronic diseases such as diabetes. • 11 Acute Care Hospitals • 4 Skilled Nursing Facilities • 6 Large D&T Centers • A Certified Home Care Agency • A Managed Medicaid/Medicare Health Plan • Over 80 Community Based Health Centers

3. Cost of Diabetes in NYC • 12.5% of New Yorkers are diagnosed with Diabetes and of those, 59% are black and Hispanic. • Health care costs attributed to diabetes and its complications for NYC are large and growing. Annual cost of hospitalizations with a principal diagnosis of diabetes – which reflects only a small portion of diabetes-related costs – doubled from 1990 to 2003, reaching $481 million.1 • 1Kim M, Berger D, Matte T. Diabetes in New York City: Public Health Burden and Disparities. New York: New York City Department of Health and Mental Hygiene, 2006.

4. Priority Areas for National Action:Transforming Health Care Quality (2003)Quality Chasm report: • At no time in the history of medicine has the growth in knowledge and technologies been so profound • Research on the quality of care reveals a health care system that frequently falls short in its ability to translate knowledge into practice, and to apply new technology safely and effectively • If the health care system cannot consistently deliver today’s science and technology, we may conclude that it is even less prepared to respond to the extraordinary scientific advances that will surely emerge in the first half of the 21st century (Institute of Medicine, 2001a:2–3).

5. The HHC Response: The Chronic Disease Collaborative • In 2003 HHC launched the Chronic Disease Collaborative to redesign and improve the care and outcomes for patients affected by chronic disease. • Collaborative data study showed that majority of diabetic patients had not met HHC management goals-HgbA1c< 7.0% and that the gap in treatment outcomes throughout the system was unacceptable

6. A Streamlined Delivery System for Chronic Disease ManagementTelehealth • Improved Safety Allows effective, efficient coordination, case management & communication between multiple disciplines • Improved Outcomes Have demonstrated significant improvement in diabetic criteria linked to decreased complications 1 • Cost Reduction Is a fraction of traditional homecare with measurable and dramatically improved outcomes2 1 Dimmick, Susan L., et.al. 2004. Outcomes of a Diabetes Self Management Program Using Home Telehealth. Home Health Care Technology Report Vol. 1 No. 5. p.65 2 Bynum, AB. 2003. The Impact Of Remote telemonitoring On Patients' Cost Savings: Some Preliminary Findings. Telemed J E Health. 2003 Winter;9(4):361-7

7. The Team Patients

8. Baseline Realities of our Patients (and probably yours) • Lack a basic understanding of how to self manage (Avg A1c@9.34%) • Are Chronic diabetics (avg. 5-20 yrs) who have learned about their illness from a variety of sources • Hold on to their “understandings” and fears about their illness until someone can demonstrate otherwise • Have a poor-at best understanding of the link between carbohydrate intake and daily blood glucose levels. • Are MOST receptive to information given in non-threatening & familiar surroundings • Are non “traditional” learners ie: not classroom learners • Trust information obtained from people who they perceive “Care about them”

9. Enter the Telehealth “Connection” Push one Button!!

10. Tabular View

11. Medication List

12. Coordination of Care

13. Behavior Change Basics for Telehealth Communication Communication Communication • Method • Frequency • Content • Coordination with Care Providers

14. Behavior Change Basics for Telehealth #1 Communication Method = Motivational Interviewing • Partner with patients: Collaborate & Empower! • Listen Reflective listening” with open questions to develop rapport and trust • Empathize with their reluctance to change. • Help patients identify the Discrepancies between what they want and what they do • Elicit most of the talking & teaching from the patients

15. Behavior Change Basics for Telehealth #2 Communication Frequency (timing is everything!) • Weeklycalls Model consistent behavior and build Trust • Alert response within 2 hrs for BG>300 or <70 Facilitate Behavioral Conditioning “I knew it was you….I knew you’d call”

16. Behavior Change Basics for Telehealth #3 Communication Content Caution: Before proceeding in conversation be sure to Establish RAPPORT!

17. Behavior Change Basics for Telehealth REFERENCES #3 Communication Content (cont.) • Discuss what’s important to the patient THAT DAY • “Explore” it’s importance • Discuss & review readings: Brainstorm with them • Allow patients to describe their “success strategies” rather than their reasons for high BG results. (Discuss the positive) • Explore their thoughts • Help them link their behaviors, food choices, portions and meds to results • Ask permission to “Suggest” new foods • Laugh with them • Slip vital information into their “comfort talk” • Count carbs with them, discuss recipes with them

18. Behavior Change Basics for Telehealth Important Points to Remember • COMPLIMENT any improvement or “positive talk” • RECOGNIZE all evidence of self management • Use “Future Talk” “The next time we talk”…. and… “When your BG is lower….”

19. Recognition • Recognize their efforts….(no matter how incremental) • Recognize the challenges of management and our availability to partner with them to make it easier. • Recognize their “success strategies” rather than their reasons for high BG results. • Recognize their testing compliance with the weekly calls and during alert response • Recognize their success publicly with Quarterly Newsletters for all patients who demonstrated improvement and those who reached an average monthly BG WNL

20. House Calls: The Virtual “Reach Out and Touch Someone” • Each patient contact is an opportunity to: Educate Listen Validate We become “the little voice” that gently encourages and reminds them that they can do it. Recognizing their efforts and progress keeps them motivated.

21. Telehealth Findings • “Alert responses” enable patients to “make the connections” • Regular conversations allow patients to begin to “normalize” discussion of diabetes. • Increased comfort with discussing ideas, strategies leads to new behaviors • Patients are able to absorb & integrate small frequent doses of information • Patients demonstrate increased problem solving • Patients express EMPOWERMENT • 68% of patients demonstrate improved glycemic control

22. Telehealth Patient Outcomes • Patients begin to: • Look forward to the weekly calls. • Stop “Dreading” discussions about their BG and disease • Become more “honest” about their foods & lifestyle and start “hearing themselves” • Enjoy the personal relationship with the nurse and want to “please” us by demonstrating med compliance & glycemic control. • “Make the connection” between the food they ate last night and today with their current BG due to immediate feedback to alert responses. (behavioral conditioning) • Look forward to the learning and ask more questions. • Look forward to the recognition of their successes and often call us to ask “did you see my BG today?” • Transfer wanting to please us, to wanting to feel better and please themselves

23. Results of the Telehealth Relationship • Develop trust through consistency of the weekly calls and follow up. • Discussion about DM is normalized” as part of daily life. • Patients stop “worrying” about their food choices; they verbalize a reduction in their anxiety & “avoidance” of F/U appts • Patients begin to become more proactive in their medical care. • Patients verbalize feeling more in control of their own lives • Patients become more willing to try new foods and make different choices • FINALLY...... Monthly BG averages start to trend down and then fall WNL! • Patients verbalize excitement with their success and increased confidence. They are EMPOWERED to make good informed choices. Most people learn their most positive lessons from their successes, Not from their failures… What do we really “learn” from our mistakes??

24. One Patient’s Success in 2007 SOC: 11/16/06 with A1c 14.3% on 10/27/06 First 2 weeks: average blood glucose = 308 Average BG w/o 10/22/07 = 87 A1c on 9/27/07 = 6.8% (Baseline reduction of 7.5%)

25. Telehealth Efficacy

26. Reduction of Hyperglycemic Values Percentage of patients on program >30 days with either a decrease in monthly average of BG readings or a sustained normal range (101/151) Baseline Latest Trend

27. Barriers Identified • Slow buy-in and some resistance by clinicians (referrals) • Clinicians concerned with appearance of decreased productivity • Resistance to change in clinic work flow • Inability to ‘integrate” website data and EMR • Language & literacy • Complexity of chronic disease management • Lack of protocols for use of email in coordination of care • Not all clinicians utilize HHC GroupWise email system

28. Lessons Learned • Significant clinical/financial outcomes can be achieved with available technology partnered with stringent case management • Effective patient interactions & interventions can be conducted via phone • Technology enables the immediate feedback that combined with expert communication and coordinated case management = Dramatic clinical outcomes! • Chronic Diabetics can learn self management and achieve glycemic control with targeted interventions and support.

29. References REFERENCES Bynum, AB. 2003. The Impact Of Remote telemonitoring On Patients' Cost Savings: Some Preliminary Findings. Telemed J E Health. 2003 Winter;9(4):361-7 Dimmick, Susan L., et.al. 2004. Outcomes of a Diabetes Self Management Program Using Home Telehealth. Home Health Care Technology Report Vol. 1 No. 5. p.65 Johnston, B. et. al. 2000. Outcomes of the KaisMedicine er Permanente Tele-Home Health Research Project. Archives of Family Vol. 9 pp.40-45 Noel, Helen C. et. al. 2004. Home Telehealth Reduces Healthcare Costs. Remote telemonitoring Journal and e-Health. Jun 2004, Vol. 10, No. 2: 170-183 Shea, S., et.al. 2006. A randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus. Journal of the American Medical Informatics Association. 13:40-51., DOI 10.1197 Woodbridge, P. Home Telehealth’s Role in Diabetes Case Management. Presentation to the American Telemedicine Association, April 19, 2005.