1. Keeping it Simple: Using IVR to Enhance Wellness Janelle Howe Sr. Director, Health Enhancement HealthCare Partners Medical Group Co-Investigator, HealthCare Partners Institute for Applied Research and Education

2. Disease Burden Disease Registry Data: COPD PatientsCHF Patients 2009: 16,6422009: 11,375 2012: 25,695 2012: 18,010 2014: 25,9312014: 20,271 Economic burden of is significant: Greater than $2,000 nationally per patient, per month Inpatient hospitalization accounts for ~50% of all costs COPD – 3 rd leading cause of death Consistently in the top 5 conditions ranked for inpatient admissions, readmissions, and ED visits. COPD: 30 day readmission rate-15% CHF: 30 day readmission rate – 15-17%

3. COPD and CHF Program Aims & Objectives To implement a disease management program at HCP focused on COPD and CHF patients Improve patient outcomes & QOL Decrease hospitalization: goal 20% reduction Decrease ED visits: goal 20% reduction Reduce cost of care: goal 10% reduction in the pmpm of study population Ultimately: Optimizing healthcare for the individual Improving outcomes for the population Reducing unnecessary cost and waste

4. Best Practices Initial face-to-face visit for assessment and education; “zones of symptoms”. Expedited access to clinical staff; including 24-hour triage Immediate intervention, including emergency prescriptions and intervention based on “zones of symptoms.” “Pathways” tracking process of patient self-management Interactive voice response technology (IVR) to monitor patient’s symptoms and symptom changes. IVR does NOT replace clinical staff visits/interaction.

5. 5 Action Plans

6. Expanding Clinical Capacity IVR Technology Expands the clinical capacity of our nurses. Supports the administration of emergency prescriptions; patients recognize worsening symptoms and are taking action. Clinicians’ Reports Reports are easy to read/actionable; Nurses: “We know which symptoms the patient is experiencing.” Frees-up time and allows clinicians to focus on patients who are more at-risk. 6

7. Optimizing Telehealth Operations Detecting Symptom Exacerbations Sooner  Not intrusive: brief calls that engage patients.  Avoided timely and complicated set up: patient uses their own phone.  Majority were Senior patients; majority use land-line phones, however, increasing cell phone use.  Convenient: calls occur either at noon with a back-up call early evening.  Provides critical and actionable information for clinicians.  Survey captures yellow zone or red zone symptoms; reinforces recognition on a regular basis.

8. Patient Monitoring Process 8 Telehealth survey call to patient’s home phone on Mondays and Thursdays. First call at noon, if that call is missed, second call at 7:00 pm Patients respond to the survey by pressing 1, 2 or 3 on their telephone keypad based on current symptoms. Vendor collects data after patients complete survey Returned to HCP which releases trending reports of the survey results are e- mailed to the care team.

9. IVR ROI Analysis; Initially COPD Analysis Pilot: 90 Enrolled Patients in IVR Disease Management program only Disease Management program + IVR Hospital admissions4822 Hospital admission rate per thousand6931 Hospital Costs ($USD)$8,529$3,909 Outpatient Clinic Visits446581 Outpatient Clinic Costs$765$996 Return on Investment $4,388 (9:1)

10. Email Alerts Emails trigger at 7AM following day Tuesday and Friday IVR Data Received

11. Triggering Reports 10 Patients in COPD triggered out of 280 patients; 4%

12. Patient Handout Explaining IVR Process

13. “Right Care at the Right Time.” Does not substitute a nurse call or face-to-face meetings with patients and educational training; it supplements these Program activities Patients/family need to know how to monitor and treat symptom exacerbation. Telemonitoring is implemented once the patient is confident that they understand their Action Plan. Reinforces the need for patients to self-manage their own condition with appropriate support Strategy also supports HCP goals for cost-effectiveness; expanding clinical capacity of the staff Patient comments: “Calls were easy” “Did not take too much time” “Helped me become more involved in my healthcare”

14. COPD Program Outcomes Page 14 MetricPrior to Program 2013-142014 IVR COPD Patients 2045 1750 622 Member Months 18,950 18,763 4,421 Acute % Admit 67.3% 41.3% 27.8% Acute APT 1,237 970 904 Acute ALOS 3.4 4.0 3.9 SubAcute % Admit 31.3% 23.0% 13.2% SubAcute ALOS 9.1 10.5 10.4 Acute DPT 4,183 3,849 3,526 SubAcute DPT 4,151 4,505 3,605 Total DPT (Acute,SubAcute, OPS) 5,358 5,094 4,552 UC/1000 306 605 475

15. Take-Aways Additive: Supplements nurse calls and face-to-face meetings with patients. Simple: “Calls were easy, did not take too much time, helped me become more involved in my healthcare.” Activation: Patients are less hesitant to contact their care team for assistance. Enhanced Wellness: Encourages patients to monitor their own symptoms; appears more effective than brochures/handouts addressing symptoms. Adaptive: IVR can be used for diabetes, oncologic protocols, hospital to home transitions, ad infinitum. 15