The February issue of Health Affairs features a series of articles on connected health and highlights the potential for telehealth and telemedicine to reshape how health care is delivered, consumed, tracked, and even paid for.
With funding support from Kaiser Permanente Community Benefit, the Center for Health Care Strategies (CHCS) recently conducted a series of focus groups that showed how one key Medicaid population — medically and socially complex, low-income individuals — stands to gain from these advances.
The four focus groups were designed to better understand the issues driving these individuals’ health care utilization, their current level of comfort with technology, and how technology might be able to help them better manage their challenges. Participants were actively receiving services from of one of four case management/care coordination programs in New York City, Long Island, the Hudson Valley, and Philadelphia, and all were Medicaid beneficiaries with multiple medical and/or behavioral health conditions.
According to a recent Health Affairs article by John Billings and Maria Raven, these individuals frequent emergency departments and have a high incidence of chronic disease. They typically have chaotic, unstable, and socially isolated lives, and many lack permanent housing and live on the street, or in homeless shelters.
They are also disproportionately diagnosed with mental health and substance use conditions (both of which frequently go untreated). As a result of these factors, these individuals are over-represented among the five percent of beneficiaries who generate more than 50 percent of total Medicaid costs.
Given the often expensive mobile technology necessary to support many electronic interactions, low-income individuals may not seem at first glance like an obvious target audience for connected health. However, a series of Pew Research Center studies showed that 43 percent of individuals making less than $30,000 per year in the U.S. own a smart phone and 54 percent own a feature phone.
The CHCS focus group findings mirrored these trends, with half of the participants stating they were comfortable using text messaging (17 out of 33), two-thirds using voicemail (22 out of 34), and over half using computers (18 out of 31). These trends suggest opportunities to expand connected health efforts to this group (outlined below).
Low-income individuals with complex social and health needs struggle with several unique challenges that connected health can address:
- Lack of consistent contact. The social instability of this group often means that they can be difficult to locate or get in touch with. Digital health tools that incorporate texting and call features can expand the ways in which care teams can communicate with patients, track their location, and monitor clinical outcomes.
- Fragmented care. Many of these high-need, high-cost individuals receive care at multiple sites from multiple providers. Tools that allow care team members and providers to share information can reduce fragmentation and enable more informed and coordinated action.
- Difficulty managing complex medication regimens. The medically complex nature of this patient population often translates into complicated pill schedules that can be particularly challenging for people with low health literacy living in under-resourced environments. Digital tools designed to improve and track medication adherence could make this easier.
- Reactively, rather than proactively, managing health needs. The high emergency room visit rate of this population is indicative, among other things, of the reactive way in which these individuals often manage their care. Remote tracking tools can let care teams know in real-time when a clinical issue is arising, allowing team members to intervene before it results in an avoidable emergency room visit or inpatient admission.
- Difficulty accessing transportation to and from appointments. Many individuals in this group often struggle to arrange and pay for transportation to and from medical appointments. Providing care through texting, email, and “telehealth” by itself can alleviate much of this logistical and financial burden, and may also reduce the number of appointment “no-shows” resulting from transportation issues.
What’s Being Done
Low-income individuals with complex medical and social needs require solutions that are specifically tailored to meet their unique circumstances. There are several new efforts underway to do exactly that. Recently, the Robert Wood Johnson Foundation announced a $500,000 partnership with StartUp Health to educate health care startups and entrepreneurs on the needs of low-income individuals and underserved communities.
Another example is the work of the Center for Care Innovations (CCI), a non-profit that works with health funders to support the adoption of innovation in the safety net system. In partnership with The Blue Shield of California Foundation, CCI recently launched a new initiative supporting text messaging to increase access and/or improve care delivery for underserved populations.
CCI is also working with the California HealthCare Foundation to support the piloting of new technologies for vulnerable populations through its Innovation Center for the Safety Net program. CHCS also intends to launch a digital initiative that will focus on this population later this spring. Undertakings will include hosting a series of design challenges centered around needs identified in the focus groups, and the piloting of promising technologies by delivery systems, care coordination programs, and payers that work with complex populations.
These initiatives coincide with a series of digital health products that also aim to address the needs of this population. Healthify and Purple Binder both address the interplay between medically complex patients and their social and environmental needs through dynamic screening tools and search engines that provide linkages to community resources. CareMessage has built its care management platform system around text messaging capabilities in order to reach individuals who may not own a smart phone.
A 2011 Stanford Social Innovation Review article posited that “…the (Medicaid) population represents a sizable opportunity for innovators who can figure out how to serve it profitably with high-value, lower-cost solutions.”
While concerns around privacy and data security must be effectively addressed in order to serve this vulnerable population through digital health tools, entrepreneurs, start-ups, health care delivery systems, payers, and providers should recognize the rise of connectivity among medically and socially complex, low-income individuals, and consider the ways in which this new connectedness can be leveraged to provide better, more efficient, and more affordable care.