Texting for Health in the Safety Net: improving health promotion & outreach

Transcription

1 Texting for Health in the Safety Net: improving health promotion & outreach Susan L. Moore, PhD, MSPH December 9 th, Denver Health

2 Acknowledgements Thanks and credit where due: The 21 st Century Care team, especially Henry Fischer, MD; Arthur J. Davidson, MD; Julia Dorado- Cole; Forrest Pugh; Loyce Laurent; Curt Straub; Jeffrey D. Berschling, MPH; Rachel Everhart, PhD; Susan Becker; Gavin Roslund; George Nicholson; Kathy Thompson; and Tracy Johnson, PhD. No conflicts of interest to declare. This presentation was made possible by Grant Number 1C1CMS from the Department of Health and Human Services, Centers for Medicare and Medicaid Services. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. 2

3 Study Setting Denver Health and Hospital Authority (DH) Integrated health care system; safety net for Denver Serves 1 in 4 Denver residents; 186,823 patients in 2013, one-third of whom were children Over two-thirds of patients are among racial/ethnic minorities Financially disadvantaged: over 92% were below 200% of the poverty level and fully 81% were at or below the poverty level 3

4 Why Text Messaging? Reminder/recall improves adherence to clinical encounters. 1 91% of people in the US use cell phones, and 81% of cell phone users send and receive text messages. 2 Higher rates of cell phone access are reported among Blacks and Latinos as compared to whites. 2,3 Medicaid patients are more likely (79%) to send and receive text messages than the commercially insured (65-68%). 4 4

5 Text Messaging at Denver Health Results from a March 2013 survey of DH patients indicate that 93% use cell phones (51% of whom use smart phones, 47% regular). 5 DH cell phone users were significantly more likely to send and receive text messages (84.4%) than to send and receive (72.7%; p<0.001). 5 Pilot study results indicate interest among DH patients in receiving appointment reminders by text message. 3 5

6 Text Messaging at Denver Health Health IT infrastructure (Patient Relationship Manager) Created 2010; expanded through AHRQ s Multiple Chronic Conditions Research Network 3,6 Bidirectional, automated text messaging Included appointment reminders and diabetes management support via collecting blood sugars, blood pressures, and step counts Integrated with clinical data sources and electronic medical record CMS/CMMI Health Care Innovation Award funding allowed expansion for large-scale text message-based population health support between visits Program evaluation using the RE-AIM framework 8 Reach, Effectiveness, Adoption, Implementation, Maintenance 6

7 Program Planning: Personnel Key Stakeholders Multidisciplinary health IT interventions team Clinical, administrative, research/evaluation, information technology (ehealth services), legal, public relations and marketing Maintained active, ongoing communication Targeted initiatives in line with larger DH goals 5 selected: appointment reminders, diet support, flu vaccine, well child checks, tobacco cessation 7

8 Program Planning: Enrollment & Content HIPAA / Telephone Consumer Protection Act Business relationship; visit w/in 6 mo. or clear, affirmative response (TCPA, pre- & post 10/16/13) Health promotion and service; no PHI (HIPAA) Initial opt-in approach: 2 text message invites Sent to patients empaneled in primary care at DH No clear, affirmative response = no enrollment Ongoing consent process Document patients contact info and preferences 8

9 Overall Activity, 3/25/13 10/31/14 In the first 2 years of operation: Well over half a million messages were sent and received (692,929 messages total). 548,983 messages sent to patients 143,946 messages received from patients Message types included: program invitations acknowledgements returned to messages received program content messages Patient satisfaction with text messaging was high. Tailored CAHPS survey question via NCQA-certified vendor 9

10 Overall Activity, 3/25/13 10/31/14 10

11 Our patients like text messaging. 11

12 Appointment Reminders: Outreach Goal: improve adult visit attendance outcomes One reminder per visit: 2 days prior, based on time in DH electronic scheduling system Your appt is on Fri, Apr 8 at 12:30 PM at Westside Clinic. Will you go? Reply Yes or No. Acknowledgements sent for every patient reply When patients respond with a clear No, we reply that we have cancelled their appointment and they can re-schedule by calling the appointment center 12

13 Appointment Reminders: 18-month Results 14,993 patients were reminded of 77,783 visits. Enrollment differences were observed by age, gender, and race/ethnicity. More likely to enroll: years old Women Black or Latino Spanish-speaking 13

14 # of text msgs 2014 Denver Health Appointment Reminders: 18-month Results 62% response rate overall English: 60.3% response rate; Spanish: 67.9% response rate (17.1%) (82.9%) (18.8%) (81.2%) 14

15 Appointment Reminders: Effectiveness Visit outcomes (kept/attended, cancelled, no-show) were examined at the visit level for all adult visits at PCMH primary care and specialty care clinics. Intervention: all visits for which a reminder was sent, for patients who enrolled in the reminder program Comparison: visits for which no reminder was sent, for reminder-eligible patients who did not enroll. Patient-level cohort comparison was conducted to assess overall performance for 6-month baseline (4/12-9/12) and intervention (4/13-9/13) periods. 15

16 Appointment Reminders: Effectiveness Kept rates were higher and cancellation and no-show rates were lower for visits with reminders than among visits without reminders. Kept Cancelled No Show p<0.001 N (%) (%) (%) Visits With Reminders 77, Visits Without Reminders 573, Patient-level baseline performance was poorer overall (p=0.002) among intervention cohort (85.4% kept/cancelled; 14.6% no show) than comparison cohort (86.4% kept/cancelled; 13.6% no show). 16

17 Challenges: Operational DH scheduling system customizations Appointment reminders sent for all visits in the scheduling system; discovered that some departments override default scheduling options Exclusions created, but potential for patient confusion about receiving some reminders but not all Need for coordination across reminder types Adjustments to cancel/reschedule processes Appointment center & registration coordination 17

18 Challenges: Privacy & Security HIPAA & TCPA HIPAA: No end-to-end electronic PHI exchange Secure messaging solutions for non-smartphones are limited; all have a cost factor and raise complexity barriers TCPA: Documentation of clear, affirmative consent Data quality issues Primary phone on file does not specify type No return receipt from cell phone service providers; unable to confirm all invites received Patient preferences and contact management 18

19 Conclusions Text messaging in the safety net is feasible at an operational level. Text messaging between visits in the safety net can improve targeted outcomes. Patient satisfaction is positively affected by text messaging. 19

20 Questions? office: mobile/text: Denver Health

21 Literature Cited 1. Jacobson Vann JC, Szilagyi P. Patient reminder and patient recall systems to improve immunization rates. Cochrane Database Syst Rev Jul 20;(3):CD Duggan M. Cell Phone Activities Pew Internet & American Life Project; [cited 2014 May 9]; Available from: 3. Fischer HH, Moore SL, Ginosar D, Davidson AJ, Rice-Peterson C, Durfee MJ, MacKenzie TD, Estacio RO, Steele AW. Care by cell phone: text messaging for chronic disease management. Am J Manag Care. 2012;18(2):e42-e U.S. Department of Health and Human Services. Health Resources and Services Administration. Using health text messages to improve consumer knowledge, behaviors, and outcomes: an environmental scan. Rockville, MD: U.S. Department of Health and Human Services, Moore SL. Consumer Health Informatics and the Medically Underserved: The Role of Information Technology in Health Information Access and Health Communication in the United States Denver, CO: Health and Behavioral Sciences, University of Colorado Denver; Moore SL, Fischer HH, Steele AW, Durfee MJ, Ginosar D, Rice-Peterson CC, Berschling JD, Davidson AJ. A mobile health infrastructure to support patients with chronic disease. Healthcare: The Journal of Delivery Science and Innovation Department of Health and Human Services. Part 1 Overview Information Dissemination and Implementation Research in Health (R01) Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE- AIM framework. Am J Public Health 1999; 89(9):