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Special Consideration Needed for Older Patients Using Telecare

Special Consideration Needed for Older Patients Using Telecare

When most people think about healthcare, the images that come to mind include a trip to their local provider’s office, lab, or hospital for services such as physicals, blood tests, and procedures. However, medical professionals and their patients are increasingly transitioning to more remote services that leverage our advances in communication technologies, resulting in the burgeoning “tele” world of healthcare. But are these services reaching everyone?

Telemedicine, telehealth, and telecare are three examples of remote, interactive services that allow patients to receive healthcare from within their own homes. Although these terms are often used interchangeably, they in fact refer to different aspects of healthcare delivery. Telemedicine applies to physicians who use technology to support the delivery of medical, diagnostic, or treatment-related services. Telehealth is like telemedicine but applies to a broader collection of providers, such as nurses or pharmacists. Telecare (see Figure 1) is generally more consumer-oriented by providing the patient with technology to manage their own care safely from home, such as health apps or digital monitoring devices.

Figure 1. Telecare Slide from MVC Workgroup Presentation

The adoption of “tele” services saw incredible growth in 2020 in response to the pandemic. A report found that Medicare telehealth visits increased 63-fold recently, from 840,000 in 2019 to 52.7 million visits in 2020. However, now that adoption of these services (and the platforms needed to host them) are more commonplace, providers are asking whether it benefits their most vulnerable patients and who may be left behind.

These questions drove the discussion of the most recent MVC workgroup on chronic disease management. Over the course of the session, attendees were particularly interested in how telecare improves elderly care, and whether patients over the age of 65 could adequately access such services. For those older adults utilizing telecare, evidence from the ongoing COVID-19 pandemic identified convenience and affordability as telecare’s primary strengths. In addition, research evidence suggests that the two most effective telecare interventions in this population are automated vital sign monitoring and telephone follow-up by nurses.

Some of the challenges often cited for this population include lack of appropriate internet access or devices, limited digital literacy, medical conditions that may impede participation (i.e., hearing or vision impairments, dementia, etc.), and the need to regularly monitor vitals in very high-risk patients. Although the authors compiling these challenges specifically reference older adults, they could just as easily apply to people experiencing poverty, people with disabilities, and people with more limited language and literacy skills.

Some recommended strategies to address common challenges include tablet delivery services, “mobile medical assistants” who perform video set-up for the patient, assistance from an on-site caregiver, practice or “mock” video visits prior to the appointment date, partnerships with community health workers to support or train patients in their homes, and providing self-monitoring devices. Other simple considerations include the size of the text displayed on the page (use larger text to enhance readability), providing adequate instructions in advance and in multiple languages, and engaging experts in user experience design.

In addition to these considerations, some researchers suggest that, in general, the adoption of new technologies can be predicted in part by Everett Rogers’ Diffusion of Innovation Theory. One study incorporating this theory found that the chances of telecare adoption were highest for three types of older adults: those already receiving long-term or nursing care, those living alone, and those who have fixed daily telecare points of contact.

Increased integration of technology in healthcare is inevitable as advancements continue and we shift to a more digital world. Since the number of people in the U.S. who are age 65 or older will more than double over the next 40 years, it is imperative that older adults are not left behind when transitioning to such services. Rather than fear the challenges, researchers and practitioners are seeking ways to find solutions and help all patients benefit from healthcare access within their own homes.

The MVC Coordinating Center encourages its members to collaborative with one another to benefit from peers’ success stories and lessons learned. If your hospital or physician organization has developed an age-friendly telecare protocol, please consider sharing your story with the MVC Coordinating Center at michiganvaluecollaborative@gmail.com. To catch up on the recent MVC workgroup discussion about telecare, watch the chronic disease management workgroup recording here.

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October 2021 MVC Semi-Annual: Virtual Meeting Recap

October 2021 MVC Semi-Annual: Virtual Meeting Recap

The Michigan Value Collaborative (MVC) held its second virtual semi-annual meeting of 2021 on Friday, October 22nd. A total of 221 leaders from a variety of healthcare disciplines attended Friday’s virtual meeting, representing 70 different hospitals and 23 physician organizations (POs) from across the state of Michigan. These participants came together to hear about the planned adjustments to the MVC Component of the Blue Cross Blue Shield of Michigan (BCBSM) Pay-for-Performance (P4P) Program for Program Year 2021 in light of COVID-19 and to discuss “the social risk and health equity dilemma” - a growing priority within the healthcare system generally, as well as within the MVC Coordinating Center.

MVC’s Director, Dr. Hari Nathan, started Friday’s meeting with an update from the MVC Coordinating Center, welcoming new collaborative members Munson Healthcare Manistee and Paul Oliver Memorial Hospital, and MVC’s newest Coordinating Center team members: Jana Stewart, Kristen Palframan, and Carla Novak. Dr. Nathan also highlighted some of the recent successes achieved by the Coordinating Center, including the launch of MVC’s new health equity report, increased custom analytic reporting, and the completion of over 50 virtual site visits with members this year.

Dr. Mike Thompson, MVC’s Co-Director, then shared information on the MVC Component of the BCBSM P4P Program with attendees. In investigating the impact of COVID-19 throughout the state in 2020, the MVC Coordinating Center found that 223 of the 25,627 (0.9%) episodes included in the P4P conditions from the first half of 2020 had a code for confirmed COVID-19 infection in the index event or other inpatient settings. The MVC Component of the BCBSM P4P program rewards hospitals for either making improvements over their baseline episode payment or for being less expensive than peer hospitals. The MVC team found that episodes of COVID-19 patients are generally more expensive than typical episodes. In addition, COVID-19 was not present in the baseline year of 2018 that hospitals stand to be evaluated against. Therefore, with approval from BCBSM, Dr. Thompson announced that, for Program Year 2021 only, the Coordinating Center will be removing any 2020 episode with a COVID-19 diagnosis on an inpatient facility claim during the 30-day episode if the COVID-19 ICD code is one of the first three diagnosis codes on the claim (see Figure 1). Looking ahead, a summary of participant selections for Program Years 2023 and 2024 were also shared, showing joint replacement as the most common condition selection, closely followed by congestive heart failure (CHF).

Figure 1. MVC Slide on Updates to MVC Component of BCBSM P4P Program for PY21

At MVC’s last semi-annual meeting in May, the Coordinating Center announced that Michigan Medicaid data had been added to MVC data sources and that the MVC Coordinating Center would be spending the subsequent months validating the data and getting it ready for member use. This work has now concluded and MVC’s Manager of Data Analytics shared what this new data source looks like. Michigan Medicaid now represents MVC’s third-largest data source, accounting for over 319,000 episodes since 2015, covering 256,889 beneficiaries, and making up 19.4% of all MVC episodes.  With this new addition, MVC data sources now comprise over 80% of Michigan’s insured population, all of which are available for members to utilize on the MVC registry.

To set the scene for our guest speakers, MVC Analyst Bonnie Cheng provided an overview of MVC’s recent health equity report (see Figure 2), highlighting racial, ethnic, and dual-eligibility variation across Michigan. The MVC Coordinating Center will look to build on this new report and undertake new activities in this area to support member activity moving forward. This will be supported by the Michigan Social Health Interventions to Eliminate Disparities (MSHIELD) collaborative – a new group recently launched as part of the Collaborative Quality Initiative (CQI) portfolio. With this in mind, MVC was joined by MSHIELD Program Manager Carol Gray to introduce this new collaborative and describe how MSHIELD will seek to interface with the health system and local communities to drive change (see Figure 3).

Figure 2. MVC Slide on New MVC Health Equity Report

Figure 3. MSHIELD Slide on MSHIELD's Role as a CQI

After hearing from MSHIELD, MVC welcomed guest speaker Dr. Nicole J. Franklin from McLaren Flint hospital. Dr. Franklin provided insight as to how McLaren Flint has devoted time and effort to bridge the gap between health and social care. This placed particular emphasis on the use of six representative sub-committees (employee resource, patient outcomes, community outreach, employee education, talent acquisition, and cultural calendar) to achieve McLaren Flint’s commitment to creating an inclusive and equitable environment where everyone is valued and empowered for success. Representing the Integrated Health Association (IHA), Leah Corneail shared how IHA has worked to actively screen and address patient social influencers of health (SIOH). This emphasized the importance of collecting actionable data through IHA’s SIOH questionnaire and the use of these data through an interactive population health dashboard (see Figure 4). The last guest speaker of the day was Melissa Gary, Community Liaison for Great Lakes Physicians Organization (GLPO). As well as providing an overview of GLPO, Melissa detailed how the organization has used a social determinants of health questionnaire and monthly tracking log to address the needs of over 2000 patients in 2020 alone.

Figure 4. IHA Slide on Social Influencers of Health Dashboard

To conclude Friday’s meeting, MVC Communications Specialist Jana Stewart provided a synopsis of the day and highlighted key upcoming activities. The slides from Friday’s meeting are available here and a recording of the meeting is available here. If you have questions about anything that was discussed at the semi-annual or are interested in finding out more about MVC’s offerings, please reach out to the MVC Coordinating Center (michiganvaluecollaborative@gmail.com). In the meantime, we look forward to seeing you all in person again soon.

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MVC Coordinating Center Launches Health Equity Report

MVC Coordinating Center Launches Health Equity Report

As hospitals begin to identify lessons learned since the start of the pandemic, providers are keenly aware of the prevalence and exacerbation of existing health inequities. Despite the fact that many providers are increasingly interested in addressing the social determinants of health (SDOH) and equitable access to care, communities of color and other minorities that are statistically more impacted by SDOH and socioeconomic status (SES) have endured even wider gaps in health outcomes and care this past year. For many hospitals and physician organizations, the way forward requires the application of a health equity or social risk lens across the board, so that basic healthcare and quality improvement decision-making can be maximized for all patient populations, not just those with fewer social risk factors. The MVC Coordinating Center is, therefore, proud to have released its first MVC Health Equity Report to its membership on Wednesday morning.

MVC began developing metrics for its membership in this area over the past year so providers might better understand where inequities are materializing within the four walls of their hospitals and beyond. One popular method for identifying low-SES patients is by determining where someone lives and applying population-level metrics to the individual. Examples of this would be using the Area Deprivation Index (ADI) or Social Vulnerability Index (SVI). Both indexes are based on census tract data and provide SES characteristics about a population within a specific geographic location (i.e., a census tract), including risk factors such as poverty, education level, transportation access, and housing security. However, in developing the MVC Health Equity Report, the MVC Coordinating Center elected to utilize a patient-level metric of SES that is compatible with MVC claims data. As a result, the report identifies low-SES patients using dual-eligibility status.

Dual-eligible beneficiaries are patients that are eligible for both Medicare and Medicaid. In the MVC Health Equity Report, dual eligibility is defined as having been eligible for both Medicare and Medicaid at any point during the year of the index admission and is limited to patients that were at least 65 years old at the time of admission. Medicaid eligibility is a good indicator of SES when using claims data since it is income-based, and studies have shown that there is a strong association between low-income status and adverse health outcomes. Dual eligibility allows MVC analysts to identify Medicaid-eligible patients within its more extensive Medicare data set for analyses. Medicare data on the MVC registry currently includes claims data from 1/1/2015 through 9/30/2020. The resulting reports prepared for members focuses on episodes occurring between 2017 and 2020, or between 2017 and 2019 if the circumstances of 2020 resulted in unusual case counts by facility.

In developing this report, there was a conscious decision to exclude any sort of comparison group alongside each individual hospital's metrics. This is because the socioeconomic factors of a hospital’s patient population cannot be changed, and there is great diversity between hospitals throughout the state and within geographic regions. For those reasons, benchmarking was not the intention of this report. However, it is important to note that across the state, the data analyzed by the MVC Coordinating Center consistently indicates that dual-eligible patients have poorer outcomes than their non-dual-eligible counterparts, including longer lengths of stay, higher readmission rates, higher post-discharge emergency department utilization, lower rates of office visits post-discharge, higher rates of post-discharge outpatient procedures, and higher utilization of skilled nursing facilities. Blinded sample graphs for length of stay (Figure 1) and readmission rates (Figure 2) were created using data from three distinct, large hospitals in order to showcase some of these differences.

Figure 1.

Figure 2.

Members receiving reports will see a variety of graphs depicting, for example, total episode payment trends, 30-day readmission rate trends, and post-acute care utilization. Also provided is a table outlining a hospital or region’s highest volume of conditions within its dual-eligible population (see Figure 3 for a blinded sample). The purpose of this table is to help members better understand the proportion of dual-eligible patients at their hospital and the prevalence of various conditions within that population. It will also help members to better understand their report overall by identifying the conditions and procedures driving the various metrics included within it.

Figure 3.

MVC is eager to do more in this space in the months ahead. With the recently added Michigan Medicaid data on the MVC registry, the Coordinating Center has a new opportunity to more closely examine the types of disparities that are prevalent in healthcare. Additionally, with the addition of 13 rural or critical access hospitals to the collaborative in the past 12 months, the Coordinating Center aims to expand its metrics outside of the episode structure to examine population health metrics. This will allow for better understanding about healthcare delivery and how outcomes differ in rural regions compared to urban.

The MVC Coordinating Center wants to hear feedback from its members. With the addition of Medicaid data, we are working hard to develop more metrics and reports that focus on health equity. If you have any questions, comments, or suggestions, please contact the MVC Coordinating Center at michiganvaluecollabortative@gmail.com.