Equality Health, a health system headquartered in Phoenix, Arizona, needed to figure out how to connect at scale with underserved and disengaged patients in a way that helps them effectively be involved in the management of their health.

THE PROBLEM
Many have experienced historical disparities in the country's "one size fits all" healthcare system, and so they're not engaged, said JoyAnn Book, head of the digital business group and senior vice president of experience design and innovation at Equality Health.

"For example, a large subset of the population has uncontrolled diabetes that puts them at serious risk, but they've left blood sugar and hypertension levels unchecked, and prescriptions unfilled, for months," she said. "They often end up in the hospital as a result."

Equality Health's care team spends a significant amount of time in the field interacting with its patients and helping them navigate the personal, social and cultural barriers to consistent management of chronic conditions like diabetes.

"And they're very good at this work," said Book. "They're effective at gaining the member's trust, and providing education about diabetes self-management. However, there is a limited feedback loop with this high-touch approach, in part because of the constraints of needing so many manual hours to track progress and measure outcomes. We needed to figure out how to do all this at scale, which cannot be done in the field alone – even if you have an army of field workers."

PROPOSAL
Equality Health has created a technology-enabled model for "activating" members into its diabetes self-management program. The crux of this solution is twofold:

• Risk stratification that begins in the health system's proprietary care coordination platform, CareEmpower. CareEmpower identifies patients at highest risk of hospitalization or an acute health event. This alone is a significant time-saver compared to manually going through member records to identify who is struggling to self-manage their diabetes, Book explained.
• Sophisticated algorithms that are not only based on the knowledge set of the health system's care team, but also apply a unique combination of activation methods, design frameworks and behavior change support systems, Book said.

"The algorithms are customized to the ethnic, cultural and background of our members; trained to learn their unique preferences; and then extract patterns from these preferences and behaviors to personalize outreach," she explained. "The algorithms include rules for a specific cadence to send well-timed and personalized messages that activate members into the program, and offer step-by-step guidance to motivate them to meet their goals once they're in the program."

Book offered a bit more context for a deeper dive into the underlying design principles incorporated into the algorithm – two primary methodologies used are Persuasive Technology combined with activation techniques and behavior change support systems; and the Power of Habit principles to encourage goal achievement and behavior modification without coercion.

"These principles should be woven into any care coordination program today; they are effective not only in encouraging healthy behaviors but also helping people meet their goals, despite challenges or setbacks," she said.

Examples of these design attributes, she said, include:

• "Tunneling" – Guiding members through a series of interactions or steps.
• "Reduction" – Providing limited but focused information to increase understanding and comprehension.
• "Self-Monitoring" – Allowing members to track their own progress toward their personal as well as health goals.

"The tech-enabled model and messages don't supplant all of the necessary in-person interactions, but they do make engagement happen at scale," Book commented. "Another way of characterizing it is: High-tech scales high-touch care coordination and fieldwork."

MEETING THE CHALLENGE
Following are the steps in sequential order of how Equality Health activates patients in the diabetes self-management program:

• High-risk members are identified using a proprietary social and cultural risk assessment tool. Risk stratification is presented within Equality Health's proprietary care coordination technology, CareEmpower. The technology simultaneously presents to the care team and providers the patients who are prioritized at risk for frequent use of the emergency department; at highest risk of hospitalization; and/or overdue for a diabetes test or medication refill.
• Patient activation begins. Patients are contacted in a variety of ways, including bilingual and culturally relevant messages that educate and encourage members on the importance of getting in touch with their care manager. Those who respond and engage in the program are considered "activated."
• Personalized, algorithm-powered guidance. Activated patients are digitally coached through personalized and timely digital messages. These range from a caring inquiry about how the member is feeling that morning to a warm congratulations for meeting a goal.
• Connection to community resources. Equality Health's care coordinators connect members with community-based organizations when unstable housing, difficulty paying utilities, lack of transportation, food insecurity or lack of access to care is identified. Digitally, care coordinators also can proactively engage members via specific digital outreaches to assure the most basic necessities always are addressed and not interfere in disease management. Partnered community-based organizations are linguistically capable, culturally competent and trusted entities in the community, Book noted.

RESULTS
Equality Health still is in pilot mode with this effort, but Book said early results are promising.

The program has resulted in a 21.6% average reduction in A1c. There has been a 27% increase in diabetes program enrollment since digital outreach was initiated. 83% of patients report an increase in confidence to self-manage their diabetes. 50% of patients report an increase in physical activity.

ADVICE FOR OTHERS
"The quality and volume of the data sets are essential for scaling personalized, effective member outreach," Book advised. "We use our own in-house developed technology, based on our own experience and field work. So there are no question marks for us about how reliable the data is; we know it's trustworthy because we collected it and created the algorithms ourselves. We developed the risk assessment ourselves."

For other provider organizations that do not have these capabilities, they really need to rigorously evaluate the data behind the solutions they are evaluating, she added.

"Another fundamental piece of advice is to understand that the technology will help your care professionals spend more time with members instead of acting as call centers," she concluded. "But they will need training and support on any new model, even those that simplify work processes and make their jobs more rewarding."