Lifestyle Medical is a primary care practice in Riverside, California, dedicated to chronic disease prevention and reversal.

THE PROBLEM

The core problem it sought to address is that lifestyle factors are the root causes for the majority of its patients’ disease burden, but more than 99% of the underlying drivers of health take place outside of the clinics.

The traditional primary care office is really not well designed to care for conditions such as diabetes and heart disease, even though healthcare now knows that these conditions can be reversed – not just managed, but truly healed – with lifestyle interventions and behavior modification, said Arwin Soetanto, CEO of Lifestyle Medical.

“We have focused on value-based revenue streams that give us the economic resources to offer team-based care and wellness programs to empower patients to build healthier habits,” he explained.

“However, with synchronous methods of communication – even with video or telemedicine – we still cannot be available to all of our patients all the time. Observing the growth of social media across all demographics, and the mass adoption of fitness trackers, we had a hunch that technology is now ready to bring a new dimension to our relationships with patients.”

"Remote patient monitoring and virtual care require significant changes to care team workflows and potentially even care team job descriptions."

Arwin Soetanto, Lifestyle Medical

So Lifestyle Medical began searching for ways to:

• Understand all of the relevant things that happened in patients’ lives in between visits so that staff can focus its time with patients on guiding them to build and refine their care plan, rather than collecting history.
• Receive real-time signals that would enable the care team to deliver the right intervention at the right time.
• Facilitate one-to-many communications between the care team and patients, and among patients.

PROPOSAL

Lifestyle Medical initially looked for remote patient monitoring (RPM) vendors who would enable it to provide patients with connected devices such as blood pressure cuffs or glucometers. These vendors tended to optimize for the reliable collection of physiologic parameters, which is required to access Medicare reimbursement for RPM. The capabilities to communicate with patients were typically limited to 1:1 text messaging.

So the practice turned to RPM vendor Carium, which offers a technically robust platform for collecting physiologic parameters remotely, Soetanto said.

“They also share our vision that great healthcare is fundamentally about great relationships, and have innovated around using technology to enhance relationships,” he noted.

“For example, we are able to send multimedia messages to small groups of patients who are going through similar conditions, and prompt discussion among patients. We can build libraries of health information that care team members can share with patients individually or as a group, and track how many patients opened each media item to help us build better content.”

From a cultural and product-design perspective, Carium understands what motivates people, he added.

“Their patient app compels patients to take control of their health,” he said. “A potential risk to implementing RPM is creating a feeling that patients are being ‘watched’ and judged. Through subtle features, such as displaying trends and insights in the patient app and an open platform to connect to most major fitness and wellness apps, Carium enables us to send a clear message to patients that they are in charge of their own health.”

Many months after the practice began using the technology for RPM, COVID-19 made it necessary to convert most care to virtual care. While the practice could not have foreseen that sudden need, the technology’s cloud-based platform was easily configurable to enable staff to offer a virtual interaction with all patients – not just those eligible for Medicare-reimbursed RPM – including collecting vital signs that staff could previously only do in the office and delivering interactive care plans to patients through an app on their phone.

MARKETPLACE

There are many vendors of remote patient-monitoring technology and services on the health IT market. Healthcare IT News recently put together a roundup of these vendors and connected health device vendors. To read this special report, click here.

MEETING THE CHALLENGE

Initially, Lifestyle Medical began using Carium only for RPM, which for eligible Medicare patients attracts reimbursement of approximately $120 per month (the exact figure depends on geography). It was quick and easy to get started. Providers got a quick training from the vendor that enabled them to onboard their own patients. All providers need to get started with the RPM technology is access to an internet browser.

“We use the Elation EHR, which can be directly integrated with Carium,” Soetanto explained. “Lifestyle Medical employs physicians with specialized training in lifestyle intervention and behavior change who are surrounded by a skill-optimized team, including health coaches to provide supplemental in-person and remote care for their patients.

“Our health coaches have taken the lead on RPM. They embrace technology as the conduit for providing scalable, personalized care across our population, and have seen increased loyalty from our enrolled members,” he added.

Patients were easy to onboard as well. They use their own smartphones integrated digitally with devices including blood pressure cuffs, glucometers and scales the practice ordered for them through Carium’s website. The initial set-up is conducted by a health coach via a phone call with the patient. The practice estimates that it takes about 30 minutes per patient.

“During the call, the health coach ensures that each patient can use the app and. if applicable, that any prescribed medical devices, such as a Bluetooth-enabled blood pressure cuff, are seamlessly connected to the app,” Soetanto said. “Patients can also connect devices and wearables through Apple Health and Google Fit. After the one-time setup, the patient is good to go. Our RPM service went according to plan.”

By contrast, COVID-19 unexpectedly forced “stay at home” mandates across the country, and businesses have adapted by pivoting to online/in-app offerings, drive-through service, delivery services and more. The current global health crisis has had a big impact on traditional in-office visits and has shifted primary modes of care for vulnerable populations, including patients with chronic diseases, to seek care virtually.

Many patients with chronic diseases don’t get the luxury of a “pause” during this time and need their care team to provide digital access, engagement and care.

“With the RPM technology, we have been able to continue achieving positive impact virtually during the pandemic,” Soetanto said. “Lifestyle Medical is now several months into our digital transformation and under the pressures of the pandemic, we were lucky to have already had our RPM program in place. We continue to enroll new patients into this program, along with the RPM vendor’s broader digital health offerings – and are reaping the benefits.”

Patients engage with the practice regularly via the Carium app on their smartphone. The combination of health coaches and purpose-built tech combine to power Lifestyle Medical’s virtual care programming, and patients benefit from that “in-between visit” connection that they now have regularly. Even after the pandemic, the practice believes the platform will continue to be an integral part of its care.

RESULTS

On average, patients enrolled in the Lifestyle Medical RPM program decreased their systolic blood pressure by 13 points. Some 71% of qualifying patients lost weight and, on average, these users saw a weight loss of 4% from their starting weight. A total of 95% of qualifying users lowered their blood pressure. The benefits to the patients are recognized and contribute to patients’ loyalty to the practice, improved activation and improved health, Soetanto said.

“Mariza Lujano is one of the health coaches at our practice,” he explained. “Before transitioning into a health coach role, she was a medical assistant for 19 years. Mariza has experienced first-hand the benefits remote monitoring has for her, and also the positive impact it has on her patients. Absent a pandemic, our comprehensive program synchronizes in-clinic visits, peer support groups and remote patient monitoring. Throughout the pandemic, we’ve been able to operate fairly seamlessly compared to other practices that did not have a similar platform in place.”

One example of the impact of the RPM program is the new awareness a patient with diabetes gained from the impact of his actions on his health. Through the app, he was easily able to monitor his daily biometric data and correlate how his biometrics positively changed with his behaviors. Through the platform, this patient and Lujano both witnessed the impact walking had on his blood glucose.

“He took his blood sugar and then took a walk and came back, and took it again and realized, 'Wow, it dropped that much from that walk?'” Lujano remarked. Lujano was monitoring this on her end, too. By reaching out to him to have a conversation and referencing their shared data set together, she saw his engagement increase, and his healthy behaviors were reinforced. For Lujano and her patient, this is the value of connected health.

ADVICE FOR OTHERS

“We found it extremely beneficial to have a small number of patients test the technology options being considered,” Soetanto advised. “The majority of our patients are Medicare age and fundamentally view technology through a different lens. The trial highlighted significant usability factors that would never have occurred to us. We found it to be more helpful to watch patients in their natural environment than asking questions after the fact.”

Having multiple disparate applications is typically a challenge for many providers and clinical staff. In Lifestyle Medical’s case, the practice already worked across too many add-on applications required by various payers.

This persuaded the practice away from point solutions, even if they may appear more suited for a specific use case, and toward a flexible platform that can be leveraged to support diverse health conditions and organizational needs. The change means the care team will only have a handful of core applications that they need to work with day to day.

“Remote patient monitoring and virtual care require significant changes to care team workflows and potentially even care team job descriptions,” Soetanto said. “It was important to us to work with a technology partner who can help design optimal workflows, and help you as an operational or technology lead to create excitement among clinicians to work through the hurdle of initial change to ultimately build more fulfilling relationships with patients.

“It has been incredibly gratifying to see how much our patients appreciate the virtual care we are now offering, and how much of a positive impact it is having in their lives, particularly in these uncertain times,” he concluded. “Our relationships with patients are stronger than ever.”

Twitter: @SiwickiHealthIT
Email the writer: bill.siwicki@himss.org
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