Automated Telephone Self-management Support:

(1)

Automated Telephone Self-management Support:

A Public Hospital Innovation with Great Potential

Dean Schillinger, MD Margaret Handley, MPH PhD

Professor of Medicine Assistant Professor of Epidemiology Professor of Medicine Assistant Professor of Epidemiology Chief, CA Diabetes Prevention and Control

CA Dept of Public Health

UCSF Center for Vulnerable Populations UCSF Center for Vulnerable Populations San Francisco General Hospital

(2)

Rationale:

What is Health Literacy?

“The degree to which individuals

have the capacity to obtain

have the capacity to obtain,

process, and understand basic

health information and services

needed to make [informed] health

decisions ”

decisions.

(3)

1

1 st

st

_{National Assessment of Health}

Literacy

n=19,714

• Below Basic: Circle date on doctor’s

appointment slippp p

• Basic: Give 2 reasons a person with no

symptoms should get tested for cancer based on symptoms should get tested for cancer based on a clearly written pamphlet

• Intermediate: Determine what time to take Rx medicine based on label

• Proficient: Calculate employee share of health

insurance costs

using table

National Center for Educational Statistics, U.S. Department of Education, 2003

(4)

1

1 st

st

_{Health Literacy Assessment}

n=19 714 U S Adults Proficient 12% n=19,714 U.S. Adults Below Proficient 14% 53% _di Below Basic 53% _Intermediate Basic 22% Hispanic 22% Average

National Assessment of Adult Literacy (NAAL): National Center for Educational Statistics, U.S. Department of Education, 2003.

Average

(5)

Patients with Diabetes and Low Literacy

L

Lik l t K

C

t M

t

Less Likely to Know Correct Management

Need to Know:

symptoms of low blood

Low

Moderate

sugar (hypoglycemia) ode a e_High

Need to Do:

correct action for

h pogl cemic s mptoms

Low Moderate High 0 20 40 60 80 100 Percent hypoglycemic symptoms Percent

*Williams et al., Archive of Internal Medicine, 1998

(6)

Literacy is Associated with Glycemic Control, N=408 50 Inadequate Marginal Adequate 40 n ts dequa e Adjusted OR=0.57, p=0.05 Adjusted OR=2.03, p=0.02 20 30 o f pa ti en 10 20 % o 0 1st Quartile 4th Quartile 1st Quartile 4th Quartile

(Tight Control: HbA1c≤7.2%) (Poor Control: HbA1c>9.5%)

(7)

Adjusted odds of self-reported diabetes complications, for patients with inadequate vs. adequate literacy (N=408)

Complication n** _AOR _{95% CI}

Retinopathy 111 2.33 (1.19-4.57)

Nephropathy 62 1.71 (0.75-3.90)

Nephropathy 62 1.71 (0.75 3.90)

Lower Extremity Amputation 27 2.48 (0.74-8.34) Cerebrovascular Disease 46 2.71 (1.06-6.97) Ischemic Heart Disease 93 1.73 (0.83-3.60)

(8)

Diabetes Patients with Limited Literacy

Experience Poorer Quality Communication

Schillinger 2004

Experience Poorer Quality Communication,

N=408 50 Inadequate FHL 40 Adequate FHL OR=3 2;p<0 01 OR=1.9;p=0.04 30 OR=3.2;p<0.01 OR=3.3;p=0.02 OR=2.4;p=0.02 OR 1.9;p 0.04 10 20 32% _26% 21% 33% 20% 0 10

Doctor Use Words Give You Test Results Confused About Doctor Understand

13% 13% _13% 20%

Doctor Use Words Not Understood

Give You Test Results w/o Explanation

Confused About Medical Care

Doctor Understand Problems Doing Rx

(9)

The Impact of Language Barriers on Poor

Glycemic Control Among Insured Latino

Diabetics: Data from DISTANCE Study

Fernandez A, Schillinger D, Warton M, Parker M, Adler N, Schenker Y, Moffet H, Salgado V, Ahmed A, and Karter A.

(10)

Glycemic Control of Latino Diabetics by English Language Glycemic Control of Latino Diabetics by English Language

Ability and by Physician-patient Language Concordance

English Speakers (n=2683) All LEP (n=510) P Value LEP - LC (n=137) LEP- LD (n=115) P Value A1c, mean (SD) 7.65 (1.71) 7.81 (1.85) 0.06 7.58 (1.62) 7.99 (1.92) 0.07

Proportion of group with

A1c≥9% (%) 18.0 21.4 0.08 16.1 27.8 0.03 A1c 9% (%)

(11)

Self-Management Support and

Communication

Research questions

1 Are vulnerable diabetes

69%

70% 80%

1. Are vulnerable diabetes patients interested in self-management support? 2. Do they perceive a benefit

55%

42%

50% 60% 70%

2. Do they perceive a benefit to improved

communication?

40% perceived a benefit from

20% 30% 40%

p

better provider

communication, higher for racial/ethnic minority and li it d h lth lit

0% 10% 20%

limited health literacy (70%)

telephone group visit

internet

Interest in Self-Management Support

C l i V l bl di b t ti t d i lf t

Conclusion: Vulnerable diabetes patients desire self-management support and perceive a benefit to improved communication.

(12)

IDEALL Project:

Improving Diabetes Efforts

Across Language and Literacy

• Community Health

Network of SF/DPH AHRQ

• AHRQ

• CMWF, TCE, CHCF

(13)

Automated Telephone Diabetes

Self-M

t (ATSM)

Management (ATSM)

Nurse Diabetes Care manager kl Primary Care Physician ATSM: Weekly Monitoring and Health Education

Interactive health technology, touch tone response

Patient

Weekly surveillance & health education (39 weeks=9 mos)

In patients’ preferred language (English, Spanish or Cantonese)

Generates weekly reports of out of range responses

Live phone follow-up through a bilingual nurse ->behavioral action plans

(14)

Components of Intervention

p

P ti t i t t d ll i t ti h lth

• Proactive, outgoing automated calls; interactive health technology, touch tone response. 6-8 minutes/call (weekly

surveillance & health education [39 weeks=9 mos] )[ ] )

•In patients’ preferred language (English, Spanish or Cantonese)

•Rotating/recurring topics of questions and health •Rotating/recurring topics of questions and health education narratives re healthy eating, exercise,

medication adherence, coping/mood, self-monitoring, etc.

G t kl t f t f

•Generates weekly reports of out of range responses based on a priori thresholds we set

•For those who “trigger”: Live phone follow-up through a gg p p g

bilingual nurse ->behavioral action

(15)

Components of Intervention

p

Ab t 50 60% f ATSM ll t d d

• About 50-60% of ATSM calls get answered and completed

• About 40-50% of these have triggered a call-back.gg

• Care manager able to reach the vast majority for f-u and develop patient-generated action plans.

•Most patients achieve partial or complete success on AP •Most patients achieve partial or complete success on AP • To date, care manager not empowered to up-titrate

medications; does communicate with PCP re safety

i i ifi t bl

issues or significant problems.

•Care manager has database for ease of data entry;

(16)

Key Findings of IDEALL Program

Estimating Public Health “Reach” of Programs

Composite reach product

ATSM Group Visits (GMV)p ( )

Overall 22.1 4.8 E li h 20 0 6 4 English 20.0 6.4 Chinese 22.0 2.7 SpanishSpanish 24 324.3 4 04.0 Adequate Literacy 15.6 7.6 Limited Literacy 28.0 3.6

(17)

Results:

S

d P

M

Structure and Process Measures

70 41 36.8 39.3 48.2 58.9 60.2 30 40 50 60 * * 73.5 71.7 73.3 71.7 77.2 77.2 65 70 75 80 * * 20 UC ATSM GMV PACIC 60 UC ATSM GMV Self-Efficacy pre post 62 9 65.4 63 4 72.9 68.9 60 65 70 75 *≠ 4.4 4.1 4 5 * * ≠ 62.9 59.2 63.4 50 55 60 UC ATSM GMV 3.9 3.7 3.9 4.1 3.8 3 UC ATSM GMV S lf M t B h i Communication Self-Management Behavior

(18)

Results: Functional Outcomes

18

15 20

5

Rate ratio 0.5 vs UC, 0.35 vs GMV OR 0.37 vs UC

13 14 18 6 17 17 0 5 10 15 * 3.9 3.8 _3.6 3.1 1.4 3.6 0 1 2 3 4 5 *≠ UC ATSM GMV Diabetes Interference pre post UC ATSM GMV Bed Days 61.7 64.2 67 ₆₃ 60 65 70 ≠ 56.7 60.2 57.1 55 60 65 58.8 57.2 50 55 UC ATSM GMV 50 51.3 50.9 45 50 UC ATSM GMV SF12 - Mental Health SF12 - Physical Health

(19)

Results: Physiologic Outcomes

80 145 78.1 75 78.1 78.5 75.4 75.5 75 139.6 136.9 142.4 141.5 137.1 138.9 135 140 5 70 UC ATSM GMV DBP pre post 130 UC ATSM GMV SBP 9.8 9.3 9.4 9 8.7 9 9 10 31.2 32.1 30 7 32.4 31.4 30 31 32 33 8.7 7 8 UC ATSM GMV 30.3 30.7 28 29 30 UC ATSM GMV HbA1c BMI

(20)

ATSM as Surveillance Tool?

Patient-Nurse

Automated Completed Calls ATSM Data CONSENSUS Patient Nurse Encounters CONSENSUS AE PotAE No event Classification - Preventability Medical _{Preventability}

- Primary Provider Awareness Record

(21)

Automated telephony provides safety

surveillance function

• 111 participants,

p

,

120 Preventability

54% inadequate

health literacy

264 t

80 100 f Events

• 264 events

among 93

participants (86%)

40 60 N umber o f

participants (86%)

• 111 AE’s and 153

PotAE’s

0 20

Incident Prevalent Incident Prevalent

N

Incident

AE PrevalentAE PotAEIncident PrevalentPotAE

Unable to determine Non-preventable Ameliorable

Preventable

(22)

Clinician Survey Findings

• Responses from 87 of 113 (77%) physicians who cared for 245 of the 330 (74%) patients (mean 2 8 per physician) 245 of the 330 (74%) patients (mean, 2.8 per physician). • Compared to UC, patients exposed to ATSM were

perceived as more likely to be activated to create and achieve goals for chronic care (standardized effect size,

ATSM UC 0 41 0 05)

ATSM vs. UC, +0.41, p=0.05).

• Over half of physicians reported that ATSM helped overcome 4 of 5 common barriers to diabetes care

• Physicians ratedPhysicians rated qualityquality of care as higher among patientsof care as higher among patients exposed to ATSM compared to usual care (OR 3.6,

p=0.003), and compared to GMV (OR 2.2, p=0.06) • The majority felt ATSM should be expanded to more

patients with diabetes (88%) patients with diabetes (88%)

• a technology-facilitated SMS model was particularly

effective for their patients and practice settings, suggesting that such programs should be disseminated and

i l t d id l

implemented more widely.

(23)

Health System Findings:

C

ff

Cost-Effectiveness; Health Plans

•Based on functional improvements, we estimated thatBased on functional improvements, we estimated that the cost per QALY for ATSM was:

>$65,000 for both set-up and ongoing costs >$ 32,000 for ongoing costs only

•Cost effectiveness could be further improved with (a) scaling up or (b) metabolic outcomes improved

•A large majority of CA Medicaid health plans reported an interest in employing ATSM-like technology

Handley, Schillinger, in press Ann Fam Med 2008 Goldman, Schillinger et al. Am J Man Care 2007

(24)

Key Findings of IDEALL Program

y

g

R h i ifi t i ll f l lit

•Reach significant, especially for lower literacy, non-English speaking, Medi-Cal, uninsured.

•Interactive health technology improves patient –centered gy p p

care, health behaviors, functional status and promotes safety, due to •proactive nature •proactive nature •hierarchical logic •communication tailoring F h i l i ff t t b hi d d di ti

•For physiologic effects to be achieved, need medication intensification

•Health plans and clinicians favorably inclinedp y

(25)

(26)

Current Project

•Partner with a local Medicaid health plan: San

F i H lth Pl

Francisco Health Plan

•SFHP care managers will make ATSM

response callsp

•Test effectiveness when implemented in ‘real-world’

•Compare ATSM-ONLY with ATSM-PLUSCompare ATSM-ONLY with ATSM-PLUS (medication activation)

•ATSM-PLUS involves merging pharmacy claims

d t ith ATSM d t t bl

data with ATSM data to enable care manager counseling

(27)

Design and Outcomes

•Wait List Design, with randomization among

d ti i t T t l N 500

exposed participants. Total N=500

•Outcomes (wait-list vs. ATSM vs. ATSM-Plus): -communication

-behavior

-functional status

-metabolic indicators -metabolic indicators

(28)

• SuboptimalSuboptimal • Refill Non- • Self-Reported Goals on Diabetes Registry Refill Non Adherence on Pharmacy Claims p Med Non-Adherence on ATSM

SFHP Care Manager Call to Patient:

• Check understanding and educate regarding diabetes goals • Elicit barriers to adherence

• Inform about current data & goals • Inform about current data & goals

• Assess understanding of discussions with PCP

• Assess willingness to increase or add new medication to meet goals • Develops action plan using motivational interviewing principles

(29)

SFHP Pre- Enrollment Post Card

E

li h

(30)

Spanish

(31)

Cantonese

(32)

SFHP Wallet-Size Card

E

li h S

i h

d C

(33)

Care manager field

(34)

Potential Safety Event

(35)

Safety event assessment

(36)

Engagement with Smart Steps

g g

p

Sample: 186 SFHP patients enrolled in Smart Steps in

2009-2010 actively receiving calls in March, 2010, who had completed at least 3 weeks of calls.

Results: Overall, 132 of 186 (71%) engaged with program This represents:

This represents:

89% engaged among Cantonese (94/106)

86% engaged among Spanish (12/14)

(37)

(38)

Improvements/Threats

•Improvements to future dissemination:

C h lth h

•Care manager—health coach

•Harnessing pharmacy claims data •Marketing and outreach

•Trusted health plan •Trusted health plan •Potentially sustainable

•Development of detailed training manual/QA processes

•Threats to implementation:

•Delays in implementation •Staff turnover @health plan •Staff turnover @health plan

•Maintaining fidelity to intervention processes

•Care mgr processes; claims data/registry data incomplete

incomplete

•Coordinating treatment preferences/medication activation with PCP