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Using technology to bridge a gap

Connecting with patients who need it most

While the Heartland Mobile Health Unit brings care to patients in rural areas of southwest Iowa, Montgomery County Memorial Hospital External Site had another challenge they wanted to address, for a different type of patient.

According to Ron Kloewer, chief information officer and director of campus development at the hospital, the areas surrounding Montgomery County have fairly low health rankings. Patients are primarily struggling with chronic conditions such as diabetes, heart disease and chronic obstructive pulmonary disease (COPD). 

When these patients leave the hospital, they face a difficult transition.

“When you live in a rural community and you’re miles from the nearest hospital, or you have limited mobility, it’s hard to feel connected,” says Kloewer. “It’s critical to stay in touch with these patients, so we started looking into how to make this happen.”

Enter another technology platform: In-home biometric monitoring. “This is an initiative that has grown out of our Population Health Program External Site, and is in sync with the accountable care organization (ACO) Glossary popover agreement with Wellmark,” says Kloewer. “It’s a way to improve the health of a population while keeping a close eye on those with chronic needs.”

Equipping patients with technology

How do they do it? The hospital issues tablets or smartphones to each patient in the program, depending on the individual’s needs. If internet access is an issue, patients are provided with their own hot spot. Then, the patient uses an app to interact with nurse case managers back at the hospital. “For example, if a certain patient has trouble remembering to take medication, a nurse assigned to that patient will check in to be sure the patient is taking the medication as prescribed,” says Kloewer.

Bluetooth technology plays a key role with in-home biometric monitoring. Patients may be provided with a Bluetooth scale, for example, if they need to monitor their weight. The nurse monitoring that patient’s care will know if the patient is or is not using the scale. Other Bluetooth technologies include blood pressure cuffs, pulse oximeters and glucose monitors. Patients may also use nutrition apps to detail food and water intake. The nurse watches the dashboard and continuously interacts with the patient to keep track of what's going on in their treatment. The nurse also works with the hospital's population health department to get them the help they need.

“Most of the people in our in-home biometric monitoring program are serious about it,” says Kloewer. “They want to stay on the road to good health and they want to stay out of the emergency room. We can effectively help manage their health and reduce the disease processes and avoid a health care crisis."

The hospital’s work with Wellmark through their ACO agreement has given them access to data they never had before. This data gives the hospital a complete picture of their patients' health, which allows for the delivery of better care. In addition to working with low risk people, the population health department and nurse case managers are targeting patients for in-home monitoring who are a rising risk. "This means that if we don't intervene soon, they will be high risk," says Kloewer.

“Working with Wellmark as a partner through the ACO agreement, we can effectively locate patients who have persistent health problems, or target those who move from one risk status to another,” says Kloewer. “For example, it is too common for a patient to have one chronic disease, but over time, develop another. Wellmark provides data that helps us identify patients who are moving toward increasing level of medical risk.”

The program has been in place for a little over a year, so it is still in its infancy. But, it’s already showing results in the form of patient success stories. Says Kloewer, “We feel we know a lot more about our patients than we ever did before. We feel encouraged. There is just a huge potential for success.”

Delivering Care Differently: Using technology to bridge a gap

Delivering value-based care through ACOs

ACOs are contractual agreements that health systems, hospitals and primary care doctors have with Wellmark to achieve certain quality and cost performance targets. They're designed to create better coordinated care, improve health outcomes for patients, reduce the ever-increasing rate of health care cost trend, and ultimately lower the total cost of care for employer

ACOs work to deliver value-based care, which is the idea that higher-quality outcomes and lower costs can be achieved by making changes to the way health care is delivered. 

"ACO arrangements were created to deliver higher-quality care and lower costs through the sharing of data that gives providers a complete picture of the member's health," says Mike Fay, vice president of health networks and innovation at Wellmark. "It is a shift to paying providers based on performance rather than per service. A persistent theme in the ACO is the importance of the relationship each member has with his or her personal doctor."

Make the most of your health care and your benefits

Your personal doctor is the medical professional you go to with your health concerns and medical history. A positive relationship with your personal doctor is associated with greater satisfaction, better overall health and lower hospital and emergency room use.

It's simple to find a personal doctor by logging in to myWellmark®. You'll find a list of network providers with locations closest to you. You can also view or post reviews of providers based on your experiences, and check quality scores to find a doctor who's right for you.

Want to learn more about value-based care? Check out the other articles in this series: