Jana Katz-Bell & Madan Dharmar

Telehealth Advancing Person-Centered Care

What is “UC Davis Health”

Single hospital academic health system

– School of Medicine

– Betty Irene Moore School of Nursing

– Practice Management Board

– UC Davis Medical Center and Primary Care Network

Research Clinical Education Service

UC Davis Health System

Medical center serves urban and rural region

– 33 counties

– 6 millionpeople

Digital health/Connected health/eHealth/mHealth/telehealth

INCREASE ACCESS TO SPECIALISTS

RE-IMAGINE SPECIALTY REFERRALS

Patient - Specialist

Live Video

Store and Forward

Live, two-way video between patient with remote PCP and tele-specialist

Transmission of history and images to specialist for diagnosis and treatment

Distance Learning

Videoconference-enabled training of PCPs by specialists

Electronic message exchange, including clinical question and related patient information

e-Consult

Syn

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Patient - PCP PCP - Specialist

Remote Patient Monitoring

Direct to Consumer

Live, two-way video between patient and generalist or PCP

IMPROVE PERSON-CENTERED CARE

Remote monitoring of patient with video and peripheral devices

History of telehealth at UC Davis 1992: Tele-fetal monitoring

1996 - 2005: Video telemedicine implemented with three sites and three specialties. Steady growth outpatient and inpatient services

2005-2015: Emphasis on statewide efforts

2015- now: Refining our telehealthstrategies to fit today’s demand and prepare for the future

Outpatient and Inpatient Telehealth Services

Inpatient and Outpatient Telehealth

Diverse strategies to achieve goals

•Specialty Referrals

•Distance Education

•ECHO

•EHR hosting

Referral Relationships

•eConsult

•Virtual Visits

•Chronic Disease Management models

Connected health/population

management

UC Davis Health E-Consults

Currently available in PCNs and hospital based clinics

• 22 subspecialties (both pediatrics and adult); and more being added

• Embedded in the Epic EMR integrated workflow

Patient visits with PCP; PCP requests E-consult with Specialist; Specialist completes consult/reports back to PCP

Allows for more intermediate steps -can request additional studies, ask follow up questions or convert to face-to-face referral

If face-to-face specialty visit needed, ensures patient sees the right specialist, has appropriate pre-visit imaging/lab tests, and is triaged based on clinical urgency

Virtual Visits – Care to the Home

Currently for established patients

– Post operative follow-up

– Specialty pharmacy (high risk/complex patients)

– Embedded in UC Davis patient portal

Urgent care with external vendor to respond to access issues

Exploration for recruitment and retention for clinical trial

12

Improving Health in Diabetes

One of the top 5 chronic diseases and a risk

factor for other conditions

Currently affects 29 million - almost 10% of

U.S. Population, expecting this to grow to 48.3

million by 2050

Modifiable behavioral risk factors (physical

inactivity, poor eating and sleep habits,

obesity and smoking)

Diabetes Mellitus

Budget: $2,098,246

Project Period: 3 years

Overall Goal: Develop and evaluate an innovative program that uses nurse health coaching, motivational interviewing techniques, and wireless sensor and mobile health (mHealth) technology.

P2E2T2 Program to Improve Health in Diabetes

Goal: Develop and evaluate an innovative program that uses

nurse health coaching with motivational interviewing techniques,

and wireless sensor and mobile health (mHealth) technology.

Aim 1: Refine and finalize the intervention elements (nurse

coaching, wireless sensor technology and mHealth framework,

relevant outcomes) with stakeholders

Aim 2: Integrate patient-generated goals and sensor data

into a mHealth dashboard linked back into the clinical record

Aim 3: Evaluate the effectiveness of the P2E2T2 Program

on diabetes management

Project Goal and Specific Aims

Patient Advisory Workgroup

Provider Advisory Workgroup

Technology Advisory Workgroup

Stakeholder Engagement

Key contributions for this project from advisors

Influencing systems: promotes understanding of systems issues/logistics/culture so that study design aligns and addresses barriers

Influencing people: credibility with expert consultation, opening doors to other stakeholders, creating a buzz and priority for the project

Influencing implementation: anticipating and addressing barriers, identifying opportunities

Patient Engagement: Changing the Conversation

DATA Knowledge

ST

EP

S

You have trouble meeting your activity

goals on Mondays and Tuesdays. What

happens on those days? What changes

might you make?

Activity levels seem to be linked to your

sleep quality at night.

Certain night time meals and alcohol

intake appear to impact sleep quality and

mood

Your blood pressure has improved due to

changes you have made to your diet and

activity in the past 3 months!

Clinical Trial

Design: Two-arm randomized controlled trial (1:1)

Inclusion Criteria: English speaking adults, last A1C > 6.5%, willing to use technology to help manage diabetes

Outcomes: Self-efficacy (primary), quality of life, clinical indicators

Usual Care

•MyChart Activation and orientation

•Access to UCD Diabetes Resources through Health Management and Education

P2E2T2 Intervention

• Usual care orientation, plus

• Physical Activity, sleep and nutrition tracking technologies – Garmin/Basis, MyFitnessPal

• 6 RN Health Coaching Sessions with focus on patient identified goal setting

Planning Conference Call with Nurse Coach

Establish priority health issue and desired goals

Technology Meeting (In-Person)

Orientation and training

Five bi-weekly support calls

Review progress and discuss approaches

Review Patient Generated Data

Final Action Plan and Follow-up with Provider

Summarize goals and progress

Communicate to Provider

P2E2T2 Intervention

Sensor & App Selections

INTEL BASIS PEAK APPLE HEALTH MYFITNESSPAL

MYCHART

PGHD EHR View

Self-Efficacy Diabetes Empowerment Scale – Short

Form (DES-SF)

Quality of Life

Patient Health Questionnaire depression

scale-9 (PHQ-9)

Perceived Stress Scale (PSS)

PROMIS (Emotional Distress, physical

function and sleep disturbance)

Readiness to Change Readiness to Change Survey

Clinical Indicators HbA1c

Patient Outcomes

Preliminary Results

Participant Characteristics– Age in Years: 59.4 (S.D= 11.4)

– Gender: 47.3% Female

– Race/Ethnicity: 61% White, 13.1% Black, 9.6% Asian, 9.9% Other

– Education: 40.9% Bachelor & Graduate or Professional Degree

Comparison of two groups– No difference at baseline

– Randomization successful

Conclusion

Significantly higher self-efficacy score in the

intervention

Differential impact based on their readiness to change

Variability in Usual care can confound the results

PCORI Video

Collaborators

Funded by PCORI: IHS-1310-07894

Primary Care Network

Investigators

Heather Young, PhD, RN, FAAN

(Principal Investigator)

Sheridan Miyamoto, PhD, FNP, RN

Madan Dharmar, MBBS, PhD

Yajarayma Tang-Feldman

Thomas Balsbaugh, MD

Bridget Levich, RN

Rupinder Colby (Project Manager)

Patient Advisory Board

Margaret Hitchcock, PhD

Mike Lawson

Diane Goodman, MA

Maria Ibarra

Tarunesh Singh

Eric Bowser

Joseph McCarthy

AcknowledgementsProvider Advisory Board

Tom Balsbaugh, MD

Patrick Romano, MD, MPH

Richard Kravitz, MD, MPH

Victor Baquero, MD

Deborah Greenwood, PhD, RN (Sutter

Health)

Antonio (Ben) Balatbat, MD (Dignity Health)

Frederick J. Meyers, MD, MACP

Jonalyn Wallace, RN, MSN

Prasanth Suramprudi, MD

Bridget Levich, RN, MSN

Barbara Pelletreau, RN, MPH (Dignity

Health)

Kameka Brown, PhD, FNP, RN (Veterans

Affairs)

CollaboratorsUC Davis Clinical and Translational Science Center

UC Davis Primary Care Clinics

Initiative for Wireless Health and Wellness Program

Center for Information Technology Research in the

Interest of Society

Technology Advisory Board

Mike Minear (CIO)

Kent Anderson, MS

Nick Anderson, PhD

Suresh Ram, MS

Scott MacDonald, MD

Amit Pande, PhD

Nina Amenta, PhD

Thomas Nesbitt, MD, MPH

Mike Hogarth, MD

Steven Chan, MD, MBA

Dan Weberg, PhD, MHI, RN

Jana Katz-Bell, MPH

Tod Stoltz, MBA

Kwan-Liu Ma, PhD

Matthew Lange, PhD

David Lindeman, PhD

Thank you!

Questions? Comments?