www.openminds.com n 15 Lincoln Square, Gettysburg, Pennsylvania 17325 n 717-334-1329 n info@openminds.com

The Digital Substitution Effect: A Guide To Supporting Consumers In The Community Through Technology

T h e 2 0 1 8 O P E N M I N D S T e c h n o l o g y & I n f o r m a t i c s I n s t i t u t eO c t o b e r 2 3 , 2 0 1 8 | 2 : 3 0 p m – 3 : 4 5 p m

K e n C a r r , S e n i o r A s s o c i a t e , O P E N M I N D S

© 2018 OPEN MINDS

AgendaI. Development New Treatment Technologies & The Digital Substitution

Effect

II. The Vinfen Case Study: Bruce L. Bird, Ph.D., President & Chief

Executive Officer, Vinfen

III. The Comprehensive Mental Health Services Case Study: Gina

Armitage, MS, LPC, Director of Quality and Compliance,

Comprehensive Mental Health Services, Inc.

IV. Questions & Discussion

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© 2018 OPEN MINDS© 2018 OPEN MINDS

I. Development New Treatment Technologies &

The Digital Substitution Effect

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© 2018 OPEN MINDS

What Emerging Science Will Have The Greatest Impact On Behavioral Health?

New Understanding Of Central Nervous

System & Brain Chemistry

Technology To Optimize the Value of Consumer Care

Technology To Support System

Performance Improvement

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© 2018 OPEN MINDS

Reducing Service Cost

Engaging Consumers

Technology Infrastructure To Optimize Value Of Consumer Care

Patient portals,

websites, and

web-based

consumer tools

Automated

consumer outreach

Telehealth and

telemedicine

Remote

monitoring

Tech improving

admin

efficiencies

Tech-enabled

treatment

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© 2018 OPEN MINDS

Treatment-Enabling Technologies Available All Along The Service Continuum

Diagnost ics

Consumer Educat ion/

Dec is ion Support

C l in ica l Treatment

Cogni t ive Funct ion Restoration

Ear ly Detect ion o f

Re lapse

Relapse Prevent ion

Remote M oni tor ing o f

Pat ient Hea l th

• Video Doctor

• Common Ground

• Virtual Handheld Clinic

• PTSD Coach

• True Colours

• ChronoRecord

• Health Steps for Bipolar

• Biomarker: BDNF levels

• myStrength

• Tele-psychiatry using IronWorks™

• M3 (My Mood Monitor™)

• Brain scanning tech

• TMS Therapy®

• Beating the Blues

• SilverCloud

• My Mood Map

• eCBT Mood©

• MyBrain Solutions

• Automatic Trail Making Tests™

• fMRI

• ITAREPS

• MONARCA

• Actiwatch

• Health Buddy®

• OPTIMI

• Technology Enhanced Recovery™

• REAC-CRM (REAC-lithium)

• PSYCHE

• Personalised Ambient Monitoring (PAM)

• MoodMapping

• ViTelCare™ T400

• SenseWear® Armband System

• MagneTrace

• ID-Cap

• Electronic Medication Management Assistant® (EMMA)

• Implantable RF Transceiver ZL70102

• Motionlogger Actigraph

• Helius™

• MOBUS

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© 2018 OPEN MINDS

So Where Does Technology Fit In This Equation? Necessary To Manage Risk & Compete On “Value”

Analytics technology to support

performance measurement

capability

Treatment technology into

increase ‘value’ of consumer care

For analytics technologies,

use of the data for decision

making is key to ROI

For treatment technologies,

increasing treatment

‘value’ is key to ROI

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© 2018 OPEN MINDS

Technology Has Changed The Expectations Of Payers & Consumers

1. Personalization of consumer treatment through analytics-informed decision support

2. More efficient and effective coordination of consumer services across the service system

3. The measurement of “value” of services

Telehealth and virtual

consultation changing

geographic market

boundaries for services

Smartphone and other technologies

for inexpensive consumer-

directed disease management

Health information exchange provides data exchange and creates ‘big data’ for

consumer service planning

New treatment technologies have

changed the options for consumers

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© 2018 OPEN MINDS

A New Market Model Is Emerging

New Genetics, Pharma, & Neurotech:The “What” of Service

Telehealth & Remote Services: The “Where” of Service

Web-Enabled Admin Tools:

The “How” of Service

Analytics & Decision Support:

The “Right” Service

New Service Delivery

Paradigm

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© 2018 OPEN MINDS

Technology Adoption In Health & Human Services Is Slow

Conflict between the technical capabilities of

HIEs and HIPAA

Slow change in reimbursement

models to support (require) new tech

adoption

Lack of ‘best practice’ models and expertise to

reengineer service delivery

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© 2018 OPEN MINDS© 2018 OPEN MINDS

Vinfen Case Study:

Bruce L. Bird, Ph.D., President & Chief Executive Officer, Vinfen

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Case Example: Evaluating the Wellframe App

for Self Management by Adults with SMI

Bruce L. Bird Ph.D.

Vinfen

OPEN MINDS Informatics Conference

October 2018

Presentation Today

Vinfen’s Experience with Remote Patient Monitoring

and Self Management Systems

Case Example : Development and Evaluation of the

Vinfen Wellframe App for SMI

Implications for Selecting and Developing Mobile Technologies

Vinfen- Our History

1977The Massachusetts Mental Hospital

Vinfen Today:A 41-Year-Old 501-c3 Non-Profit Corporation

In Over 200 Programs Providing Community Based Services to

About 9000 Individuals Annually with:

– Psychiatric Conditions

– Intellectual and Developmental Disabilities

– Acquired Brain Injuries

– HIV

– Substance Abuse And Addiction Disorders

– Multiple Diagnoses

In Over 350 Locations in Massachusetts and Connecticut

With a Dedicated Staff of Over 3500

And an FY 2019 Annual Operating Budget of About $180M

Relevant Massachusetts Programs

DMH Funded Community Based Services for SMI• 22 DMH Funded Interdisciplinary Outreach Teams (Clients: 2500)• Transition Age Youth Outreach Program (Clients: 100)

Integrated Care:• Com Behavioral Health Home (n=800)• Certified Partners Programs(LLC with 7 Other Community Orgsfor Care Coordination with 14 ACOs (n=3500)

• Funded by Center for Medicare and Medicaid Innovation Grant

Imbedded the Bosch Health Buddy System into a Behavioral Health Home Model In a CMS Innovation Grant

Added Nursing and Health Outreach Worker to Existing DMH Outreach Teams for Adults with SMI and Chronic Medical Conditions

The project described was supported by Cooperative Agreement Number 1C1CMS330983

from the Department of Health and Human Services, Centers for Medicare & Medicaid Services.

The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department

of Health and Human Services or any of its agencies

Project #1 Health Buddy Project – Bosch (Started in 2012)

Annual Total PMPM Payments Decreased by 5.6% Combined Medicaid Only and Duals Excluding Outliers

$-

$500

$1,000

$1,500

$2,000

$2,500

$3,000

2011 2012 2013 2014

Change in Annual Total PMPM Payments 2011 - 2014

Behavioral Health PMPM Physical Health PMPM

Behavioral Health Payments Decreased by 40.1% ($452 PMPM)

2011-2014

Physical Health Payments Increased by 16.6% ( $283 PMPM) 2011-

2014

WellframeSelected Wellframe – an MIT Spinoff

– Brigham and Women’s: Surgery Recovery

– Plans (Blue Cross) : Diabetes

– McLean : Psychiatry

Content for Transition Age Youth:

• Focus Groups with Young Adults and Staff

• Some Public Domain Content (e.g., SODAS)• Adapted Evidenced Based Practices from SAMHSA

• Protocols Used by Vinfen Clinical Staff from Emerging EBPs

• Functional Info on Daily Living

Evidence Based “Manualized” Programsfor the SMI Population

• Illness Management and Recovery (IMR)

• Integrated Illness Management and Recovery (IIMR)

• Whole Health Action Management (WHAM)

• Wellness Recovery Action Plan (WRAP)

• Transition to Independence Program (TIP)

What do we Build as Clinical/Rehabilitation Content ?

TIP Manual200+ Pages30 Modules Staff Guidelines and User Aids

How Do We Get From This:

Video “Tools” include staff and young adults

in the program

Elizabeth discussed health choices at McDonalds

Jairo shares exercise tips

To This

Clinical Rehabilitation: Common Elements (Modules)Partial List of Clinical / Rehabilitative / Recovery

“Modules” in the Adult SMI Literature

• Psychoeducation• Motivational Interviewing• Personal Goal Setting• Medication Self Management• Coping with Stress• Relaxation Training• Problem Solving• Health/Wellness• Sleep Hygiene• Exercise• Nutrition Management

“Common Elements” in Most Packaged Evidence

Based Practices

Sample Content Library Topics

• Mental Health Conditions• Stress • Symptom Management• Community Life Skills• Personal Safety • Finances• Coping Strategies• Goal Setting• Purpose• Condition Specific

• Physical Activity• Medications• Nutrition• Safe Sex Practices• Sleep• Smoking• Substance Abuse• Using the Health System• Social• Purpose• Relaxation Techniques

Organized by SAMHSA’s Eight Dimensions of Wellness

http://www.samhsa.gov/wellness-initiative/eight-dimensions-wellness

Wellframe Health & Wellness App

4 Main Elements:

1. Personalized Daily Checklist

2. Personalized Profile

3. Care Team Communication

4. Content Library

Vinfen - Wellframe App for Young Adults

Other Features

1. Passive Data Collection (Exercise)2. Daily Topic on Self Management 3. Daily Personalized “ To Do” List4. Personalized Tool Box – Goals5. Links to Content Library6. Data Collection on Use- Times, Amounts,

Selected Content, etc7. User Reports on Achieving Targets8. Rewards for Use9. Staff Reports for Trends10. Communications w Staff Within System

Profile Page

DailyChecklist

Profile Page

• Progress

• Client Instructions

- Coping Strategies

- Goals

• Medication

Care Team Communication

• Communication within the app

• Used to enhance engagement

Chloe explains belly breathing (video)

Content Library

Video “Tools” include staff and young adults

in the program

Elizabeth discusses health choices at McDonalds

Jairo shares exercise tips

Videos

TAY Data- Activity—Six Months

36

99.23%

92.08%

71.01%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

M1 M2 M3 M4 M5 M6

Ave

rage

Act

ivit

y in

a G

ive

n M

on

th

Months on App

n=32 users

TAY Activity—12 Months

37

100.00%95.57%

87.20%83.06% 82.80%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Ave

rage

Ati

vity

in a

Giv

en

Mo

nth

Month on App

n=15 users

Percent of Tasks Completed-12 Months

38n=15 users

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

M1 M2 M3 M4 M5 M6 M7 M8 M9 M10 M11 M12

Pe

rce

nt

of

Pu

she

d It

em

s C

om

ple

ted

Months on App

Video

Tasks

Surveys

Content

Med Reminders

Physical Avtivity

5.65

6.82

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

10.00

Pre App Post App

Co

nfi

de

nce

Ran

k (1

-10

)

Observation Point

Confidence significantly improves after use of the app, T(9)=-4.00, p=.003.

Preliminary Self-Efficacy for Managing Chronic Disease 6-Item Scale

7.5

7.3

6.4

6.9

6.4

6.4

5.7

6

5.8

4.3

6.6

5.5

0 1 2 3 4 5 6 7 8

How confident are you that you can do things other than justtaking medications to reduce how much your illness affects your

everyday life?

How confident are you that you can do the different tasks andactivities needed to manage your health condition so as to

reduce your need to see a doctor?

How confident are you that you can keep any other symptomsor health problems you have from interfearing with the things

you want to do?

How confident are you that you can keep the emotional distresscaused of your disease from interfearing with the things you

want to do?

How confident are you that you can keep the physicaldiscomfort or pain of your disease from interfearing with the

things you want to do?

How confident are you that you can keep the fatigue caused byyour disease from interfearing with the things you want to do?

Confidence Level (1-10)

Pre

Post

Stanford Self-Efficacy for Managing Chronic Disease 6-Item Scale–Item-by-Item

Second Wellframe Project

Evaluating an Expanded Wellframe App for Adults with SMI

• BCBS Foundation of Mass 3 Year Funded Project• Launched in April 2016• Targets: Adults (wider age range) in DMH Outreach Program

in Plymouth• To Date: 62 individuals and 15 staff used system• Measuring a range of user experience, process and functional

outcomes• Control group for functional outcomes : Weymouth CBFS• Good Adherence to Date

Data Tracking for App Users:

Use of the App

Adherence

Patterns and frequency of use

Content Library access

Communications with staff through the App

Alerts triggered

Responses to emotional and mental health status

Outcomes

Changes in health outcomes such as acute service utilization currently tracked by Vinfen

Milestones of Recovery

Monthly Functional Outcomes

Comparisons to non-users

Encounters

Changes in user satisfaction (SF-12), Healthy Lives Scale, Wasson Health Confidence Measurement

Older Adults: CLIENTS HAVE BEEN ENGAGED FOR AN AVERAGE OF 188 DAYS

Older Adults: PROGRAM RETENTION AND WEEKLY ENGAGEMENT ABOUT 80% THROUGH 350 DAYS; DAILY ENGAGEMENT ABOVE 60%

Days in Program 0-90 0-180 0-360

Daily Engagement 68.9% 66.8% 64.9%Tasks Completed 64.1% 63.4% 63.9%Medications Taken 64.2% 59.8% 56.4%Surveys Completed 64.96% 64.0% 67.1%

Older AdultsADHERENCE AND TASK COMPLETION % PER CLIENT PER MONTH

How Easy Is Navigating the Wellframe app?Average rating (out of 10) from 50

respondents: 8.4

App User Feedback

Favorite Use: • Physical activity/step tracker• Articles/educational content• Reminders• Encourages goal achievement• Helpful with daily living routines• Makes users “think”, surveys orient them

to how they’re feeling that day

Staff Engagement with Health and Wellness App

• 62 total enrolled app users through 3/18

• 30 project iPhone 6’s distributed

• 58 avg additional touchpoints (messages to users) from 12/17-3/1

Client Comprehension:• 46% are confident that they can perform effectively on many different tasks• 64% believe that they can succeed at most any endeavor to which they set their mind to

Client’s Behavioral State:• 38% stated they will be able to achieve most of the goals they have set for themselves• 64% will be able to successfully overcome many challenges they may face

Proactively-identified Opportunities For Intervention:• 54% stated that in the past 7 days, they sometimes feel depressed• 28% stated that in the past 7 days, they sometimes felt like they needed help for their anxiety

Data on Self Ratings

• 60 yr old male with a history of bipolar disorder plus physical health conditions: obesity, arthritis, rheumatism, back pain, and peripheral neuropathy.

• Difficulties with lifting, twisting, and standing for long periods of time.

• Participant in app program 7/8/16 to 11/29 17; completed the Foundation program as well as the anxiety, depression and diabetes supplemental programs.

• Highly engaged and completed his checklist in the morning every day.

• Worked on losing weight and becoming more physically fit and stronger.

• The step tracker helped significantly increase his walking and flexibility and he was logging an average of 4 miles per day.

• Lost a total of 15 pounds since being on the app.

• Reported a reduction in depression symptoms and ability to do more ADL’s than before, such as make his bed every morning.

• Found the content interesting and helpful and was committed to applying at least one piece of info or skill from each article into his healthy routine

Client Story

Planning

• Full Data Analysis for Wellframe Groupand Comparison Group to Occur in the Spring

• Identification of “Responders” and Review of Their Process and Outcome Data

• Need Better Information on Initial Engagement and Rejections

• Questions Regarding Structuring Interventions-• Long list of modules with varying content may be good for

engagement, but may need more guidance for users to focus on contact related to their behavioral health challenges which are barriers to achieving their goals.

• Considering Targeting High Utilizers of Acute Care for Medical Problems• ACOs Expressing Interest

• Evaluating Other Technologies• Goal: Develop a Suite of Technologies for a Tech-Enabled Clinic

Established in 1977, Vinfen is a private, nonprofit human services organization and the leading mental health provider in Massachusetts. Vinfen provides a comprehensive array of services to youths and adults with psychiatric, developmental and behavioral disabilities. Vinfen's 2,300 dedicated employees are experienced, highly trained professionals who provide a full range of educational, rehabilitative and clinical services in more than 200 programs throughout eastern Massachusetts and northern Connecticut. For more

information, visit www.vinfen.org.

950 Cambridge Street, Cambridge, MA 02141

© 2018 OPEN MINDS© 2018 OPEN MINDS

Comprehensive Mental Health Services Case Study:

Gina Armitage, MS, LPC, Director of Quality and Compliance,

Comprehensive Mental Health Services, Inc.

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myStrength

About CMHSComprehensive Mental Health Services began in 1969 as a satellite

service provider of the Western Missouri Mental Health Center. As we

continued to grow, we moved into the Independence area and

increased our catchment to the Eastern Jackson County area. In 1989

we added substance use treatment to our services and began adding

more facilities to our campus, including residential programs, youth

and adult programs and independent living. We moved into our main

center at the William H. Kyles Building and now serve around 3500

clients a year.

CMHS ProgramsThe programs at CMHS include:

• Outpatient Therapy Services

• Medication Clinic

• Crisis Services

• Community Support Services

• Substance Use Disorder Services

• Residential Services

• Healthcare Home/Healthy Lifestyles

• Supported Employment

Personalized Emotional Health Resources

Mind + Body + Spirit • Wellness• Spiritual• Social and Community

• Stress• Depression• Anxiety

• SUDs• Chronic Pain• Insomnia

Interactive Applications

Cognitive Behavioral

Therapy

Behavioral Activation

MindfulnessMotivational Interviewing

Positive Psychology

myStrength FeaturesDaily Trackers

In-the-Moment ToolsCoaching and Community Interactions

Interactive Self-Care Programs

Adoption of myStrengthWe officially adopted myStrength into our curriculum and treatments in July of

2018, beginning with a series of agency wide trainings.

1. Management Staff – first staff trained as well as becoming trained

trainers to begin training their own staff.

2. Clinical Staff – staff that provide direct services to our clients.

3. Support Staff – this includes administrative staff, technicians and

financial/business staff.

Adoption of myStrengthThanks to support from our

Executive and Leadership Teams, we

can ensure that we have the support

we need to keep myStrength an

active part of our training curriculum

and treatment plans.

myStrength Supports CCBHCsTo facilitate Certified Community Behavioral Health Clinic (CCBHC) status,

myStrength empowers consumers with person-centered, family-centered, trauma-

informed care outside of traditional four walls.

• Access anywhere, anytime, at any help level

• Extends evidence-based self-care resources 24/7

• Empowers clients to be active in their recovery

• Opens access to families, networks and peers

• Enhances care in clients’ setting of choice

• Incorporates the Triple Aim to improve population well-being and lower costs

• Reporting on service usage/access, clinical outcomes, and more

myStrength at CMHSmyStrength is introduced to CMHS staff from their very first orientation as well as a focused training for

all clinicians on how to introduce it into their client caseloads.

OR

IEN

TATI

ON Staff are introduced

to the myStrength website, given a tour,

personal card and access codes.FO

CU

SED

TR

AIN

ING Clinicians are given a

1 hour training that goes deeper into the

website, its practices, activities and functions, and

given tools to facilitate use with

clients. CLI

NIC

AL

PR

OC

ESS Clients, as well as

their caregivers or family members, are given personalized access codes and assistance with signing up and

logging in, given a tour and encouraged

to customize their experience.

FOLL

OW

UP Clients are asked if

they are continuing to use myStrength

and are welcomed to bring their insight into treatment or

follow activities on their own.

SUD Program Integration

myStrength is incorporated into educational groups within the SUD program

When a client attends a SUD group, they can sign up for a

myStrength account with staff support

During group, the client is shown how to access

myStrength and explore the resources and educational materials to support their

individual goals

Following Up on myStrengthClient use of myStrength is followed up in two ways: via questionnaire and through our EMR.

QUESTIONNAIRE

• Upon every outpatient or medication clinic visit, clients are given a questionnaire. One of the questions indicates if they have utilized myStrength since their last visit.

VIA THE EMR

• In applicable programs, the use of myStrength is recorded via the EMR in the Daily Living Assessments that are completed for clients by the clinician.

The impact of myStrengthAlong with myStrength use, client symptoms are also tracked via questionnaires and recorded based on a number of factors including date,

program, clinician and symptom. The scale is similar to a class grade, 100% indicating no symptoms and 0% being multiple symptoms.

The impact of myStrengthStarting in February 2018, we began officially tracking myStrength use in our clients via the questionnaire. The data below

indicates clients that do not utilize myStrength. While the average grade is steady, it doesn’t indicate a great improvement.

The impact of myStrengthHowever, the clients who do utilize myStrength report improved symptoms over time as well as a greater overall

average critical grade.

Clinical ImprovementsMENTAL HEALTH

• 70% of users scoring with clinical levels of depression report improvement

• 42% average reduction in depressive symptoms across all users

• 45% of users scoring with clinical levels of anxiety report improvement

• 25% average reduction in anxiety symptoms across all users

SUD• 66% of patients participate in the SUD

program (357 out of 538)

• 47% of patients who used myStrength successfully met treatment goals at discharge

• 18% of patients who did not use myStrength successfully met treatment goals at discharge

Client Feedback: myStrengthHow has myStrength been helpful to you?

• “MyStrength has been helpful to me, because it has helped me to focus on the

recovery of my mental health…”

• “It gave me several recommendations on ways to divert my worries/stresses

into a less significant section of my mind.”

What were you hoping that myStrength could do for you?

• “Help me remain positive and learn how to deal with stress.”

• “Help me regain my focus and set goals for moving forward in my new life.”

What would you have done if myStrength wasn't available to you?

• “…I would have less coping mechanisms for stress.”

Joseph: A Case StudyJoseph was a client who found myStrength to be a key component in his

treatment. Joseph initially came into CMHS symptoms of depression,

anxiety, and panic attacks. He also had trouble managing his health and

smoked a pack of cigarettes a day. When Joseph was introduced to

myStrength, he had some hesitation at first as the idea of a technology-

based tool was intimidating to him. He was open to giving it a try and

began utilizing it within therapy sessions and at home. After approximately

3 months of incorporating myStrength into his treatment, Joseph was able

to start taking control over his life. Joseph compiled his completed modules

and exercises in a binder and would log in during therapy to indicate his

progress.

Name/identity has been changed for privacy

Joseph: A Case StudyMindfulness and deep breathing were two primary practices that

became significant towards his well-being. Joseph also used specific

resources for his physical health. He was able to quit smoking in

two months without the use of any nicotine replacement therapies.

The client’s therapist would always check in on the use of

myStrength, and at the beginning of every session, would start with

a mindfulness exercise. This supported the integration of the

myStrength platform into the client’s treatment. This client stated,

“myStrength saved my life.” He has since met his therapy goals and

completed individual therapy.

Name/identity has been changed for privacy

The future of myStrengthWhile we are excited about the current effect myStrength has with CMHS staff and consumers, we are

always looking forward to the future and continuously improving our processes and outcomes.

MORE CLIENTS

•As the agency continues to expand, continue

introducing more clients to myStrength.

MORE COMPONENTS

•Continue expanding use of myStrength to include any

updated modules as well as more individualized training

plans for clients. Enhance integration with EMR

platforms.

MORE EMPLOYEES

•Clients, as well as their caregivers or family members, are given

personalized access codes and assistance with signing up and logging in, given a tour and encouraged to

customize their experience.

MORE COMMUNITY

•Continue to invite family and caregivers of clients to

myStrength to further our whole-person supportive

approach and assisting clients with finding a

supportive environment.

Questions?

© 2018 OPEN MINDS© 2018 OPEN MINDS

Questions & Discussion

73

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