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Engagement: The key to complex care

Tom Cox, Chief Executive Officer, MyHealthDirect
Tom Doub, Chief Executive Officer, Centerstone Research Institute

The U.S. Department of Health and Human Services estimates that 25 percent of all Americans – and 75 percent of those over age 65 – are dealing with multiple chronic conditions. A landmark study by the Center for Health Care Strategies found that about two-thirds of Medicaid patients with the five most common chronic physical conditions – asthma/COPD, congestive heart failure, coronary heart disease, diabetes and hypertension – also have a behavioral health comorbidity like depression or substance abuse (Figure 1).

Those who have a mental illness in tandem with chronic physical conditions have healthcare costs up to 75 percent higher than those dealing with physical conditions alone (Figure 2).

Despite the seriousness of their health situation, many people with comorbidities aren’t adequately engaged with the healthcare system for a variety of reasons. A recent study published in the New England Journal of Medicine found that fewer than half of those who survived a major heart attack adhered to their medication regimen after the attack. Study authors Lee Goldman, MD and Arnold Epstein, MD noted that “Perhaps the most sobering findings were the low baseline adherence and the small improvement in adherence in what should have been a highly motivated group of patients.”

At the heart of the problem is the fact that adherence can be extremely complicated. For example, a diabetic must manage medications, monitor glucose levels and adhere to dietary guidelines throughout the day. If that same person also suffers from depression and COPD, there are more medications to manage and more things to do in order to adhere to multiple treatment plans. And a patient with depression often lacks the motivation to tackle this daunting task.

Improving outcomes for superutilizers

Last year, our non-profit research institute launched a two-state initiative called coactionHealth, a novel clinical intervention that integrates mobile technology and data analytics into a coordinated care program. coactionHealth was designed to improve outcomes and lower the cost of care for Medicaid superutilizers – those who have more than $25,000 in annual healthcare-related expenses. These individuals typically rely on the emergency room (ER) and hospital visits to treat complex mental and physical health conditions.

The coactionHealth program leverages technology, but it’s not designed as a showcase for the latest gadgets and software. The main objective is to make patient engagement easier and more frictionless – and to provide round-the-clock data that doesn’t require any effort on the part of either patients or clinicians.

Former Facebook executive (and now at Mount Sinai School of Medicine) Jeff Hammerbacher has noted that the traditional healthcare system consists of infrequent, invasive and expensive events. He feels that the health system should operate more like good technology: frictionless, always available and easy to use.

The coactionHealth initiative is helping to lead that transformation. Participants receive a smartphone featuring secure texting, email and video chat capabilities. The phone uses the app that collects passive data 24/7, gathering information on patient communication, activity and sleep patterns. There’s no snooping into exactly where a patient goes or the people they call. The app merely looks for patterns: not leaving the house for several days, not responding to text messages, etc. To assess sleep patterns, the app monitors smartphone activity during the overnight hours. Any worrisome changes in behaviors create an alert for the wellness coach – providing a prompt avenue for rapidly addressing concerns before they become crises.

Here are some of the benefits that coactionHealth is providing:

  • Inexpensive way to help patients become more engaged in their healthcare. They can reach out to clinicians anytime – securely and easily – which greatly reduces the likelihood of them winding up in the ER.
  • Timely education and reminders – Superutilizers can get care tips and education in a manageable way, avoiding the information overload of printed brochures and flyers. Technologies are much more reliable than humans in giving timely reminders about upcoming appointments and medication schedules.
  • Less need for self-reporting – Although coactionHealth gathers brief questionnaire data each week, the passive data collected can alert clinicians to unusual patterns like isolation and poor sleep, prompting a check-in call or text.
  • Better outcomes, lower costs – coactionHealth has reduced superutilizers’ ER days by 23 percent and hospital days by 51 percent.

Programs like coactionHealth are proving that the healthcare system doesn’t need hundreds of discrete tech “solutions” but rather a system redesign aided by technology. Patients are much more engaged when communication and data collection are easy – and that drives better outcomes and lower costs. Best of all, this long-overdue redesign can benefit not just superutilizers but all healthcare consumers.


Figure 1 Source: CHCS study
Figure 2 Source: CHCS study


chronic condition, coactionHealth, app, MyHealthDirect, patient engagement, superutilizers