A 5-Step Population Health Initiative Could Reduce Your Asthma ED Admissions by Half

A digital therapeutic device is the centerpiece of Dignity Health's model that decreased ED admissions by 54%, improved outcomes, and reduced costs.

How did Dignity Health reduce asthma-related emergency department visits by more than half (54%) in a pilot study? Through the use of digital therapeutics to help asthmatic patients control their disease.

The one-market pilot, which used digital sensors from Propeller Health that slip over patients' inhalers and connect via wireless technology to their smartphone app and a clinician dashboard, also reduced emergency department visits combined with hospitalizations by 57%. The digital sensors remind patients to take their routine medication, collect and transmit information to physicians about missed doses and rescue inhaler usage, and alert patients and the care team when negative trends about the patients' asthma are developing.

The population health initiative was so successful, the San Francisco–based health system is absorbing the cost of the devices for enrolled patients and is expanding the program to additional markets. Eventually, it will be deployed throughout the entire Dignity Health system. The reductions in admissions were documented in a peer-reviewed study published December 3, 2018, by World Allergy Organization Journal, provides a model for other systems to emulate.

[Editor' note: On February 1, Dignity finalized a merger with Catholic Health Initiatives. It is not yet apparent whether this program will be available throughout the new organization, which will be known as CommonSpirit Health.]

Following are five steps a health system can take to launch such an initiative based on Dignity's experience:

1. Focus on Strategic Objectives
 

A population health initiative addressing asthma makes sense for health systems focused on improving patient outcomes and reducing costs, as well as those involved in value-based care. With those strategic objectives as the backdrop, Dignity's office of innovation was seeking solutions that dovetailed with the organization's goals. Propeller's solution seemed to fit the bill.

"This is a digital tool that can provide convenience and access to our patients and really meet the triple aim in terms of improving quality and reducing costs," says Christine Brocato, Dignity's director of strategic innovation.

Asthma is a pervasive and costly disease. As previously reported by HealthLeaders in a story about similar population health initiatives conducted in Los Angeles and Louisville, Kentucky, each year in the U.S. the disease accounts for 14.2 million doctor’s office visits, 439,000 discharges from hospital inpatient care, and 1.8 million emergency department visits, according to the Asthma and Allergy Foundation of America. Nationwide, medical costs associated with asthma totaled $50.3 billion between 2009–2013.

"We're very interested in digital tools that are relevant for population health … and value-based care," says Brocato. After evaluating Propeller's solution, Dignity decided to work with the company to "collect a body of evidence that could help us understand the clinical impact that this technology would have."

Asthma treatment often requires multiple medications with a schedule that can disrupt a patient's normal routine. "This presented the opportunity to test out a technology that seamlessly fits into a patient's life and have a frictionless experience," Brocato says. With a variety of sizes to accommodate different types of inhalers, the Propeller sensors attach to inhalers patients are already using.

"There are no added steps," she says, "so it really has the potential to fit seamlessly into a patient's life. When you do that, you can increase adherence, and when you increase adherence, you tend to see better outcomes."

2. Identify a Physician Champion
 

Health systems often seek enthusiastic clinicians to champion a solution, particularly when it involves technology. To test the concept, Dignity's innovation office turned to Rajan Merchant, MD, FACAAI, an asthma expert at Dignity Health Medical Foundation in Woodland and Davis, one of the system's multispecialty physician groups near Sacramento, California. Merchant began using the devices with his own patients, as well as those referred by other physicians in the practice, such as primary care practitioners. To date, about 600 patients have been enrolled.

One key to broader adoption by other physicians was to evaluate the effectiveness of the tool in a health system. Merchant conducted a couple of studies that have been published in peer-reviewed journals, which further solidified the evidence. The initial study, published in the May–June 2016 edition of the Journal of Allergy and Clinical Immunology, concluded that Propeller device usage significantly decreased the use of rescue inhalers by patients. The second study in the World Allergy Organization Journal, cited above, documented the reduction in ED visits and hospitalizations.

This convincing data enhances referrals. Out of 90 physicians in his multispecialty practice, Merchant says that about a third have referred patients for enrollment into the program.

While there is no longer a need to study the effectiveness of the device in a health system, the studies may be helpful to physician champions at other organizations as they educate their colleagues about the advantages of these devices.

3. Establish Monitoring Capabilities
 

Monitoring capabilities are the heart of the system, enabling caregivers to ascertain which patients are not adhering to their medication regimen or are beginning to show signs of distress. A dashboard provides access to this information and more, even pinpointing locations where a patient is most frequently symptomatic.

The system issues alerts, but is not intended to deal with emergency situations; it is designed to pick up trends before an acute situation occurs. Patient also receive the alerts via text or their app. Physicians can monitor alerts and intervene if a patient is not taking their medication or if inhaler use is accelerating, for example. The caregiver might prompt the patient to use medication as prescribed, change a prescription, or suggest an office visit.

There are a variety of ways to set up monitoring capabilities. At Dignity, a population health coordinator is responsible for reviewing the dashboard daily and initiating interventions along with the physicians. Merchant and another physician manage the program for all enrolled patients, and keep the referring physician informed. While referring doctors have access to the dashboard, few monitor it because it requires training, daily dedication to monitoring, and a workflow commitment that is difficult to justify if only a handful of patients are enrolled in the program.

4. Scale Across the Enterprise
 

Once the champion has completed a pilot and monitoring responsibilities have been established, the program can be scaled across the enterprise. Dignity is doing this in stages. 

The program has now expanded to other locations, including Dignity Health Medical Group Arizona, located in Phoenix, and Dignity Health Medical Group Ventura County, in southern California.

At least one physician in each location will manage the program and monitor the dashboard for patients enrolled in each clinic. In addition to referrals from physicians in each clinic, Brocato says that Dignity is now actively mining the data to identify patients who are good candidates and encouraging them to enroll in the program.

Initially, the objective is to "see if we can replicate some of these outcomes that we've been able to demonstrate [in our market] in other markets throughout the organization," says Merchant. Dignity will use this experience to determine the best way to roll it out systemwide, but suspects that this hub-and-spoke model will likely work best.

5. Consider Future Capabilities
 

While the system is currently geared to improve outcomes for individual patients, the data it collects could have other benefits. Each time a rescue inhaler is activated, information about weather conditions and pollen count and geolocation is also collected. This could eventually be used to create a forecast for patients to better prepare them for the day ahead.

In addition, "one of the major issues is that we know people don't use their inhalers appropriately," says David Stempel, MD, senior vice president clinical and medical affairs at Propeller Health, which was acquired by ResMed in December. A proper inhalation takes about 30 seconds, perhaps longer. "Because we know the time of inhalations, we can actually see that a large proportion of patients are doing their inhalations too quickly."

Meanwhile, Dignity Health's population health initiative is being recognized by the Intelligent Health Association (IHA). At the upcoming HIMSS 2019 conference, the organization will present the health system its GRAND Award, which according to IHA, recognizes the most compelling healthcare projects that incorporate wireless technologies to deliver a sustainable impact on the patient experience, safety, and healthcare facility operations.