With the Cardiac LIFT Clinic, Akron Children's Hospital is giving single-ventricle patients and their families an opportunity to 'survive and thrive' at home, rather than in a hospital or clinic.

Young children with acute care needs don't necessarily have to be in a hospital to get them. Healthcare organizations are now using virtual care platforms and digital health tools to give these patients and their families the care they need at home.

Akron Children's Hospital has gone all-virtual with the Cardiac LIFT (Lifelong Interventions Focused on Thriving) Clinic, reportedly the first program in the country to offer completely virtual care for young single-ventricle patients from prenatal early diagnosis through early adulthood. The program enables families to transition from an NICU to the home and stay there.

"We want [these patients] to survive and thrive," says Kathyrn Wheller, MSN, APRN-CNP, a pediatric nurse practitioner and the clinical lead for the Cardiac LIFT Clinic. "The single-ventricle population is a complex population for cardiology patients in general. This program gives them … that freedom."

Single-ventricle patients are born with one lower chamber of the heart that is smaller, underdeveloped, or missing a valve, and occur roughly in five out of every 100,000 newborns. Three of the most common diagnoses are Hypoplastic Left Heart Syndrome, Pulmonary Atresia/Intact Ventricular Septum, or Tricuspid Atresia.

They start their lives in a neonatal intensive care unit (NICU), and require open-heart surgery at 2-6 weeks, 4-6 months, and 3-5 years to reconstruct their hearts as they grow. These surgeries are called Fontan procedures, and for that reason the patients are often called Fontan patients.

Kathyrn Wheller, MSN, APRN-CNP, clinical lead for the Cardiac LIFT Clinic at Akron Children's Hospital. Photo courtesy Akron Children's Hospital.

The survival rate for all three surgeries used to be low, but improvements in surgical techniques and clinical care have pushed that rate upwards, so that many children can now expect to live into their 40s, if not longer.

Because of the complex nature of these surgeries and care management, single-ventricle patients and their families spend a lot of time in the hospital, clinics, and doctor's offices, meeting with a care team that often consists of several specialists. At Akron Children's, executives had been mapping out a full, multi-disciplinary clinic for these patients.

"Then COVID hit," says Wheller. "We skipped right over the planning and launched our program [on a virtual platform], focusing on the first few months. It's not that easy to do in the cardiac world, but we had to do it."

Wheller said the hospital made plans to go to a hybrid setup once the pandemic waned, "but the virtual visits went great. We didn't need to see them in person when we could do everything we'd need to do with a virtual visit."

The Cardiac LIFT clinic opened in January 2021, and has conducted more than 130 unique visits for about 70 of the estimated 140 patients within Akron Children's Hospital's coverage area (another 35 patients are adults, who receive care separately). Wheller says those numbers will grow in time, because the hospital will be able to serve patients and their families for a broader geographic area.

Wheller says the platform not only allows the patient and family to meet with the care team and specialists from the comfort of their own home, but it gives that care team an opportunity to see more of that patient's home life and environment, which could factor into care management plans. And in a less formal setting than a doctor's office, patients, family members, and the care team could talk about diet and exercise, behavioral health issues, and other factors that affect that patient's health and wellness.

"When you see them in their home environment, you understand better the challenges they face, and just as importantly, the challenges their family faces," Wheller points out. "You can then make more reasonable plans for care."

The platform also helps the care team. Specialists can be brought in virtually, no matter where they're located, and scheduled to meet individually with the patient or as a team. Through an audio-visual link they can arrange to meet weekly or bi-weekly, especially during the first few months, then monthly or as needed.

Wheller says the program is also incorporating remote patient monitoring tools, which allow the care team to keep a daily eye on cardiac function and other vital signs, tracking the trajectory of the heart and the patient in between necessary in-person appointments.

Sara Rush, MD, Akron Children's Hospital's chief medical information officer, says the platform allows the care team to be creative in how it develops a care management plan. They can include physical therapists, nutritionists, behavioral healthcare providers, teachers, and social workers as the need arises.

"This is not the way we learned to practice medicine, so it takes a little time to get used to things," she says. "Then you start to realize that reaching out and pulling in all these resources makes so much sense. You can even bring in community resources."

While the platform is designed with the patient at its center, there are clear benefits for parents and other caregivers as well. Virtual care can help to reduce the stresses on parents and caregivers who struggle with their own health and wellness, cutting down on travel time to and from the doctor's office and missed work, and offering resources for coping with the burden of being a caregiver. Many health systems, in fact, are integrating family and caregiver services and resources into their virtual care programs, with the understanding that a patient's health is directly affected by the health and wellness of those around him or her.

"This is one of those things that can make us better at what we do," says Wheller.

The Centers for Medicare & Medicaid Services has proposed a 12% reduction in reimbursement for CPT codes supporting RPM. Health systems and advocates say that could affect a service that has been known to reduce unnecessary hospitalizations by 50%.

A provider of remote patient monitoring services to several health systems in six states warns that proposed cuts in Medicare reimbursement could endanger those services, which it says are saving thousands of Medicare dollars per patient served.

New York-based Cadence, which partners with health systems in Alabama, Arkansas, North Carolina, Washington, Wisconsin, and Michigan, recently submitted comments to CMS on the proposed cuts (the comment period is slated to end on September 6).

"By driving better patient outcomes, we're reducing emergency room visits by up to 50% for patients who are enrolled in Cadence programs and decreasing their cost of care by $5,000 on average," says Chris Altchek, the company's founder and chief executive officer.

Cadence, which has partnered with LifePoint Health, Community Health Systems, and ScionHealth, is one of dozens of telehealth companies in the rapidly growing RPM space, which saw a surge of interest when the pandemic pushed health systems to curtail in-person services and push more programs onto virtual platforms. Proponents say RPM will continue to grow as healthcare executives see the value in improving care management for patients in their own homes.

Among other stakeholders expressing concern about the cuts so far are the American Telemedicine Association, and Altchek hopes the American Hospital Association, the Alliance for Connected Care, and the Federation of American Hospitals will also file concerns.

Like many others using RPM, Cadence is targeting care management for patient with chronic health conditions, including congestive heart failure, hypertension, and type 2 diabetes. About a quarter of its patient base lives in underserved areas, where RPM programs may be a lifeline for people who face barriers to accessing care.

Chris Altchek, founder and chief executive officer of Cadence. Photo courtesy Cadence.

"CMS has done a lot of good work trying to focus on these chronic conditions," Altchek says.

Under current CMS guidelines, CPT code 99454 specifically reimburses providers for devices and transmission of data to collect vital signs from patients at home. RPM programs typically send digital health devices, such as blood pressure cuffs, weight scales, and blood glucose monitors, home with patients, who monitor their health, send data back to care teams and collaborate on managing their care.

In its proposed 2023 Medicare Physician Free Schedule, CMS is proposing a 12% cut for 99454. It's one of several significant modifications to RPM reimbursement, as outlined in the ATA's August 24 letter, written by Kyle Zebley, executive director of ATA Action.

"These cuts run counter to CMS' stated goals of improving patient outcomes, advancing health equity, and reducing spending through the use of remote patient monitoring technology," states the Cadence letter to CMS.

[See also: CMS Proposes to Cut Audio-Only Telehealth Coverage.]

Altchek is hoping the groundswell of support for RPM programs and criticism of the proposed cut will spur CMS to reconsider.

"CMS is aware and engaged on this topic," he says. "Something could change. They spent a lot of time, almost 10 years, building out a framework to allow these codes to come into play, so they're as motivated as anybody else to make sure they don't limit innovation that they sparked before it can really take hold."

Altchek says accountable care organizations (ACOs) using RPM programs supported by Cadence are seeing a 19% savings on average total cost of care.

"We're sharing everything we have [with CMS] and have offered to update them every six months on the total cost of care savings across our patient population," he says.

CMS has scheduled a 2023 policy review of the cuts affecting 99454 and related CPT codes 99453 (patient onboarding), 99457 (first 20 minutes of monitoring and delivering care to a patient remotely), and 99458 (the next 20 minutes).

"We were not listened to last year, but next year, they've scheduled a real conversation around it," Altchek says.

The policy review will be conducted by the RVS Update Committee, a volunteer group of 32 physicians and other healthcare professionals who advise Medicare on how to value a physician's work.

"My guess is it would go through that process, and then CMS would take it under review as part of its rulemaking," says Meryl Holt, head of legal and chief compliance officer at Cadence.

CMS is also somewhat constrained by existing law. "CMS as the agency is somewhat restricted by the legislative framework that's in place, so they have limited tools with which to actually affect change with particular codes," Holt says.

Should appeals to CMS fail, Altchek says a push for a legislative solution is another option.

"CMS data show that among original Medicare beneficiaries aged 65 years and over, the prevalence of CHF, type 2 diabetes, and hypertension was 13%, 25%, and 58%, respectively," says Cadence's letter to CMS. "This translates into direct medical costs, which for heart disease (excluding stroke) totaled $281 billion in 2015 and $237 billion for diabetes in 2017. Using RPM services to manage these conditions will improve patients’ access to quality care, while also alleviating the burden on clinicians and Medicare spending."

If the CMS reimbursements decline, Altchek says Cadence would withdraw from serving certain regions rather than reducing the quality and quantity of remote patient monitoring.

"We won't deliver the service if we don't think we can do it in a way that's a high-quality way," Altchek says.

Eric Gantwerker, MD, MMSc (MedEd), FACS, a practicing pediatric otolaryngologist and medical director for Level Ex, explains how healthcare organizations can use video games and gamification as an educational tool for clinicians.  

Editor's note: This article appears in the September/October 2022 edition of HealthLeaders magazine.

Video games aren't just for fun any more.

Healthcare organizations are finding uses for video games that go far beyond entertainment. They're being used to help patients – particularly younger ones – understand healthcare concepts, from chronic disease management to medication adherence, while care providers are using games to track patient outcomes in cases ranging from autism to concussion treatment.

More recently, health systems are using them as educational resources, with the idea that a game can work better than a book or classroom event.

HealthLeaders recently sat down (virtually) with Eric Gantwerker, MD, MMSc (MedEd), FACS, a practicing pediatric otolaryngologist at Northwell Health's Cohen Children's Medical Center and medical director for Level Ex, a video game studio that has designed games for continuing medical education (CME). Gantwerker, who holds degrees from Harvard Medical School and Georgetown University and was recently inducted as an associate member of the American College of Surgeons' Academy of Master Surgeon Educators, shares his thoughts on how the power that practicing through play can improve a clinician's ability to learn and adopt new skills.

Q: What are the benefits to using video games for continuing medical education (CME)?

Gantwerker: While video games are inherently built for entertainment, at their core, they are built on deep knowledge and understanding of how to activate and stimulate the brain to induce learning.

For hundreds of thousands of years, humans have learned through play. Whether playing pretend, turning over a snow globe, or knocking over a maze of dominoes, our minds are constantly developing new mental models to understand the world around us. Expert game designers are well-versed in sociology, psychology, and the cognitive sciences that underlie motivation and behavior. They know how to achieve the perfect balance between challenge and mastery and they develop games deliberately to build reward-driven experiences that capture the attention of billions of people. Games are also intentionally designed to quickly and easily onboard players to the rules and progress swiftly to developing strategy by simply playing the game.  

Eric Gantwerker, MD, MMSc (MedEd), FACS, a pediatric otolaryngologist at Northwell Health's Cohen Medical Center and medical director for Level Ex. Photo courtesy Northwell Health.

Because video games are built for entertainment, they create an intrinsically motivated environment for players where they play for the sheer pleasure of playing. Traditional medical learning and CME are a requirement of medical practice, creating an extrinsically motivated environment for physicians, but they are not fun by design. Lectures, webinars, and thick textbooks are a passive form of learning that often require more time to learn from, but don’t always translate into strong knowledge retention. When games and medicine collide, healthcare professionals are thrust into an entertaining environment that they actively want to engage with - the material just happens to be something they are very familiar with and can learn from. If done well, games can be an extremely powerful tool. 

Q: How are these games introduced or incorporated into an education regimen?

Gantwerker: Oftentimes, the best way to integrate them is to augment formal learning for both knowledge and skills. Games are not intended to replace entire curricula, nor should they. Medical education that is rooted in facts, such as learning the bones in the body, can be easily learned through passive activities like reading or simple matching exercises. For more challenging, experience-based interactions in medicine, such as performing a knee replacement operation or diagnosing a skin disease, the power of video games to create mental models and build 3D spatial skills helps physicians actively make sense of the complexity through play. Imagine the physics that is learned through playing Angry Birds. Players understand mass, velocity, inertia, and all of Newton’s three laws of motion just by playing a game. 

Q: What are the drawbacks or challenges to using video games for CME?

Gantwerker: Perception is the major challenge facing video games for CME. There are 2.6 billion video game players in the world and their average age is 36, yet people still associate games with child-like and brain-numbing entertainment and there continues to be a lack of understanding by educators and faculty that video games aren’t just for kids. In fact, they are a powerful educational tool and often better than reading an article or chapter or sitting in a lecture.

Another challenge is that there are a lot of applications of game elements or 'gamification' that don’t work that well. This gives a bad connotation to game-based learning as the effectiveness studies done may conflate games that are developed with the deep-design principles and psychology of video games and those that just add leaderboards and quizzes to educational contexts. This leads both the public and discerning educators to believe that games aren’t as powerful as traditional learning methods, which is not true. 

Additionally, the technologies that are used to create medical video games are tremendously powerful, but they require expert game designers and engineers to realize their full potential. Because of this, we are now seeing more digital health startups hiring from the ranks of triple-A game studios to advance their work in this area. 

Q: How does a video game improve a healthcare provider's skills that traditional education doesn't?

Gantwerker: Motivation and engagement are some of the biggest challenges named by medical educators today, but they also happen to be the major advantages of playing games. When players are both motivated and engaged they enter a state of mind called the 'flow state.' A well known psychologist named Mihaly Csikszentmihalyi coined this term to describe elite athletes and musicians. This period of intense concentration denotes a maximally efficient period of learning and contributes to better knowledge retention and skill development. The flow state creates a game environment where fun and entertainment are prioritized and education becomes the unintended consequence – it’s why people can lose track of time while playing.

Q: How does one convince a health system's executive leadership to embrace video games for CME?

Gantwerker: It all comes back to perception. There is ample evidence proving the power of games when learning technical and knowledge-based skills. Even consumer games have shown effects on learners with several studies showing that those who played action video games at a young age had better visuospatial skills and performed better on laparoscopic surgery-based tasks than those that did not.

The other critical component in gaining executive leadership’s support is helping them understand the difference between 'gamification' and true video game design. Gamification takes elements devoid of deeper learning and connection to gameplay and applies it to a separate context like leaderboards and badges. You can easily turn a learning activity like watching webinars into a game by slapping a leaderboard on to the video platform so users can see where they fall amongst their peers. It may be motivating at the start, but it does not contribute to a stronger understanding of the skills being taught.

My advice to leadership is to always give games a chance -- the risk is low and the reward can be quite high. Put a well-designed game head-to-head with any other learning modality and you’ll see the advantages of time, enjoyment, and depth of understanding. 

Q: How do healthcare-related video games differ from typical video games?

Gantwerker: This is all about context. Typical video games that use healthcare as the context are often a parody of medical practice. But if you respect the field, design games for entertainment and create a game environment that requires healthcare professionals to apply applicable knowledge to a situation, they are surreptitiously learning something medically relevant. That’s the secret sauce to creating an effective medical video game.

However, healthcare-related video games do have a lot in common with typical video games as they are both built on fundamental core gameplay loops -- the main set of actions undertaken by a player that define the game -- that have been trialed billions of times. These game mechanics and styles are ubiquitous and can easily be applied in healthcare games. They include things like match 3, collection mechanics, puzzle mechanics, first-person shooter, real-time strategy, set and play mechanics, experience points, virtual currency, etc. 

Q: How will this field evolve? What new technologies or strategies do you see on the horizon that might improve video games for CME or make the C-suite more receptive to using them?

Gantwerker: I think perceptions are finally changing and people are realizing the power of game design and technology. As I noted earlier, we are seeing a huge influx of game designers from big name studios coming into the healthcare technology startup world to advance the design of medical video games. We also see the morphing of digital entertainment and the movie industry that is pushing the boundaries of what computers and AI can do in the games industry. This will bleed over into healthcare in meaningful ways, creating much more realistic virtual patients, more natural virtual patient interactions, and more visually appealing virtual healthcare environments.

The metaverse is another concept that comes up a lot when talking about the future of gaming, but it’s important to note that the metaverse is just a platform. It’s software-based, and can be viewed through different hardware, such as a VR headset, but it is still just a platform. Many health tech companies have put their stake down on one platform, say VR or AR, but in doing so have limited themselves to that single platform. Medical video games, however, are platform-agnostic given their software-based modality and can be played on a phone, through a web browser or with the use of external hardware like a VR headset, making them much more accessible. We also see a lot of extended reality (XR) being applied in healthcare and games and this hardware will continue to get better, faster, less bulky and intrusive, and hopefully more intuitive to use as well.

I hope that the studies done on medical video games continue to evolve and not lump games like Jeopardy in with action-adventure games, when trying to draw conclusions about efficacy. Authors in this space need to be better about discerning based on educational levels and outcomes, educational context and game-type, and software vs hardware solutions. Once we have a better understanding and definition of true medical video games, we can start speaking the same language and see the widespread application of these tools in the healthcare space.

The technology cuts log-in times by 70% and leverages other cost-saving cloud efficiencies.

A hybrid cloud architecture is slashing log-in times and optimizing IT costs at a Montage Health.

Led by Tahir Ali, chief technology officer and chief information security officer, the Monterey, California-based health system's virtual desktop infrastructure (VDI) initiative is saving $298,000 yearly in productivity gains by clinicians, as well as other infrastructure costs.

That figure, Ali says, comes from slashing the initial system log-in times of each clinician from 100 seconds to 30 seconds, helping to improve more than 100,000 patient visits annually, and also aiding in rapid response to emergent care situations.

"Some people call it agile infrastructure," he says. "Consumption-based IT is where we set up different infrastructure in a way where we can scale it very quickly."

In the background, the system creates Windows-based virtual machines only when a staff member logs in, with sessions remaining available for up to six hours after initial log-in. After clinicians log out or time out, the system deletes these virtual machines, leaving only the saved data residing in Montage servers. In between log-in and log-out, clinicians' desktops can follow them from workstation to workstation, instantly available with a swipe of their badges.

The system "makes sure [that] if we have ebbs and flows, we have enough capacity on demand to give," Ali says.

Tahir Ali, chief technology officer and chief information security officer at Montage Health. Photo courtesy Montage Health.

Such an arrangement is well-known to retailers dealing with surges in computing demand during peak buying seasons, but is relatively novel in healthcare IT, he says.

"I thought, why not do it for the hospital?" he says. "We have to have people physically in the hospital at a certain time vs. maybe the middle of the night. We can do the same thing in IT."

At the heart of Montage Health's data center is a refrigerator-sized data hardware appliance provided and maintained by Dell, which creates and maintains the APEX Private Cloud that manages the provision and release of computing resources to Montage Health staff.

For further scalability, the private cloud is connected via triply redundant 10 gigabit-per-second links to the internet, where Montage maintains public cloud 'pilot lights' at Amazon Web Services as well as Microsoft Azure clouds.

"I understand that running on the cloud is expensive," Ali says. "The key is running on the cloud pay-per-use. We have [a few] VDI sessions if somebody is working from home. If we need something, we start to build that [public cloud] stack."

In the event of a disaster, Montage Health can quickly scale up those public services to meet unexpected demand, Ali says.

"The pilot light is very cheap, and we are running it inside our data center," he says. "And you have to have a multi-cloud strategy. Each cloud vendor has its strengths and weaknesses."

Montage Health's specialized VDI infrastructure can also tap the private cloud's graphics processing unit (GPU) resources to help radiologists and cardiologists read images.

Beyond the improved clinician productivity, Ali says Montage Health's infrastructure saves money compared to traditional hybrid cloud architectures.

"The traditional way is, you have your VDI infrastructure fully blocked," he says. "You have a replica of at least 70% of the same capacity running on a 'backup data center.' All licensing, hardware, and support is twice as much, because you're running in two different places. We run it in one place."

This hyper-converged infrastructure depends upon the APEX Private Cloud's 80 gigabits-per-second backplane, which eliminates the need for cables to connect the servers operating in the private cloud. Additional FSLogix software from Microsoft, powered by Active Directory, allows individual clinicians' desktop profiles to be delivered to workstations when the clinicians log in, displaying only those applications required for each clinician's work, further boosting system efficiency. If they move to different workstations during their workday, those profiles and applications follow them from workstation to workstation.

A change in how Montage Health conducts video calls internally and externally played a role in the timing of the move to the new infrastructure last November.

"Skype was going to go away, and Microsoft Teams was going to come in, and our traditional hardware was not capable at that time to run Teams with a video," Ali says.

It also was a time of standardizing after employing a variety of video call technology across the enterprise.

"We wanted to converge into a single face of Montage," Ali says. "When patients come to our facility, it doesn't matter if it's ambulatory, the hospital, even our wellness center. It's a single company called Montage Health, and we will take care of them accordingly."

The new architecture also lends itself to a zero-trust data security strategy.

"We have a product that has a full trending of every single packet that goes from one place to another place," Ali says. "If there's any deviation, the flag goes up, and they take [devices] off the network automatically.

"I can bring the technology to a cutting edge. But the security needs to be a little ahead of that."

With an emphasis on mobility and innovation, mobile health clinics are helping to tackle care gaps, reach underserved populations, and give hospitals a new access point.

Editor's note: This article appears in the September/October 2022 edition of HealthLeaders magazine.

Healthcare organizations are realizing that some services need to be brought to the consumer, rather than waiting for that person to visit a doctor. And they're using mobile health clinics to make that connection.

Mobile health clinics come in many shapes and sizes, from fully equipped, customized RVs or trailers offering a range of primary and specialty care services, to small vans with the supplies and resources needed to address one particular goal, such as sexual health education, mammography screenings, or vaccinations. They're designed to go into communities that lack brick-and-mortar healthcare resources or have populations that won't or can't access healthcare services.

"They are becoming more prevalent, in part because of the pandemic," says Mollie Williams, DrPH, MPH, a lecturer on global health and social medicine at Harvard Medical School and executive director of The Family Van and the Mobile Health Map, a resource for mobile health clinics with more than 700 members.

Mollie Williams, DrPH, MPH, executive director of The Family Van and the Mobile Health Map and a lecturer on global health and social medicine at Harvard Medical School. Photo courtesy of Harvard Medical School.

"One of the benefits of mobile health clinics is their adaptability," adds Elizabeth Wallace, executive director of the Mobile Healthcare Association (MHA), the leading membership organization for mobile health professionals in the US and Canada. "They're designed to turn the traditional healthcare relationship on its head … and create a new model of care."

Williams and Wallace were part of a team that put together The Case for Mobile, a report recently released by the Mobile Health Map and the MHA that examines how mobile health clinics support the business objectives of health systems and impact community health and health equity initiatives.

A surge in popularity as healthcare goes mobile

Williams estimates a few hundred mobile health clinics were in operation prior to the pandemic, and that number has increased to about 2,000 as healthcare organizations look at new ways to deliver care that meets consumers where they are. In addition, they're as popular in urban areas, such as inner cities, as in rural regions.

"The pandemic has sparked innovation in healthcare, including greater interest in mobile programs," the Case for Mobile report states. "Healthcare providers have adopted or scaled up other innovations, including telemedicine, drive-through testing and vaccination sites, and 'pop-up' clinics. It is very likely that innovations sparked by the pandemic will continue in various forms long after the crisis has ended. For example, many mobile clinics that began as a way to expand access to COVID testing or vaccinations are planning to continue operating and adjusting their service offerings to meet other community needs."

[See also: Upstate NY Health System Finds Strong Demand for Mobile Healthcare.]

"Because of the pandemic, everyone had to think creatively," says Williams. "Now [healthcare executives] are thinking about new ways to use mobile clinics. Some are using them to expand business lines, while others want to expand capacity or reach new communities."

And while some have classified mobile health clinics as "alternatives" to healthcare models, a 2017 study published in the National Library of Medicine and authored by researchers at Harvard Medical School indicates these vehicles can also serve as entry points to a health system, helping consumers navigate the complexities of healthcare access, and paving the way for future in-person and virtual connections.

"In many contexts, [mobile health clinics] can and do play an integral part in a healthcare system, providing accessible and sustainable care with quality that matches traditional healthcare settings," that study concluded.

These mobile access points "can identify pressures that a hospital is facing and address them in a different way," Wallace says. They can be located next to a retail center, like a mall or supermarket, or alongside a library or town offices, even next to a theater, park, beach, or motel, attracting people who might need care but are wary of going to a crowded ER or urgent care clinic.

Finding the right use case for a mobile health clinic

Williams says a common misperception about mobile health clinics is that they have to be expensive or filled with the latest in digital health technology. A health system can spend as little as $150,000 or $200,000 in startup costs for a mobile health program and see success, as long as the program reaches and engages its target population with services that meet a gap in care.

"Those costs don't have to be substantial compared to what you're probably spending" to address the care needs of that population, she says.

And they can be flexible. If one approach or one location isn't working, pull up stakes and move, or redesign the mobile clinic to address a different healthcare concern.

Wallace says healthcare organizations looking to launch a mobile health program should first conduct a community needs assessment. This gives the organization an opportunity to talk to the community about what it wants and needs, as well as identifying partners in the project. That may include health systems and local doctors, charitable groups, civic organizations, and even local government. The idea is to create a group of stakeholders who can help guide the program as it launches and evolves and identify any issues it may have to address.

Elizabeth Wallace, executive director of the Mobile Healthcare Association. Photo courtesy of the MHA.

"It shouldn't be thought of as a pilot project," she adds. That evokes images of a test, or something that's being tried out and can be cancelled at any moment. This, instead, is a program that aims to stay in the community and foster a lasting relationship.

In addition, mobile health clinics don’t have to be dependent on technology to be effective.

"Technology and mobile healthcare, they're not in the same universe," Williams says. "I would say they can complement each other and stimulate each other … but they don’t have to both be there."

"We've found, in some cases, that technology doesn't resonate with them," she says of the typical mobile health clinic visitor. "They don't seek out [healthcare services] like you or I. They are coming to a mobile clinic, in many cases, for that personal touch."

This, in turn, can help a health system connect with its surrounding communities. That point was made by a health clinic operator interviewed for the MHA/Mobile Health Map report.

"For communities that have been disinvested or marginalized by our healthcare system through generations, being able to go to them, make the effort to get right where they are-say here I am," the clinic operator said. "I’m here to respond to you. It’s a good way to be able to bring them into a healthcare system that maybe they are distrustful of."

Sowing the seeds for sustainability

The challenge for many mobile health programs lies in finding a means of continuing past the loan, grant, or award used to get the program up and running.

"The launch is just the beginning," says Williams. "You need to establish a plan for getting support, especially from payers."

The key, as with any new healthcare program, is to gather evidence that the program works. That may be in reduced ER visits, which help a hospital's bottom line and lessens the pressure on 911, ambulance and EMS services, or an improvement in screenings, public health education, chronic care management, and other services that boost clinical outcomes down the line. The unmeasured effect, meanwhile, lies in an improved community.

The drawbacks? It's hard to find any.

"We worked really hard to find people who would disagree with us," Williams chuckles. "We tried really hard to find people to tell us that mobile clinics were a bad idea, and that just didn't play out."

New York City's Mount Sinai Health System is launching a digital health program aimed at relaying teenager-friendly messaging for teenagers at risk of type 2 diabetes.

It's never easy to communicate with a teenager—just ask any parent. But care providers at the Mount Sinai Health System are making that connection with a new digital health platform aimed at young adult at risk of developing type 2 diabetes.

The New York City-based health system is partnering with digital health company mPulse Mobile on a digital health engagement platform that meets teens where they want to be met and gives them access to resources focused on education and prevention.

The key to engagement, say researchers, is involving teens in the planning process.

"We did a lot of the buy-in work early on," says Nita Vangeepuram, MD, MPH, a pediatrician, clinical researcher, and assistant professor at Mount Sinai's Icahn School of Medicine. "We turned the program on its head a little bit and decided, why not ask them for their thoughts and how to make this work? I don't know if that's been done before."

Type 2 diabetes was once thought to be an older person's disease, while Type 1 diabetes was called pediatric diabetes. Type 1 is genetic, while type 2 develops over time, often due to a predisposition toward diabetes combined with bad diet and exercise habits. More and more teens and young adults, however, are becoming type 2 diabetic. According to the National Health and Nutrition Examination Survey (NHANES), one in every five teens and one in every four young adults can now be classified as  prediabetic.

Put those teens and young adults in an underserved population, such as East Harlem, and the risk increases. Between one-third and one-half of the teens in that area are prediabetic. Access to health resources, including digital literacy education, telehealth technology, and even in-person primary care services, is more complicated.

"We actually don’t know what's going to work," says Vangeepuram, who's been working on the program for the past few years and is eager to start collecting and analyzing engagement data. "We know that what's been tried in the past hasn't worked, and pediatricians are struggling. It's time to recognize that the patients here are the experts."

Making the Message Matter

Those experts are telling Mount Sinai's care teams how they want to communicate. For example, Vangeepuram says the teens involved in the early part of the program prefer texts, rather than either an mHealth app or social media. And while automated messages are good to get certain points across, they still want to talk to real, live care providers, either in person or virtually.

"We're seeing that there's some balance that needs to happen," she says. "Not all of the interactions can be automated; there has to be some interaction."

Vangeepuram and her colleagues are being specific in how they tailor the program. Choose the wrong medium or message, and teens won’t be interested in collaborating with the care providers on better lifestyle choices, and the advice will fall on deaf ears. They also won’t be interested in a generic, cookie-cutter approach that uses the same message for everyone.

"This is why research and behavioral science are important," Vangeepuram says. "You have to understand what works and what doesn't. And you do it by telling a story … that engages them."

Teens helping to develop this platform preferring texting over social media and apps surprised her in a way. So much of today's teen culture is wrapped around social media and apps that it just seemed natural to follow that route. They weren't interested in sharing photos, either.

"They prefer messaging, and goal-setting is extremely important," she says. "They want to be involved in the process."

Making Prevention a Priority

Programs like Mount Sinai's hold significant promise for value-based care because they target chronic disease prevention, alongside health and wellness. According to the Centers for Disease Control and Prevention's National Diabetes Statistics Report, some 37.3 million Americans, or more than 11% of the population, have been diagnosed with diabetes, while another 96 million people aged 18 and older are classified as prediabetic.

The American Diabetes Association, meanwhile, notes 1.4 million Americans are diagnosed with diabetes each year, and that number is going up. Also increasing are the costs to treat people living with diabetes: $327 billion in 2017, with $237 billion tied to direct medical costs. This means a person living with diabetes spends 2.3 times more on healthcare than someone without diabetes.

Due to the nature of type 2 diabetes, which can be avoided through better diet and exercise, healthcare organizations are planning and launching diabetes prevention programs (DPPs), which funnel in-person and group counseling with targeted resources aimed at helping people live a healthier lifestyle.

Federal officials have also gotten involved. The National Institutes of Health's National Institute of Diabetes and Digestive and Kidney Disease (NIDDK) developed a DPP model in the 1990s. The Centers for Medicare & Medicaid Services (CMS) used that model to create the Medicare Diabetes Prevention Program (MDPP) in 2018, enabling care providers to qualify for Medicare reimbursement for diabetes prevention services.

The program has been met with skepticism, with critics arguing that it isn't reducing costs or keeping a measurable amount of the prediabetic population from developing diabetes. The main problem is that few health systems are launching or supporting DPP programs, and despite intense lobbying, CMS has not expanded coverage to include virtual programs.

Proving the Program's Value

Vangeepuram says Mount Sinai will be looking at engagement metrics with this program. She wants to see that teens are getting these messages and responding to them and interacting with their care providers, and she wants to see that these actions help teens improve their health and reduce the chances of developing diabetes.

For now, they'll be rolling out the digital health platform, looking for engagement, and making any tweaks necessary to improve the process. They'll be working closely with not only primary care providers and diabetes educators, but with the teens, themselves.

Eventually, Vangeepuram says, they'll launch a clinical study, which will look to tie engagement into clinical outcomes. Those numbers might help state and federal payers, like CMS, to show more support for the program. They could also be the catalyst to scale the program out to other populations and target other chronic disease or health concerns.

After all, if you can connect with a teenager, you've made quite an accomplishment.

"It's better to teach them to be healthy, and that part isn't really complicated," she says. "You have to make sure that they're listening. That's the hard part."