Build a strong virtual relationship between the care team (case manager, primary care doctor, cardiologist) and the patient.
Use patient-centric design from the inception of the project to ensure that the technology is simple to use and easily integrated into patients’ lives.
Offer local wraparound services that are specific to the patient and a 24-7 care network.
Create a symbiosis between innovation and operational teams: operational teams need to be consulted during the problem definition phase, and the innovation team needs to stay involved during the transition to operations.
Engage resilient leaders to maintain direction in the face of inevitable operational challenges.
Every year, about 735,000 Americans have a heart attack. Of these, 525,000 are a first heart attack and 210,000 happen in people who have already had a heart attack. Some of the major risk factors that contribute to an adverse cardiac event include: physical inactivity, obesity, uncontrolled hypertension, high LDL, and smoking. Lifestyle modification in the form of cardiac rehabilitation (cardiac rehab) is well studied and proven to have positive outcomes such as reduced secondary events and rehospitalizations.
Cardiac rehab includes a prescribed exercise regimen, counseling, health education, and behavioral and lifestyle risk reduction techniques. Historically, there are two types of cardiac rehabilitation programs. The first is paper-based, in-home cardiac rehab, where patients are required to use paper and pen to track exercise regimens. The second is in-person, site-based cardiac rehab.
While these programs are successful in controlled environments, they present a number of hurdles for patients: time commitments, expense and inconvenience associated with multiple trips per week to the doctor’s office, lost time at work and, most significantly, the difficulty of adopting radical behavioral changes necessary for good health. These traditional programs are inconvenient and a bit archaic, leading to mediocre completion rates for home-based (48%) and in-person (50%) cardiac rehab.
Our goal was to develop a solution that would make cardiac rehabilitation fit more seamlessly into patients’ lives while improving clinical outcomes. As we scaled the program, our goal was to maintain the same completion rate we achieved in the pilot (87%). In addition, we wanted to improve access to cardiac rehab through growth in the total number of patients enrolled in home-based or site-based rehab:
- Improve enrollment rates, patient adherence, and completion rates to the cardiac rehab program.
- Reduce readmission rates post-completion.
- Use technology to enable 24-7 care coverage by case managers.
- Ensure that usability is at the core of the experience.
To achieve our goal, we created a technology enabled, evidence-based remote cardiac rehab program that would improve clinical outcomes while greatly expanding patient access. The home-based cardiac rehab solution consists of patient-facing applications that were designed and developed collaboratively with Samsung. The patient-facing mobile applications are available for download on a patient’s smartphone (iOS or Android) and linked to a wearable that is configured specifically for this solution.
Patients with a clinical indication for cardiac rehabilitation are referred via our electronic health record, HealthConnect. The first appointment is made face-to-face to begin establishing a bond between the patient and care team. In the subsequent 7 weeks, the same case manager conducts weekly phone calls to further deepen the bond of trust with that patient. We observe it in a number of different ways. Our primary observation is in the direct patient feedback provided to their doctors regarding the program. We also closely monitor adherence rates and conduct chart reviews to see the specific program components that are being discussed.
Once enrolled, members are scheduled for an on-site evaluation, where they undergo a 6-minute walk, download the program mobile app, and are provided with a wearable. The wearable allows selection of preferred exercise regime, self-assessment and rating of perceived exertion, and self-assessment of symptoms. All data input through the wearable is transmitted to a compatible clinician dashboard. The clinician uses the dashboard to set exercise goals for the member and to monitor adherence, compliance, and overall progress. The members are provided with educational materials (written and electronic) and referred for additional local patient education classes based on specific comorbidities. Lastly, members schedule weekly virtual visits with case managers for disease modification in conjunction with the physician, as well as depression screening, behavioral coaching, and support.
The case manager provides coaching and support to help members navigate through the 36-session, 8-week program. The bond between patient and provider is continually noted as a key element of success, according to our patients. The accountability provided by the provider and technology has a profound impact.
After graduation, wellness coaching is offered for another 8–12 weeks to assist members in their journey toward lifestyle change.
Here are the various steps we took to make this program a reality:
1. Leadership buy-in: We engaged clinical, medical, and technology leaders at all 13 service areas in the Kaiser Permanente Southern California (KP SCAL) region to gain alignment and sponsorship. Our team also conducted process reviews with security, legal, and compliance teams.
2. Human-centered design: Working with our technology partner, we utilized human-centered design (HCD) to understand and capture the needs of patients/caregivers and care teams (physicians, case managers, physical therapists, nutritionists, etc.). Then we built a product around these needs. We brought together a multidisciplinary team of user experience (UX) designers, providers, technologists, and strategists in a series of HCD workshops to solve the patient/caregiver needs and determine what was technologically feasible and economically viable. The insights gathered, along with clinical review, input, and rapid iteration at every stage of the process resulted in a simple to use, clinically supervised, digital remote end-to-end cardiac rehab solution. The HCD framework encouraged us to work collaboratively to find a creative solution to a complex problem.
3. Prototyping: We created several iterative prototypes that built on each other. The innovation team used agile development frameworks to rapidly design, iterate, and create prototypes to test while driving toward a validation pilot. During the process, we continuously tested the prototype with end users via both alpha and beta testing. We ran an alpha test with five patients, got feedback, and then ran a broader test with 37 patients.
4. Pilot: After iterating on several prototypes, we conducted a pilot with 37 patients in Riverside, California, over a 6-month period. Riverside Medical Center was chosen as the pilot site because it is the only American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR)–accredited on-site program in KP SCAL.
Yet, the program was continually underutilized because of insufficient provider referrals and problems with patient attendance/adherence. The average Riverside patient lives 32.7 miles away from the rehab center and 45.7% are of working age (under 65). The significant distance and job responsibilities create obstacles for site-based program participation and enrollment.
Over the course of 6 months, the team translated AACVPR core components of multidisciplinary cardiac rehab into an app that would run on a smartphone and Samsung watch. Exercise, medication adherence, education, and behavioral modification were core components of the program.
Thereafter, this program compared favorably to traditional site-based programs; in fact, completion rates were almost double (87%) the rates of site-based programs. When compared to traditional site-based programs, our pilot increased cardiac rehab enrollment rates by 74%. Based on the positive results of the pilot, a scaled version of the program was approved for all Southern California sites.
5. Training: Training was conducted with two end user types: clinicians and patients. For clinicians, we conducted in-depth one-on-one trainings with case managers to create a strong understanding of the technology and locally available support. Patients received training via a take-home paper instruction manual, in-app training tips the first few times of use, and a website with short videos explaining the technology.
6. Regional deployment: When structuring the regional program, we had the case managers report to a regional leadership team but sit locally with the care teams. It is important to collaborate with local sites as much as possible. The local sites are involved in the interview process for new case managers.
- Regional teams (business development): IT, Health Innovation, Center for Healthy Living (patient education)
- Clinical teams (operations): case managers, primary care physicians, cardiologists, quality improvement
Today, virtual cardiac rehabilitation is available in 12 of Kaiser Permanente’s 13 Southern California medical centers. As of June 2019, the program has enrolled 2,362 patients and graduated 1,880 patients. The program completion rate for those other than current patients is 87%, with an average of 67% of patients exercising on a daily basis. When compared to site-based cardiac rehab programs, completion rates have improved by 74%. Total referrals to any site Cardiac Rehabilitation have increased 44.5% since the launch of the home-based program.
In addition to the video education program in nutrition, cardiac health, and exercise that is compulsory, 37% of the participants chose to attend an in-person patient education class. The two most popular courses were heart health and sleep. We anticipate serving the needs of over 5,000 patients in the home-based program in 2019.
Twenty-seven patients were rehospitalized for any cause within 30 days after program graduation, 17 of which were cardiac-related. The national average readmission rate is about 10–15%, the best studies — for acute MI and stent — showing 7% at 90 days. We know our <2% rate would compare favorably to these studies.
Where to Start
- Strong core team: Build a strong, small (4–6 people), multidisciplinary team representing administration, medical, technology, and operations. This team can drive the project forward and ensure the creation of a robust program.
- Extended technology partner teams: Extension of capabilities in technology design, user research, engineering, and service development is critical to support the core team initiatives.
- Identify an evidence-based program and infuse technology: In KP SCAL, there is only one AACVPR-accredited on-site program located at our Riverside Medical Center. We partnered with Riverside Medical Center and augmented their existing program to make sure it was AACVPR-certifiable.
- Best form of shared understanding is a prototype/pilot: People need to see/experience the solution to understand it. It is important to spend a lot of time with people to help them understand the possibilities and set expectations; oftentimes, the best communication method is showing what’s been done.
Consumer technologies are not the norm in care today. We anticipated a number of challenges with physician and patient adoption.
With physicians, we needed to promote the idea that home-based cardiac rehab would provide a quality and predictable service for our patients. For each site, we had a checklist of items that included meetings with the cardiologist to discuss the program and benefits. We monitored referral patterns and published results as to the highest referrers. This allowed us to understand where we had resistance and create action plans.
Each site also had a personalized communication plan that was executed by our nurse case manager. This was designed to promote awareness and engage key stakeholders. A great indicator of success in this area is that in 5 of our 12 sites, the department chief is the number one- or two-ranked referrer to our program.
Our case managers were also fitted with wearables during their orientation so they could provide first-person guidance. We had the experience from the pilot, which also led us to devote the first week’s education to use of the technology.
In the pilot phase, teams are more tolerant to technology glitches and setbacks, but once it becomes a scaled technology, it is important to ensure the efficacy of the technology because it can have negative ramifications. Operational teams are accustomed to the highest reliability and predictability in their solutions.
The experience has exceeded our expectations. With few exceptions, we have not had patients drop from the program as a result of technological challenges. A close partnership between Samsung support and our case managers has created a strong safety net.