We collect available information about a Care Receiver, including medical records, data from personal monitors, claims and surveys and then use it to segment the population, predict behaviour propensities and prioritize nudging interventions.
We then create highly personalized, learning care journeys that match the behaviour propensities (MoBE Maps) of the Care Recipient to act (adhere to medications, manage diet, etc.).
Based on the most recent MoBE map we send triggers (or Nudges) to engage and shape the behavior of the Care Recipients to achieve healthier outcomes.
We nudge the patients ‘where they live’ - these precision nudges delivered through phone calls, personal visits, online messaging, smartphone Apps, Siri, Alexa, and other communication channels.
The ability to engage in their own care has been shown to improve health outcomes and reduce the overall cost of care significantly in several chronic conditions. Diabetes, cardiovascular disease, respiratory conditions and even the prevention of pre-term birth can all be managed better with higher engagement and activation of the patient in following their care plans and adopting lifestyle habits that reduce complications. By creating a digital care journey for each of these conditions, a Patient Engagement Platform can allow the patient to access information on their condition, remind them of actions they need to take, help with upcoming care encounters, raise alerts or exceptions for their care team's attention and even access their care team, often asynchronously, to address specific concerns. It is a digital companion that uses a smartphone or tablet to follow the patient through their care journey.
While all the focus has been on clinical treatment to improve outcomes of chronic conditions, it is now evident that social and economic factors are the most powerful and sustained determinants of health. What patient's say they do within the confines of a physician's office or hospital is less important than what they do outside of it. Emerging evidence supports modifying patient behaviors outside of physician offices to align with the recommended norms for healthful practices ranging from adherence to medication and care plans to adopting lifestyle behaviors like exercise or refraining from smoking, etc. This is now believed to deliver on the triple aim of healthcare, i.e. improved patient satisfaction, improved health outcomes and reduced cost of care delivery. This explains the emerging attention to shaping the patient's health behaviors.
In our observations, the opposite happens at our client sites. Care Managers on the MoBE platform are now able to handle exceptions and alerts instead of reaching out to a much larger number of patients. The quality of interaction with patients on the MoBE platform is personalized and patients feel the power of personalized care without the care managers having to call in. Yet, when they do call, it is to resolve a specific issue that the patient may have raised, which makes them far more effective in their roles of supporting the patient on their care journey.
The CareCentra team has configured a variety of Digital Care Journeys on the MoBE platform. They have been tested successfully in randomized trials with Intermountain Healthcare among patients with cardiovascular conditions and among expectant mothers to improve safety in maternity (preventing pre-term births and postpartum care). These Care Journeys combine robust clinical care instructions designed by health care professionals, with social authority drawn from how patients translate these instructions into action, influenced by social determinants. A library of Nudges are built for each condition and the MoBE platform uses these nudge pathways to shape patient’s compliance behaviors. Clients can use these existing Care Journeys to innovatively transform how they deliver care to patients.