Double-digit improvements in health outcomes are among the results of a recent care coordination pilot program led by Hawai‘i Island Care Coordination Services (HICCS), a joint venture between Ho‘okele Health Innovations and West Hawaii Home Health Services, with the support of the Hawai‘i Island Beacon Community (HIBC).
Seventy-eight high-cost, high-risk patients across Hawai‘i Island enrolled in the program by invitation and received, at no charge, the help of a care coordinator Registered Nurse (R.N.) and a Health Coach for one year. Forty-two patients also received, at no charge, Ho‘okele’s iHealthHome in-home health monitoring technology for one year. All patients had complex care needs due to chronic diseases such as diabetes, high blood pressure, and high cholesterol and were high users of emergency departments and inpatient care.
The R.N. worked with each patient to create a service plan to improve their health. They provided ongoing education about their complex conditions, helped patients get access to specialists, and helped keep track of prescriptions and appointments. The Health Coach provided support to make lifestyle changes. The iHealthHome technology enabled the patient to take biometric readings at home such as blood pressure, blood sugar, and weight; submit the data electronically to the R.N.; track their own progress; log food intake, exercise, and activities; and communicate with the R.N. via video calls.
Data showed a significant impact during the pilot’s 12-month timeframe, including:
- 36 percent improvement in HbA1c blood sugar
- 37 percent improvement in triglycerides
- 29 percent reduction in inpatient hospital admissions
- 25 percent reduction in emergency room visits
“These results show that care coordination is highly effective, even in a short amount of time,” said Susan B. Hunt, M.H.A., project director and CEO for HIBC. “This new model of care for patients with chronic disease is being tested across the nation.”
“The early successes we’ve achieved on Hawai‘i Island, through this pilot and the others we conducted, indicate the tremendous potential to improve care, improve health and, ultimately, lower costs by combining technology with increased patient education and support,” added Hunt. “There’s pride and accomplishment in seeing how health care in our community can be improved and knowing that this is just the beginning.”
“It was inspiring to watch people’s lives change,” said Dew-Anne Langcaon, Co-Founder of HICCS. “People who were homebound, overwhelmed and in declining health are now hopeful and excited to live life again. They gained confidence in knowing how to manage their health together with their primary care physician, and by the end of the study, most felt empowered to take control of their own plan for wellness. Utilization changes were at or better than similar programs on the mainland. We believe that this model can be replicated and adapted for other communities. With health information exchange systems underway locally and on the mainland, we’re going to see technology and care coordination working hand-in-hand to achieve even greater results.”
This complex care coordination pilot with HICCS was one of HIBC’s nine initiatives to improve health care on Hawai‘i Island: care coordination, care transitions, patient engagement, practice redesign, health information technology, health information exchange, payment reform, wellness, and data collection and analysis. In addition to the HICCS care coordination pilot, additional care coordination pilots were conducted at Bay Clinic, Hāmākua Health Center, and West Hawai‘i Community Health Center.
HMSA, an HIBC collaborator, conducted a limited financial analysis of the 42 patients with health insurance through HMSA. The post-intervention reduction in expensive services like hospitalization and patient’s reduction in the use of the emergency department suggests improvement in patient self-management has the potential to reduce care costs, though the study was not conclusive due to a small sample size and short intervention period.
“Pilot programs such as those led by HIBC provide evidence that innovation in the health care industry can materially impact patients living with chronic disease,” said Elisa Yadao, HMSA’s senior vice president of consumer experience and an HIBC board member. “The collaborative efforts that have taken place on Hawai‘i Island have given us invaluable insights and lessons for the rest of our state.”
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