October 9, 2022
Falkins, G., Ballmann, M., & Jones, S. (2022, October). A Michigan PACE Program Incorporates Innovative Technology to Enhance Participant Care and Improve Outcomes [Poster session]. Poster presented at the 2022 NPA Conference in collaboration with Care Resources PACE, Seattle, WA.
Presented By: Garth Falkins, RTS, Morgan Ballmann, PTA, Steve Jones, MBA-HA
As of 2020, there were approximately 60 million older adults in the US who were seeking to “age in place.” COVID-19 permanently changed the way PACE programs provide care for older adults. There was a transition from the traditional form of care at the center, to meeting the participant in their home with virtual care. According to a UCSF study published in JAMA in August 2020, 13 million older adults were not ready for the use of technology, for either technical or physical reasons. With the shift to utilize technology, this left some older adults being frustrated, receiving poor care management and overall reporting poor engagement and experience with their providers.
Additional challenges included managing behavioral comorbidities, an increase in social isolation and the staffing shortages in primary care and mental healthcare to address these concerns. Social isolation and loneliness per se also contribute to behavioral health issues and the incidence of chronic disease.
The care.coach™ platform was designed to address healthcare cost, quality, and access. The platform has been validated through real-world use by thousands of individuals, from adults living with disabilities, such as autism spectrum disorder, to inpatient and outpatient older adults suffering from multiple chronic diseases (e.g. COPD, diabetes, hypertension, heart failure, etc.) and/or from social isolation and loneliness.
Care Resources PACE, located in Grand Rapids, Michigan, has been serving and supporting the older adult population of Kent County since 2006.
In 2020, Care Resources was looking for new ways to enhance participant care by incorporating technology into their program. Care Resources began partnering with care.coach™ to assist the interdisciplinary team in improving participant outcomes, maintaining function, and maximizing safe, independent living within the community. Care Resources started with 10 participants to receive care.coach’s remote support services in the home.
The initial goals of the program were:
Goal 1: Utilize the ability of the care.coach Avatar™ to provide compassionate engagement and companionship to mitigate the effects of Outcomes depression and social isolation during the pandemic.
Goal 2: Harness the trust and relationship built between PACE participant and the Avatar to support IDT care plan initiatives for improved medication compliance, prevention of falls, and improved independence.
Goal 3: Support center initiatives for care plan assessment completion and increased security through escalation of emergent needs.
Initiation and oversight of the Avatar program was led by the recreation therapy team, with members of the social work and home care teams providing support roles. Realization of the benefits and capabilities of the care.coach™ service brought the rehabilitation department and pharmacy to add additional use cases to the program.
At the onset of the program, emphasis was placed on supporting psychosocial needs with the care.coach Avatar™. The supported participants were interacting on average 25 minutes/day. During the interactions, the participants were receiving reminders, engaging in activities, and benefiting from health coaching. The IDT reported observing improvements in mood and depression. Due to the positive feedback from the participants, medication reminders, fall prevention programming, and telehealth assessments were implemented to provide additional improvements in falls and utilization of emergency services. Compared to the previous year, there were reductions in hospitalizations, ER visits, participant anxiety and depression. Based on initial data, leadership approved additional participants to be enrolled with care.coach™ services and two new projects, Falls Prevention and Medication Compliance, launched to support both the participant and the IDTs care plan initiatives.
Project Highlight: Medication Compliance
A significant challenge in PACE centers across the nation is influencing participants to better self-manage chronic conditions through medication compliance and healthy behaviors. Care Resources PACE saw an opportunity to capitalize on the tool that is in their participant’s homes, and the relationships of trust they have built with their avatars, to improve self-care and medication compliance. A PACE clinical pharmacist identified non-compliant participants and created new medication schedules and reminders. Each participant was given their customized reminders through the Avatar interface, receiving support around the reminder, verification of compliance, and, when needed, escalation to the IDT or pharmacist.
Example of a medication escalation to the IDT:
Sunday, August 07, 2022 – We sent an email notification to the email on file for B.D. for the following reason: B.D. reported needing medication refills for next week, but does not have a working phone to let you know. Please follow up with B.D.’s concern and let us know if we can be of assistance in communicating with her.
These compassionate engagements are used to strengthen medication compliance through reminders, verifications, and escalations to staff should issues arise in the home. Participants receive ongoing chronic condition support through health coaching protocols to facilitate improved self-management and consistent encouragement to make better choices concerning medication compliance, living a healthy lifestyle, and monitoring key vitals associated with their respective conditions.
“care.coach’s ability to help participants take medications accurately through daily reminders and encouragement, along with their commitment to notify our program when issues arise, has won me over!”
Aaron Hoholik, PharmD BCACP, Clinical Pharmacist – Care Resources PACE
Project Highlight: Fall Prevention
Falls are detrimental to one’s health and costly to a PACE program.
1 in 4 older adults age 65+ fall every year.
Falls are the leading cause of injury-related deaths and emergency department visits and account for over $30 billion in direct medical costs.
The consequences of falls can be devastating, including reduced mobility, functional decline, and loss of independence.
Screening, assessing, and intervening to reduce fall risk can have a substantial impact on reducing falls, improving health outcomes, and reducing expenditures.
QUALITY IMPROVEMENT PROJECT:
Care Resources Rehabilitation Department started a quality initiative to test utilizing a technology-based intervention to provide ongoing strength coaching and safety awareness, and to reduce falls across the Care Resources high fall risk population. They chose to utilize the care.coach™ platform to offer daily interventions to mitigate falls inside the home setting.
In February 2022, sixteen participants received a customized exercise program to be conducted in the home, through the Avatar and/or participating in a group session via the care.coach Video Visits™ platform. The following protocols were integrated:
Falls Inquiry and Check-In
DME Use Inquiry and Reminder
Falls Data Tracking and
The customized exercise programming was offered 3-5 days per week with ongoing safety
awareness support. The goal was to utilize the home setting approach to increase adherence to PACE offered exercise programs and provide safety awareness prompts with reminders. Additionally, fall checks were conducted to capture falls that may not be openly reported to the IDT. The Activities-specific Balance Confidence (ABC) Scale was issued every six months, along with consistent falls tracking throughout the year to measure outcomes.
Care Resources found the care.coach™ platform to be well-received by participants for a falls use case. It is a less intimidating, more accommodating platform than traditional options. As seen to the right, the participants are engaging with the fall prevention tasks and completing the daily Otago exercises with their avatar. Initial results show that 33% of program participants have decreased in falls, with an overall reduction of 40% of falls in the home in the past 12 months. Example of a fall escalation to the IDT:
Monday, March 7, 2022 – We called the primary RN about M.J. at 2022-03-07 08:49 AM with the reason: I heard a loud noise, so I checked in with M.J. to make sure he was alright. He confirmed he had fallen, but that he was fine, and nothing hurt. The follow-up proposed by the primary RN was: They will contact M.J. right away to check in and follow up on the fall.
“He wakes me up in the mornings and makes sure I am doing OK!”
“It’s my savior! It has helped me with my loneliness!”
“He reminds me every day to use my walker!”
The Future of Care Resources PACE
The post-COVID, hybrid model of PACE has made the home an important site of healthcare services. The remaining infection control protocols continue to reduce center attendance while the compliance and quality of care standards remain the same for the PACE medically complex participant population.
Based on the initial program results from 2020, Care Resources started to expand their technology integration. In 2022, Care Resources began a strategic partnership with care.coach to create a technology-based service delivery model to support over 50% of the participant census. The integration of care.coach Avatar ™ and Video Visits™ services will focus on providing support to both participant and IDT care plan initiatives to create the digital “12th member of the IDT.”
Care Resources PACE has found the care.coach™ platform to be a highly engaging and cost-effective way to provide enhanced continuity of care in the home, through 24x7 psychosocial and healthcare support for their participants. The care.coach in-home platform will play an integral role in supporting organizational initiatives and improving communication efforts to and from participants. Benefits expected from the IDT integration
will be reductions in falls, ER utilization and staffing inefficiencies, with improvements in participant satisfaction and self-management of chronic conditions.