In this white paper, real-life use cases and outcomes demonstrate that it is practical and possible to have a significant positive effect on health outcomes for people with life-threatening conditions, such as heart failure, while reducing healthcare costs. By applying an evidence-based behavioral science and telehealth system of remote care, patients and clinicians have a greater ability to achieve their desired goals.
Delivering Behavioral Cardiology with Telehealth Therapeutics: Improving Treatment Outcomes, Increasing Medication Adherence, Reducing Healthcare Costs, and Empowering Patients and Clinicians
© 2025 GOLD GROUP ENTERPRISES, INC. CONFIDENTIAL AND PROPRIETARY
Table of Contents
Prelude.............................................................................................................................4 Why You Should Read This White Paper
Section 1...........................................................................................................................8 Introduction: Patient-Partnered Care Plans Work Better for All Participants
Section 2........................................................................................................................12 A Day in the Life of The Heart House Patient and Caregiver
Section 3........................................................................................................................18 BehavioralRx: The Science of Precision Health
Section 4........................................................................................................................21 The Heart House Cardiac Concierge Care Program
Section 5.......................................................................................................................30 How Was BehavioralRx Applied to the Heart House Cardiac Care Program?
Conclusion.................................................................................................................... 34 Getting to the Heart of Healthcare
PRELUDE Why You Should Read This White Paper: Reader Takeaways on Provider Best Practices and Lessons Learned in Integrating Telehealth into Core Practice Management Methods
PRELUDE | WHY YOU SHOULD READ THIS WHITEPAPER
T he mission of this white paper is to demonstrate to the reader, via a real- life use case and its outcomes, that it is practical and possible to have a significant positive effect on health outcomes for people with life-threatening conditions, such as heart failure, while reducing healthcare costs to both patients and providers. This is achieved by applying an evidence-based behavioral science and telehealth system of remote care that simplifies the ability of patients and clinicians to achieve their desired goals. For centuries, clinicians have applied their craft by evaluating patients (either in person or more recently via televideo), reaching a treatment decision, and providing a care plan with instructions that may or may not include medications. It is always the hope and expectation that patient adherence to clinician instructions and care plans extend well beyond their 15 to 30-minute appointments and follow-up calls. In the last decade, telehealth and digital healthcare have been expanded and refined, but without sufficient patient input or
consideration for patients’ psychosocial states and lifestyle factors. Many provider organizations have implemented patient portals, apps, and appointment reminder software that have not, for the most part, improved adherence or outcomes, while costs and adverse events continue to increase. In this white paper, you will discover telehealth clinical and operational insights and best practices that have achieved the Quadruple Aim. A primary goal for achieving success is for care teams to become more (cognitively) present in the minds of patients as they go about their activities of daily living on their own terms, and to create a patient-partnered care plan that dynamically adjusts to patients psychosocial and physical states, making it much more likely that they will stay on course and activate the behaviors necessary to achieve their health goals. This integrated approach has also shown the following benefits to provider organizations: reduced clinician fatigue, increased joy in practice, scaled population served with same FTEs, and increased community referrals. Further, in today’s value-based payment structure, practices can experience increased reimbursements, increased opportunities to obtain shared savings dollars for hospitals and practices, and avoidance of potential penalties for excessive ED visits and hospital readmissions.
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This report embeds five key takeaways and best practices while demonstrating how Concierge Care ® accomplishes them in a simple and easy way for care teams and their patients:
Extend Point of Care: Integrate the home environment into care plans and utilize it as part of the “Point of Care” (not just televideo).
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1
Behavior Drives Health Outcomes: It is practical and possible to achieve sustainable lifestyle behavior modification if patients BELIEVE these three things: + They have direct influence and shared decision making in the plan of care. + The care plan makes sense to them and considers their specific lifestyle factors. + They can accomplish the tasks in the plan. Accomplishing this level of behavioral and cognitive modification, which leads to meaningful, improved quality metrics and health outcomes, requires proactively delivering individualized content and resources, at the right time and place, in a consistent manner. This approach increases confidence in self-management, positively impacts outlook, and reduces patient stress and their perceived burden of adherence to the plan of care. Relying on patients to initiate access and navigate an app or portal, particularly if under medical distress, is an obstacle to achieving the level of psychological and cognitive “believability” or change in outlook that fosters sustained resilience in behavior modification.
Activate Caregivers: Empower patient caregivers as (free) FTEs on the integrated care team.
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Integrate Mind/Body Care Plans: Include day-to-day psychosocial activities and resources, in care plans for all medical conditions, which enable patients to self- manage and cope with anxiety, stress, fatigue, and sleep challenges.
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Become Part of Patients’ Daily Activities and Schedule: Extend the telehealth therapeutic beyond the 15-30 minute in-office or televideo visit with flexible patient- partnered care plans that are adjustable to patients’ ever-changing ADLs driven by emotional, social, and physical factors.
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PRELUDE | WHY YOU SHOULD READ THIS WHITEPAPER
Interview with the Experts: HCP Live For helpful context, before reading this paper, please watch this brief video featuring Dr. Sanford Gips, Cardiologist and Director of Population Health and Josh Ginsberg, Executive Director Practice of Management, Clinical, and Operational Staff of The Heart House, along with Bob Gold, Chief Behavioral Technologist at GoMo Health, discussing the value of personalized remote care coordination and its impact on patients and staff of The Heart House. To watch the video, click on the thumbnail to the right or visit www.hcplive.com/view/concierge-medicine-cardiac-care-covid-19
“Keep It simple, but at the same time, make your patients feel like you care about them. That is exactly why our Concierge Care program from GoMo Health is working so well. One of the things in my 20+ years of practice I’ve discovered is that heart failure readmissions occur more often for psychosocial reasons than that their heart failure is really worse. Many of these people might live alone, they don’t have as much family backup, they might have financial insecurity, food insecurity, those kinds of things. The more involved that you can make them feel builds a deeper connection to our practice and motivates them to be more involved in their own wellbeing, and the less likely they are to have adverse outcomes.”
SANFORD J GIPS, MD, FACC, FSCAI Director of Population Health Interventional Cardiology, The Heart House
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SECTION 1 Introduction: Patient- Partnered Care Plans Work Better for All Participants
SECTION 1 | PATIENT-PARTNERED CARE PLANS WORK BETTER FOR ALL PARTICIPANTS
“The American Heart Association is passionately driven to reduce deaths, improve outcomes, and increase prevention of cardiovascular disease. We value innovators like GoMo Health who embrace those objectives and are focused on behavior-based, patient-centric care leading to measurable and sustainable population health. Bob and his team incorporate health literacy into their platform extremely effectively. It’s not just about an information surge for the person with information that’s not relevant, they do an excellent job of really getting to those points that lead to better health outcomes.”
PATRICK DUNN, PH.D. Manager of Connected Health at the American Heart Association
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T he following report has been created to illustrate the impact, methodology, and future potential for improving telehealth practice management by using the GoMo Health Cardiac Concierge Care Program developed in collaboration with the American Heart Association’s (AHA) Center for Technology & Innovation. The program embeds the GoMo Health evidence-based science of BehavioralRx ® to engage and support patients and caregivers in their lived environments (home, work, and play).
Through partnership with the American Heart Association Center for Technology & Innovation, GoMo Health was able to establish a heart failure digital therapeutic program for The Heart House that continues engagement between patients and caregivers post-discharge and brings improvements to their outpatient care. The Heart House is a multi-location cardiology practice serving more than 20,000 patients that provides treatment for a variety of conditions, including arrhythmias, cardiomyopathy, congenital heart disease, congestive heart failure, coronary heart disease, high cholesterol and lipid conditions, hypertension, rheumatic heart disease, and valvular heart disease. Since its inception, the program has achieved the Institute for Healthcare Improvement Quadruple Aim: improved treatment outcomes for participating patients; reduced costs related to avoidable ED visits and hospital readmissions; better care through more consistent and intuitive provider engagement and education; and a deeper joy in practice among providers through increased patient partnership, appointment adherence, and preparation.
SECTION 1 | PATIENT-PARTNERED CARE PLANS WORK BETTER FOR ALL PARTICIPANTS
These promising results, as well as many others revealed in this report, further reinforce the effectiveness of BehavioralRx and Personal Concierge™ in applying telehealth remote therapies as an integral component of the care plan and clinical pathway. BehavioralRx is the GoMo Health proprietary behavioral and cognitive science of precision health that has proven to develop and foster increased patient activation and resiliency, resulting in better patient self-management and decision making that leads to improved outcomes. One of the primary means through which GoMo Health deploys BehavioralRx is through our Personal Concierge programs. Personal Concierge is a cloud-based virtual care coordinator that offers, via “snackable bites” of individualized
and timed mobile messaging, personalized care that interactively guides patients and caregivers through their healthcare journey. This science illustrates that engaging patients in their lived environment; individualizing dialogue based on their schedule, preferences, and psychosocial environment of need; and offering opportunities for care, support, and practical resources outside of doctors’ offices and telehealth appointments must be an integral part of every care plan’s creation and delivery, going forward. Patients need consistency and frequency of engagement to guide their decision making during times when they are not directly interacting with their care providers.
Among the most impactful quality metrics were:
98%
12%
43%
Medication Adherence Rate Versus 40%-60% for the National Average 1
90-Day Hospital Readmission Rate Compared with 25% for the National Average 2
Decrease in Tobacco Use Following Program Enrollment
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SECTION 2 A Day in the Life of The Heart House Patient and Caregiver
SECTION 2 | A DAY IN THE LIFE OF THE HEART HOUSE PATIENT AND CAREGIVER
W hile the subsequent sections of this paper detail the program itself, we’re sharing the following “Day in the Life” of The Heart House patient and caregiver in order to best demonstrate the program’s impact on the patients and caregivers it engages, as well as the operational and practice management efficiencies it affords The Heart House clinical care team. Read on to “experience” how this program simplifies information exchange for patients, offloads The Heart House clinical care team from individual phone calls, and creates efficiencies in practice operations and patient support.
Three days before his initial in-person appointment, Dave receives a text message from The Heart House, asking him to click a link to confirm his appointment and answer a few questions prior to coming into the office in the COVID-19 environment. Dave answers the questions and is cleared for his appointment.
During the appointment, The Heart House determines that Dave has the start of congestive heart failure, explains the inclusion of The Heart House Personal Concierge™ telehealth program as part of their care delivery model, and lets him know he will be receiving communications related to appointments, prep, logistics, and his overall condition via mobile text message.
Dave Anderson
The following day at noon, Dave receives a text asking him to provide feedback about his experience at the appointment the prior day. Dave completes the one- minute survey.
Patient:
62 y/o
Age:
Diabetic, High blood pressure
Condition:
Dave, a 62-year-old diabetic with high blood pressure, has been experiencing shortness of breath and a high level of fatigue, making it difficult for him to get through his day. Given his health and his family history of heart disease, Dave was recently referred to The Heart House for a cardiac consult.
Dave also receives confirmation that he is enrolled in The Heart House Concierge program and he starts receiving daily information that educates him about his condition and provides suggested lifestyle changes to improve his health.
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+ Reducing stress
Dave’s wife is also very concerned about his condition, so she signs up for the messages as well. Dave and his wife receive daily messages on a variety of topics:
HeartHouse: Have you ever tried guided meditation, Dave? It can be very helpful if you need to relax. Check out this short video: http://gcv.me/8ee035
+ Explaining congestive heart failure and its impact
HeartHouse: Dave, the most important part of any new diagnosis is understanding your condition. For a basic overview of CHF, read this: http://gcv. me/7733ae
+ Every Tuesday Dave receives a message related specifically to his diabetes
HeartHouse: Dave, having a hard time adapting your diet to better suit a life with diabetes? Read about diabetes and superfoods: http://gcv.me/41a95b
+ Reminding him of the importance of taking his medication
HeartHouse: Dave, starting new medication can be overwhelming, especially understanding why and how to take it. Here are some tips: http://gcv. me/97cfaa
HeartHouse: Dave, feelings of anxiety and depression are natural. Learn more about ways to relieve and deal with these conditions: http://gcv.me/97c9d3 Dave’s wife starts reading the package labels when she shops and modifying their meals to include more vegetables and lean meats. Dave, sedentary in nature, tries to be more active, but it is hard for him. All these changes to his lifestyle feel very constraining and increase his level of anxiety. He tries to focus on suggestions in the messaging: Dave’s initial consult at The Heart House indicated the need for a variety of tests, including a stress test. The morning of the test, at approximately 6am, Dave receives a stress test reminder message from The Heart House reminding him to avoid caffeine until after the test, and that they look forward to seeing him at his appointment that day.
+ Increasing physical activity
HeartHouse: Exercising does not require a big time or cost commitment. In fact, many exercises can be done for free. Dave, try this out: http://gcv.me/da2318
+ Adjusting his diet
HeartHouse: Dave, healthy eating is important, but it can be hard to get started. Learn some basic info about nutrition labels to help: http://gcv.me/ded5f8
SECTION 2 | A DAY IN THE LIFE OF THE HEART HOUSE PATIENT AND CAREGIVER
After a few months of ongoing issues, The Heart House care team directs the implant of a loop recorder for Dave to provide ongoing monitoring of the rhythm of his heart. The night before, Dave receives a text confirming his appointment and reminding him to take his antibiotic an hour before the procedure. Dave gets a monthly survey asking about his outlook on his well-being and his optimism for the future. Early on, Dave was somewhat negative; however, as the months pass and his condition improves, Dave becomes more positive. Dave and his wife are thankful for the frequent, timely, easy-to-understand care messages and information they receive via text. The Heart House saves hours of time on calls, messages left for calls not returned, and lost appointment time for patients who show up unprepared for their appointments. In turn, when Dave receives the electronic patient satisfaction survey from The Heart House the day after each appointment, he is happy to complete the brief questionnaire and offer his positive feedback on his experiences with The Heart House – both in person and remote. As Dave continues to monitor his condition, he is encouraged by the information he receives from The Heart House on his mobile device. It encourages and empowers him, and he is happy to receive the information that helps him to manage his physical and psychological well-being. His wife and caregiver also appreciates the information she receives, as it enables her to better care for Dave proactively.
Upon completing the stress test, Dave lets the nurse know that he is a bit anxious about his condition, as is his family, and that they are anxious to receive the results. The nurse assures Dave that he will receive feedback as soon as it’s available. Within two days, Dave is informed via text by The Heart House that his test results indicate no abnormalities, and his anxiety is greatly reduced. Every Monday Dave receives a survey asking him if he has gained weight, has increased shortness of breath, swelling in the legs, or has stopped taking his heart medications. He completes the survey most weeks. Several weeks into the program, Dave has a particularly bad weekend. He had a lot of trouble sleeping and his ankles swell to the point at which he contemplates going to the ER. On Monday when he gets the survey, he indicates that he has additional swelling and trouble breathing. New/worsening moderate swelling and new/ worsening shortness of breath have been reported for DAVE ANDERSON on the most recent wellness survey. Survey submitted by the patient. Patient’s contact number: 1-848-467-4560
That afternoon, Dave receives a call from the nurse. She reviews his symptoms, makes several recommendations, and discusses with his physician whether an adjustment to his medication is warranted. After it’s made, Dave feels much better and is glad he didn’t go to the ER.
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Redefining the Point of Care: Engaging Patients in their Lived Environment The process of engaging patients in their lived environment means extending the “Point of Care” into their daily lives and homes going beyond the 15-30 minutes of a telemedicine visit. It’s a precision-focused condition management model that gives patients like Dave consistent support throughout their daily life and addresses their physical conditions, behavioral issues, and lifestyle factors within their existing daily framework. This engagement approach is necessary to change behaviors that reduce adverse events (ED visits), increase medication compliance and improve quality metrics. Switching an office visit to a televideo visit alone will have limited impact on quality and cost metrics. There are multiple limitations to traditional in-office and telehealth visits, including time constraints, logistical difficulties that interfere with appointment adherence, and even patients’ reluctance to fully engage with physicians and be transparent during visits. Furthermore, patients often “disconnect” from their doctor once they leave the office. Their physicians’ instructions fade as they return to their normal life until the next appointment, three to six months later. Concierge Care behavioral digital therapeutics engage patients in their lived environments by deploying evidence-based personalized logic and customized practices, surveys, and assessments to learn about their specific clinical and lifestyle profile (physical co- morbidities, behavioral and emotional challenges, and practical as well as social determinants of need), to treat them as whole patients, with consideration for the lifestyle factors that influence their ability, capacity, confidence, and desire to activate and sustain a care plan. It helps to keep the physician and care plan present and relevant each day, and increases the sense that the physician cares and is continuously involved. SECTION 2 | A DAY IN THE LIFE OF THE HEART HOUSE PATIENT AND CAREGIVER
While Concierge Care is deployed digitally, typically via short Care Messages™ delivered via SMS text with personalized mobile web Care Pages™, there is an ongoing level of deep and highly personalized engagement that goes beyond the temporary experience of a telehealth visit. Like a caring clinician or friend, Concierge Care proactively and consistently engages the patient and caregiver based on their current challenges, time of day, and day of week. The burden and stress of relying on the patient to go to an app or portal is removed.
“The bottom line is that what we’re doing with GoMo Health is in place to improve both the behavioral and the emotional well-being of our patients. With heart disease in particular, behavior — when it comes to diet and exercise — and emotions — when it comes to stress and anxiety — both play a crucial role in how someone develops the condition, or if they already have heart disease, how they manage it. With regard to behavioral and emotional support, that boost that we get by adding GoMo Health to our platform has been tremendous for our patients.” SANFORD J GIPS, MD, FACC, FSCAI Director of Population Health Interventional Cardiology, The Heart House
This type of engagement approach has been instrumental in gathering information that can support patient care, while engaging patients with their providers outside of traditional in-person visits. Patients receive these Care Messages from their doctors in a manner that makes them feel listened to, valued, and empowered. This level of intuitive engagement includes the delivery of patient- specific condition and quality-of-life information, activities and resources, feedback, questions, and surveys that assess mindset and outlook, appointment preparation and medication scheduling, and escalations to care team staff concerning early warning signs of toxicity and other potential adverse events. In the context of this heart failure program, engaging patients in their lived environments includes providing information, guidance, and support with respect to the most common co-morbidities related to heart disease: smoking, diabetes, renal failure, and emotional anxiety and coping.
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SECTION 3 BehavioralRx: The Science of Precision Health
SECTION 3 | BEHAVIORALRX: THE SCIENCE OF PRECISION HEALTH
T he Heart House Concierge Care program uses the GoMo Health BehavioralRx evidence-based science. BehavioralRx stimulates activation and fosters and develops resiliency. It is a behavioral and cognitive science using proven psychological techniques, leveraging emotional attributes and cognition to motivate in-the-moment actions at home, work, and play. Just as care plans and treatment protocols are unique, so are patients. BehavioralRx, created by behaviorists and behavioral scientists, clinicians, educators, and human factors engineers, is designed from the ground up to work in harmony with the day-to-day natural changes in a patient’s emotional, cognitive, social, and physical states. Using the science of BehavioralRx, the GoMo Health Cardiac Concierge Care program not only helps patients and providers within The Heart House ecosystem, it demonstrates the ability of the Concierge Care program to meet the glaring need for consistent, disciplined, and intuitive support for the ongoing care timed to an individual’s journey to recovery and wellbeing. This is crucial for the next generation of healthcare delivery to reduce costs and improve health outcomes.
The Science and System Behind the Outcomes and Impact on Human Resiliency 1. Enables a person to forget less 2. Stimulates early awareness of signs of adverse events 3. Creates motivation as to why a person should listen, learn, and act 4. Reduces feelings of loneliness and social isolation 5. Stimulates memory retention and recall 6. Produces honesty and transparency 7. Increases reciprocity to act (follow through, attend, perform tasks) 8. Builds confidence and believability (trust and credibility) to self-manage 9. Builds back capacity to have friendships, love, and socialize 10. Develops, fosters, and strengthens resiliency
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The GoMo Health Cardiac Concierge Care program applies the BehavioralRx science of precision health to deliver contextually relevant resources, which are timed to personal preference, individual need, and time of day, for optimal cognition, retention, activation, and ongoing resiliency. Resources include mobile messaging, rich multi-media content, interactive surveys, and bi- directional assessments. By engaging with patients early and continuously throughout the program to capture personal preferences, social and environmental determinants, and delivery resources to match their evolving needs, the program not only improves treatment outcomes and reduces costs for The Heart House patients, but also increases satisfaction and engagement for every stakeholder in their care ecosystem: caregivers, providers, nurses, and practice administrative staff.
BehavioralRx Engagement Approach
Keeps it Simple and Highly Directed + Stimulates AHA moments + Provides information in snackable bites + Typically, provokes only one thought, question, or action at a time Creates Intimacy and Makes it Feel Personal + It’s “In-The-Moment” — time of day and day of week matter + Immediately responsive — provides reciprocity and therefore participants stimulate the same back + Can initiate “conversation” flows Will Meet Individuals Where They’re At + Creates bonds + Creates feeling of belonging + Allows participant to choose their method of communication Enables Individuals to Influence Based on Their Life and Timely Needs + Responsive to human need + Program participants can interrupt the current regimen and go into triage mode to handle their “event/issue” Optimizes Organizations Time, Minimizes Costs, and Adverse Events + Algorithms for optimizing the use of human care coordinators as part of a seamless conversation flow with program participants — increasing efficiency, effectiveness, and impact
SECTION 3 | BEHAVIORALRX: THE SCIENCE OF PRECISION HEALTH
SECTION 4 The Heart House Cardiac Concierge Care Program
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PATIENT GOALS + Reduce the impact of symptoms on quality of life + Reduce anxiety and the stress of adapting to lifestyle changes to manage CHF + Feel better about themselves and their ability to resume activities of daily living + Keep out-of-pocket health costs to a minimum + Decrease ED visits and hospitalizations Program Goals and Objectives
PRACTICE GOALS: QUADRUPLE AIM PLUS + Improve patient compliance with self-care in a remote setting + Reduce cost of care, including avoidable ED visits and hospital readmissions + Increase adherence to care plan and medication compliance + Decrease tobacco use + Decrease missed or canceled appointments for office or telehealth visits + Increase patient satisfaction with lifestyle modifications + Increase patient satisfaction with practice + Increase efficiencies in practice operations (e.g. decreased patient phone calls) + Increase utilization and time spent by nurse triage on high-impact situations + Scale population served with existing clinical and service team + Increase practice visibility in community + Increase referrals + Increase joy in practice for The Heart House staff
SECTION 4 | THE HEART HOUSE CARDIAC CONCIERGE CARE PROGRAM
Program Description and Componentry PROGRAM TIMELINE
The program launched in June 2019 and has a duration of six months for each participant. Metrics used to determine program efficacy include return ED visits, hospital admissions, wellness and quality of life responses (gathered through periodic surveys gauging patient and participant satisfaction), appointment adherence (measured through participating provider cooperation), and resolved incidents of escalation for various co-morbidities. See Outcomes Section for detailed outcomes.
PARTICIPANT POPULATION ENROLLMENT PROCESS
52046 1 00 PM
100%
The program is delivered to all Heart House patients diagnosed with congestive heart failure and is a built-in component of the organization’s care plan protocol. Patients must have a cell phone, and they have the option to decline participation. Participants may opt out at any time. Patients begin the program once they come in for an appointment, and receive their welcome message the following day. They receive messages six days per week, and will receive a seventh message if they indicate one of the following comorbidities at the time of enrollment: tobacco use, diabetes, or renal failure. Patients and caregivers appreciate a consistent, dependable, and individualized communications regimen
as they navigate intimidating and stressful lifestyle changes necessary to attain and maintain good heart health. On the same day that the patient receives their enrollment confirmation message, they receive a message asking if they would like to enroll a caregiver to receive the same messaging; this creates further accountability, reinforcement, and encouragement for patients to remain adherent to health care directives. Further, it reduces caregiver anxiety by providing them with what they are so often searching for: a way to provide consistent patient support. They know they want to help; they just don’t know how.
You’re enrolled in Heart House Concierge! You’ll get 7 msgs/wk to help with your care. Text STOPALL to end msgs. Msg&DataRatesMayApply Monday 1 00 PM Heart House: Would you like a partner or caregiver to also get these messages? Sign them up here: http://gcv.me/9f6968
Tuesday 1 00 PM
Heart House: Andy, in order to properly manage your condition, your medication needs to be taken as prescribed. Learn more here: http://gcv.me/181b86 Wednesday 1 00 PM Heart House: Once you’ve quit smoking, you can protect yourself from relapsing. Identify your triggers & select coping skills to deal with high-risk situations.
Text Message
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PROGRAM MESSAGE CONTENT, SURVEYS AND ASSESSMENTS
Messaging covers a number of topics, including general information on heart failure, blood pressure control, medication management, patient testimonials, food choices, eating out, exercise, quality of life, health literacy, stress management, emotional support, and more. If patients use tobacco or have diabetes or renal failure, they will receive appropriate messaging for those co-morbidities, including resources for smoking cessation. Patients also receive weekly wellness surveys to track their progress in managing their condition with their doctor and on their own. Surveys are also administered to determine need the for intervention if an escalation of health issues occurs, such as weight gain, edema, shortness of breath, or medication non-compliance. Patients are also given monthly surveys to gauge their outlook on life. Smokers receive a monthly message to check if they have successfully quit smoking. If a queried health issue results in a response that warrants escalation to a nurse, the response is appropriately triaged according to The Heart House protocol. Otherwise, survey response data is collected in real time through the GoMo Platform, and is accessible by designated members of The Heart House staff for tracking and monitoring. Text messages
contain links to AHA-approved and GoMo Health-developed information about the related topics to help patients and caregivers feel more empowered and informed.
Once the program launched, The Heart House began to recognize just how valuable the ability to receive in- the-moment feedback from participants was, and soon began adding other messaging related to appointment preparation. Patients with cell phones scheduled for a stress test receive a 6am message with their appointment time and a reminder not to drink caffeine. Patients scheduled for a loop recorder implant procedure receive a message at 6pm the day before with their
Weekly Wellness Check In
What is your current weight?*
lbs.
Have you experienced a weight gain of 2lbs overnight or 5-7lbs in 1 week?* Yes No If you measure your blood pressure at home, what is the most recent reading? If you have no blood pressure device you may skip this question.
Systolic (Upper Number)
Diastolic (Lower Number)
In the last week, have you experienced NEW or WORSENING swelling?* Yes No
SECTION 4 | THE HEART HOUSE CARDIAC CONCIERGE CARE PROGRAM
appointment time and a reminder to take their antibiotic an hour before the appointment. With COVID-19, and the need for pre-screening patients, a text message with a link to a COVID questionnaire has also been added. This has saved staff considerable time pre-screening patients by phone. The messaging is used in other ways as well. In the past, patients who completed various tests, where the results were normal, did not receive a call from The Heart House (patients with abnormal test results received a call). Now patients with normal results receive a text message indicating that there were no abnormalities. This has greatly reduced the number of calls coming into the practice for test results. All patients with a cell phone also receive a request to complete a survey the day after their appointment. The Heart House staff monitors the responses and follows up with any patient who expresses dissatisfaction. These text messages, surveys, and care pages are instrumental in engaging patients in their lived environments, connecting them to information, support, and provider dialogue on a consistent basis to help them feel empowered and valued.
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Program Results and Outcomes PATIENT, CAREGIVER, AND PRACTICE OPERATIONS FEEDBACK
The GoMo Health Cardiac Concierge Program has dramatically improved patients’ experience with their cardiac care providers, from clinical treatment to the actual office experience. Shared below are just a few examples of the positive participant feedback we’ve received: Caregivers Have Shared + “As a caregiver, it helps me understand what my husband is going through mentally and physically whether pain or fatigue and how I can help him to go through and also helps me know our options of good diet and light exercises.” + “It helps me. Everything you send I explain to my husband so we can together figure out any problem we face...thanks.”
As of August 5, 2020, the program had 1,406 auto- enrolled patients and a current enrollment roster of 1,077, representing a retention rate of 76%.
Patients Have Shared + “Telehealth should become a permanent option in your locations. It works very well.” + “First time using telemedicine. It was a great experience.” + “I love that you are texting me changes in taking my medication. Better than phone calls since I have a record of the changes.” + “LOVE the text test results. Hope I also get other results in a similar fashion.” + “You are all working very hard to assist patients in accessing and navigating your services during these difficult times. We thank you and appreciate your kindness and patience with elderly people.” + “Very helpful tool to alert you to signs to be aware of, as well as helpful hints in managing symptoms.” + “It’s a good reminder for me to keep up with my health. It’s good to know someone out there, besides family members, is concerned for my wellbeing…it’s very helpful for me.”
SECTION 4 | THE HEART HOUSE CARDIAC CONCIERGE CARE PROGRAM
PROGRAM OUTCOMES
Escalation Symptom Details
The Heart House continues to see positive results across all predetermined goals and objectives, including increased medication adherence, drastically reduced hospital readmissions, tobacco cessation, continued patient satisfaction as documented through electronic patient reported outcomes (ePRO), and quality-of-life improvement. View current outcomes below:
To date, there have been 806 unique escalation incidents, including:
311
Moderate Shortness of Breath
251
Improved Medication Adherence
Moderate Swelling
Participants reported 98% heart failure medication adherence, compared with the national average of 40-60%1 and the average patient self-reported adherence rate of 78%.3
98%
307
Weight Gain of Five Pounds or More Since Last Survey
62
Severe Shortness of Breath
Improved Escalation Outcomes
48
One of the pivotal elements of the program is the in- the-moment escalation resources that allow patients to get immediate support if they’re in distress. The program has identified early onset of adverse events with a total of 806 unique escalation incidents to nurse triage. These notifications alert nurses to intervene and engage with the patient to discusses causes, potential risks, and corrective solutions.
Severe Swelling
75
Stopped Taking Medication
27
Reduced Hospital Readmissions and Out-of-Pocket Costs and Time Approximately 82% of heart failure patients who visit the ED for their symptoms are hospitalized for treatment. With a typical stay lasting over five days, the national average cost of a hospitalization for heart failure is $11,840.40 If each escalation incident prevented the advancement of serious symptoms that would have ultimately resulted in such an ED visit, as much as $7,825,292 may have been saved in total. + One-year hospital readmission rates of 44% prior to entering the program dropped to 19% after activating the program, representing a 69% improvement
Provider Appointment Compliance Within the first four months of entering the program, current participants who remained enrolled demonstrated a 10% increase in doctor/nurse appointment attendance when compared to their attendance rate prior to enrollment. Patient Satisfaction Survey Completions (Pre-Concierge Program) Before concierge program implementation, one of The Heart House’s hospital affiliates, Virtua Memorial Hospital, tasked them with collecting 30 patient satisfaction surveys by the end of the 2018. GoMo Health was notified of this need in December and worked quickly to deploy a real-time survey solution that could be delivered electronically immediately following participant appointments. This not only allowed us serve Heart House’s general need for a survey, it enabled the capture of real-time, in-the-moment feedback when patients are generally more inclined to provide honest responses. Surveys were delivered via a secure link through mobile text messaging. By the end of 2018 (less than a month after the survey was developed and launched), there were 204 respondents, well over the the original target of 30. The survey continues to be deployed to each participant following their appointment. Data integrity is maintained through paperless storage. Since the launch of the survey, 9,460 have been completed. See the following page for results.
+ 90-day readmission rates of 19% prior to activating in the program dropped to 12% after activation, representing a 37% improvement.
Increased Self-Management to Sustain Lifestyle Changes
Among completed smoking surveys:
of patients self-reported decreasing tobacco use.
43%
22%
self-reported quitting tobacco.
SECTION 4 | THE HEART HOUSE CARDIAC CONCIERGE CARE PROGRAM
Provider Appointment Compliance
Communications and Interactions with Physicians and Nurse Practitioners 87% Very Satisfied 9% Satisfied
Participants completed a total 582 QOL (quality of life) surveys, rating their current well-being and optimism for future quality of life.
Communications and Interactions with Front Desk
82%
Very Satisfied
Current Wellbeing
13%
Satisfied
56%
“Manageable”
Communications and Interactions with Medical Assistants
39%
“Wonderful”
86%
Very Satisfied
10%
Satisfied
Optimism for Future Quality of Life
50%
“Extremely”
Appointment Scheduling Process
80%
Very Satisfied
42%
“Somewhat”
14%
Satisfied
Would Recommend Program to Friends and Family
98%
Very Satisfied
2%
Satisfied
These high rates of survey completion further prove that the BehavioralRx principles of engagement, when applied to this measurement tactic and method of delivery, one thought at a time, delivered in the environment of need — yields results.
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SECTION 5 How Was BehavioralRx Applied to the Heart House Cardiac Care Program?
T he science of BehavioralRx is largely driven by a collection of Cognitive Action Response Behaviors (CARBs) which serve to activate human resiliency and orient the brain toward positive decision making. CARBs work in harmony with a person’s day-to-day life by contextualizing their care plan guidance and resources based on interactive message response feedback- exchange with the patient. To maximize memory encoding, long-term memory storage, persistence, and recall, BehavioralRx mixes and matches the various CARBs engagement methods (described below) using proprietary algorithms.
For purposes of orienting the reader, four of the BehavioralRx CARBs methods applied in The Heart House Personal Concierge program (to produce the outcomes) are described here.
TAILORING TECHNOLOGY Activation through Customization + Applied to Heart Failure – The program is deeply personalized, adjusting to patient feedback, accounting for gender, comorbidities, and different psychosocial lifestyle issues that affect clinical care and everyday condition management. + Behavioral and Cognitive Effect – Concierge Care delivers information and resources to the person (rather than relying on them to access an app or portal) to maximize memory persistence and recall as the platform includes only what the patient indicates as relevant. Concierge Care offers disciplined and consistent delivery of information using patterns, and considering emotions, relevance, context, content, and sense- making to boost attention and memory formation. As Stanford Ericksen summarized the requisite emotional element in learning, “People learn what they care about and remember what they understand.” When information is determined to have potential long-term value, the hippocampus (brain component) links the significant elements of that event or experience together, forming a permanent memory.
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ENVIRONMENT OF NEED TECHNOLOGY Intervening at the Right Moment + Applied to Heart Failure – The program enables patients to provide ongoing feedback on health and adherence issues. Those responses that indicate early warning signs of a potential adverse event trigger immediate care messages to support patients in their moment of need and inform nurse triage who intervenes. + Behavioral and Cognitive Effect – Concierge Care positively “disrupts” negative mental models that, if unchecked, often lead to adverse events: cognitive models of mood disorders have shown that a person experiencing levels of anxiety, stress, and depressive symptoms has a deficit in being able to regulate mood as this state of mind leads to negative impairments in cognitive control. Patients vulnerable to negative moods and depression may linger (“ruminate”) on these negative cognitions, thus consuming working memory and preventing launching of memory resources that can activate a positive mental or physical action.
REDUCTION TECHNOLOGY Activation through Simplifying + Applied to Heart Failure – Messaging is delivered one thought or question at a time, which allows participants to fully engage with the content without missing key insights. The cadence, tone and content vary, based on a number of personalization variables and participants’ specific responses. + Behavioral and Cognitive Effect – Delivering information in small, “snackable” bites with content sensitive to appropriate social cues of the population served significantly increases long-term memory storage and recall (the first brain process in sensory memory, where input from external stimuli is initially stored for two to three seconds before deciding to process it further or reject it). If the brain discards the information because it is too much to process (information overload) it is inevitably forgotten. However, should one choose to transfer information, it moves to short-term memory, where the information is kept for a longer time frame (anywhere between 5 and 15 seconds) as the brain decides what to do with it. The decision comes down to using the info, discarding it to be forgotten, or committing it to the final step of long-term memory. Akin to the hard drive in a computer, long-term memory is where we keep data we don’t need in that particular moment. The information in long-term memory can be housed indefinitely to be called upon and used at a later, more appropriate time..
SECTION 5 | HOW WAS BEHAVIORALRX APPLIED TO THE HEART HOUSE CARDIAC CARE PROGRAM?
NURTURING TECHNOLOGY
Guided Motivation + Applied to Heart Failure – Concierge Care understands an individual’s current state and, over the course of this program, guides people through adjusting to new medications and lifestyle, nurturing actions to improve quality of life in a practical and methodical approach. Any patient program needs to have at least 50% of the information and resources devoted to improving quality of life in order to develop and foster resiliency around healthy behaviors, otherwise patients will ultimately lose interest and relapse. + Behavioral and Cognitive Effect – Concierge Care nurtures and acts behaviorally and cognitively as a good friend and concerned clinician. As reported by the Mayo Clinic, the benefits of friendships are numerous. Good friends are beneficial to your health. They can help celebrate good times and provide support during bad times, prevent loneliness, and give people the opportunity to offer needed companionship to others
Like a good friend, BehavioralRx has also been shown to: + Increase sense of belonging and purpose + Boost happiness and reduce stress + Improve self-confidence and self-worth + Help cope with traumas such as divorce, serious illness, job loss, or the death of a loved one + Encourage positive change or avoid unhealthy lifestyle habits, such as excessive drinking or lack of exercise
Friends play a significant role in promoting overall health. Adults with strong social support have a reduced risk of many significant health problems, including depression, high blood pressure, and an unhealthy body mass index (BMI).
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CONCLUSION Getting to the Heart of Healthcare
T he GoMo Health Personal Concierge Care program has proven successful by numerous quality metrics, including patient experience and empowerment, medication adherence, reduced avoidable hospital readmissions, overall treatment outcomes, and life satisfaction. It demonstrates that applying a validated patient-partnered behavioral engagement approach to a serious or chronic condition, such as heart failure, can alter patient believability and outlook to activate, develop, and foster human resiliency, leading to a healthier and happier life.
References
1. Kleinsinger, Fred MD. “The Unmet Challenge of Medication Nonadherence” Permanente Journal Online 2018; 22: 18-033. https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC6045499/ 2. Kilgore, Meredith; Patel, Harshali K.; Kielhorn, Adrian; Maya, Juan F. and Sharma, Pradeep. “Economic Burden of Hospitalizations of Medicare Beneficiaries with Heart Failure” Journal Risk Management and Healthcare Policy 2017; 10: 63–70. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5436769/ 3. Shah D, Simms K, Barksdale D, et al. “Improving Medication Adherence of Patients with Chronic Heart Failure: Challenges and Solutions.” Research Reports in Clinical Cardiology, 2015: 6: 87-95. https://www.dovepress.com/ improving-medication-adherence-of-patients-with-chronic-heart-failure-- peer-reviewed-fulltext-article-RRCC 4. Peacock, W. Frank, MD. “Heart Failure in the Emergency Department.” Emergency Medicine, October 2017: 443. https://www.mdedge.com/emergencymedicine/ article/148682/cardiology/heart-failure-emergency-department
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