This program supports new parents and caregivers as they identify and navigate early child development milestones, home safety, and how to emotionally cope with the responsibility of a newborn.
CASE STUDY COLLECTION WELLNESS RISING Accelerating Diversity, Equity, and Inclusion
2023
TABLE OF CONTENTS
INTRODUCTION................................................................................................... 4 BEHAVIORALRX®................................................................................................. 8 CONCIERGE CARE® ............................................................................................ 9 CASE STUDY 1: AMERIGROUP GEORGIA............................................................ 10 Key Program Outcomes and Results ............................................................ 15 CASE STUDY 2: RIMROCK FOUNDATION........................................................... 16 Key Program Outcomes and Results ............................................................ 21 CASE STUDY 3: FIDELIS CARE®......................................................................... 22 Key Program Outcomes and Results ............................................................ 27 CASE STUDY 4: SOURCEWISE........................................................................... 28 Key Program Outcomes and Results ........................................................... 33 CASE STUDY 5: BRIGHT HEALTHCARE.............................................................. 34 Key Program Outcomes and Results ........................................................... 39 AT A GLANCE: DEI IN ACTION........................................................................... 40 SCHEDULE A 1:1 CONSULTATION...................................................................... 42
INTRODUCTION
Defining Diversity, Equity, and Inclusion
Diversity, equity, and inclusion (DEI) has become a buzzword reference in healthcare, driven by ongoing events that have illuminated a system struggling to fairly accommodate an increasingly diverse population with complex, evolving needs. In doing so, widespread inequities and gaps in access to and delivery of care have been exposed worldwide. Activating programs that address diversity, equity, and inclusion directly affects patient health outcomes, quality of life, and cost of care – impacting the communities served and the way healthcare organizations and professionals interact with and treat patients from diverse backgrounds.
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Let’s first define what exactly diversity, equity, and inclusion mean:
DIVERSITY is understanding the background of persons served including culture, gender, sexual orientation, religious beliefs, and socioeconomic status, as well as hiring and retaining a workforce that is representative of a diverse population. EQUITY is ensuring the care delivery team has the necessary resources to effectively do their jobs, and persons served are empowered in and out of treatment settings to optimally benefit from best treatment practices. INCLUSION is giving both care teams and persons served a voice to help provide, receive, and influence high-quality care delivery and encourage a diverse healthcare staff in the treatment experience of patients.
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Our Guiding Principles
At GoMo Health, one of our guiding principles is delivering sustainable, person-centered, remote care programs that address diversity, equity, and inclusion. Our programs have engaged patients, members, and consumers worldwide, including millions of underserved, vulnerable people of all backgrounds in rural and urban communities, creating one of the first engagement and data hubs for integrated care — coordinating physical and behavioral health, human/social services, law enforcement, and judicial organizations. This booklet features a collection of case studies, highlighting our evidence- based solutions that address patient- reported social determinants of health that complicate access to care, identify disparities, and reduce gaps in care and diversity. At GoMo Health, we believe that improving health outcomes for our most vulnerable populations improves health for all.
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We call it Wellness Rising. Join our movement.
For a quick one minute overview of our mission, check out this video! Click directly on the thumbnail above.
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Meeting People Where They Are
This collection of case studies utilizes BehavioralRx®, our proprietary science of precision engagement, to determine the patient and/or member activation strategy, approach, and content delivered. BehavioralRx has proven to increase adherence to care plans and directives resulting in better patient health outcomes, increased clinical joy in practice, and reduced physician and nurse fatigue.
Our Engagement Approach
Simple and Highly Directed
Is and Feels Personal/ Creates Intimacy
Is “In the Moment”
Enables Patients to Influence Based on Their Lives and Preferences
Optimizes Human HCP Talent/Minimizes Adverse Events
Goes to the Person
For additional insights into the GoMo Health BehavioralRx science, view this video from Chief Behavioral Technologist and GoMo Health Founder, Bob Gold and Chief Marketing and Client Services Officer, Shelley R. Schoenfeld: https://youtu.be/bB2eN-YeoZk
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CONCIERGE CARE®
Digital Therapeutics to Reduce Gaps in Care
BENEFITS INCLUDE: OPTIMIZED REIMBURSEMENTS Increase patient satisfaction scores and satisfy value-based care delivery requirements to maximize reimbursements PERSONALIZED PLANS OF CARE Deliver personalized resources, support, and care while enabling the collection of electronic patient-reported outcomes (ePRO) data to drive predictive modeling TRANSITIONAL CARE MANAGEMENT Virtual care delivery empowers patients to activate their self-care and enables providers to scale clinical services provided to high-volume populations
IMPROVED PATIENT EXPERIENCES Trust and credibility are fostered with patients, building resiliency and long-term adherence
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CASE STUDY 1
Early Intervention Concierge Program
Breakthrough Early Intervention Digital Care Management Program to Support Children and Families Amerigroup Georgia helps improve health care access and quality for more than 600,000 Medicaid recipients in Georgia by developing innovative care management programs and services. Amerigroup Georgia and GoMo Health partnered to launch an Early Intervention Mobile Concierge Program to support members with autism and their caregivers and provide all members with children under the age of four with resources to ensure adherence with autism screenings and milestone tracking to support early detection. The program provides interactive education, actionable guidance, psychosocial support, and connections with local and national resources to ultimately ease the stress and anxiety of overwhelmed caregivers and members.
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AMERIGROUP GEORGIA
PROGRAM DEMOGRAPHICS
Participants are Medicaid members and/or caregivers of children ages six months through four years as well as children with an autism diagnosis (ages 0 through 21). The program includes a unique care management component for those in the foster care system that enables care coordinators to track when a child’s main point of contact for care changes. These changes trigger escalations to ensure messages are being delivered to the current caregiver and all information is up-to-date in the system.
SNAPSHOT OF THE LANDSCAPE: AUTISM AND DISPARITIES
Children with autism have nearly four times higher odds of having unmet health care needs compared to children without disabilities. 1 Parents of children with autism reported a higher level of psychosocial distress and less social support than their counterparts with children with Down syndrome and the more commonly diagnosed type 1 diabetes. 2 Children with autism, specifically, are 2.4 times more likely to be in foster care than their neurotypical peers. 3 Children with autism depend fiercely on routine and familiarity, which is hard to maintain in the foster care system which lacks predictability and consistent healthcare providers.
1 Health Disparities among Children with Autism Spectrum Disorders Analysis of the National Survey of Children’s Health 2016 2 Clinical Practice and Epidemiology in Mental Health 3 SpectrumNews
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“Early diagnosis and intervention for children with autism can provide long-term benefits for children’s health, wellbeing, and their ability to develop to their fullest potential. Since launch, the program has already had a positive impact in our community and specifically for this population, and we are thrilled to see results that help ensure our members can live happy, healthy, and fulfilled lives.” Mel Lindsey, President, Amerigroup Georgia
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AMERIGROUP GEORGIA
PROGRAM GOALS
The evidence-based digital therapeutic was created with a two-prong engagement strategy to support both parents and caregivers of children with autism (early intervention) as well as identify potential developmental delays (early detection) through milestone tracking, wellness visit reminders, and follow-ups. LEVERAGING THE PRINCIPLES OF BEHAVIORALRX, THE PROGRAM WAS CREATED TO: Improve health outcomes of members as well as overall family environments Reduce adverse events, emergency department visits, inpatient stays, and total per member per month (PM/PM) costs Provide caregivers additional psychosocial support and build confidence in ability to care for a child with autism Enable care coordinators to improve productivity and increase joy in practice
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Key Program Outcomes and Results
84,900 members enrolled in the early detection program (pre-diagnosis)
5,407 program participants enrolled with an autism diagnosis in the early intervention program
17% of those enrolled have requested additional help from care coordinators via the program escalation-of-need process
98% average retention rate across both programs
“It has been amazing to see the immense impact of this program. One memorable example is a parent who was escalated due to high caregiver stress levels and challenges understanding insurance coverage. Once escalated, her care coordinator was able to connect with her, understand her challenges, and in turn, place her into a higher level of care coordination to support her and her family. This is just one example of how this program is reaching families who would have fallen through the cracks.”
Wenjie Sun, LCSW, CCM, Manager, Special Programs, Amerigroup
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CASE STUDY 2
Recovery Pathways Substance Use Program
Remote Care Management to Enhance Behavioral Health Treatment Programs Rimrock, the largest treatment center for adults with substance use and co-occurring disorders in Montana, views addiction as a whole person illness, affecting an individual’s emotional, physical, spiritual, and social wellbeing. GoMo Health collaborated with Rimrock to deliver Recovery Pathways , a personalized engagement solution for justice-involved participants from seven different treatment courts.
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RIMROCK
PROGRAM DEMOGRAPHIC HIGHLIGHTS
A DIVERSE POPULATION 25% of enrolled participants are Native American 14% of enrolled participants expressed interest in Native American content, 80% of whomare enrolled members of a tribe
Recovery Pathways serves members in treatment court and members returning to the community. Core to the program is the understanding that failure to prepare someone for community re-entry, especially by leaving substance use disorder untreated, will result in an unreasonably high risk for re- offense.
Did you know... While Native Americans account for only a small part of the U.S. population (about 1.7%), this group experiences much higher rates of substance use compared to other racial and ethnic groups. 4
4 U.S. Department of Health and Human Services, Office of Minority Health. (2018)
Factors that contribute to the increased risk of addiction among Native Americans include:
Historical trauma
Poverty
Racism
Violence (including high levels of gang activity, domestic violence, and sexual assault)
High levels of unemployment
Lack of health insurance
Low levels of attained education
Discrimination
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“As a treatment court partner providing services, we have long envisioned the cooperation, support, and synergy of the Recovery Pathways program. The GoMo Health personalized engagement platform enables us to embrace mobile technology to focus on ongoing healing and nurturing of positive behaviors.” Coralee Schmitz, Chief Operating Officer, Rimrock “Montanans who work in treatment court, corrections, and addiction treatment have built and deployed a solution which will save lives, reunite families, and reduce recidivism. They are dedicated to helping Montanans rebuild their lives by getting clean, sober, and healthy. Recovery Pathways is the result of all three branches of government working together with the best private sector treatment providers and cutting- edge technology to treat addiction as it should be treated, as a disease.” Greg Gianforte, Montana Governor
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RIMROCK
PROGRAM GOALS
For Members
Address social determinants of health that are barriers to recovery Reinforce therapies outside of program sessions
Reduce member relapse rate
Increase program completion rate
For Support-persons Provide behavioral and emotional support Share proven tactics for engaging with member in the program Increase empathy for loved ones in the program Increase appropriate boundary- setting
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Key Program Outcomes and Results
48.6% increase (50.02% to 74.36%) in full-time employment
2020-2021: Increasing Access and Activation as a Result of Inter-Agency Engagement and Data Sharing
10% relapse rate (compared to national average of 40-60%)
72% improvement YoY in incomplete discharge status per medical record
6x safety condition improvement of current living environment
89% program completion rate in 2021 (compared to other states’ rate of 50-70%)
“Treatment court judges need as many tools as possible to serve participants with substance use disorders. Accountability coupled with treatment enhancements assist the court in halting recidivism and encouraging life-long recovery.”
Judge Mary Jane Knisely, 13th Judicial District Court in Billings, Montana
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CASE STUDY 3
Condition Management Concierge Program
High-Quality Healthcare for High-Risk Medicaid Members Fidelis Care provides quality, affordable health insurance coverage for more than 2.4 million children and adults. As a Medicaid program offering services to high-risk members, the Fidelis Care Concierge program, created by GoMo Health, enables the case management team to provide a more personalized member experience and relevant condition-specific education while increasing the efficiency and effectiveness of the care plan by integrating the Personal Concierge program into day-to-day workflows.
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FIDELIS CARE
PROGRAM DEMOGRAPHICS
Participants are high-risk members who need advanced health management, care coordination/education, strategic health reminders, and simplified access to local health, social and transportation resources, as well as live 24/7 help and triage options.
Background and Demographics
Medicaid and Marketplace plan members
Pregnant women
Elderly individuals
Medically-fragile children
Low income individuals
Challenges
Social determinants of health
Chronic condition management
Behavioral health
Substance use
Commitment to health
Knowledge of available resources
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“A member of our plan made contact with their RN case manager from right outside the Emergency Department to let them know they were going in to be evaluated. This was a major turning point for us. Not only did the member have a relationship with their case manager (as a result of the consistent communication the GoMo Health program enabled) and felt comfortable reaching out, but the case manager was able to refer the member to the resources they needed and avoid the ED utilization.” Jenny, RN Case Manager
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FIDELIS CARE
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PROGRAM GOALS
The Fidelis Care concierge program was created to enhance and extend the care provided to NY Medicaid members with specific conditions, empowering them to better self-manage, adhere to treatment, and take a more proactive approach in condition management while enabling the case management team to more effectively and efficiently support them.
Enhance member service quality
Increase service referral connections
Improve HEDIS measures
Improve joy in practice
Reduce PM/PM costs
Increase member utilization of resources
Increase adherence and activation levels in members
Decrease anxiety, depression, and other mental health challenges
Key Program Outcomes and Results
6-7% closure of gaps in care for engaged members in multiple categories
4% reduction in ED visits with engaged members vs. non- engaged members
206% increase in case manager efficiency due to improved workflows that minimized staff burnout (measured by caseload per manager)
95% program retention rate
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CASE STUDY 4
MyPlan Caregiver Support Program
All-in-One Care Coordination Solution for Caregivers and Care Managers Since 1973, Sourcewise has provided services and support to seniors in Santa Clara County, CA with a mission to empower the persons cared for and caregivers with the tools and services they need to effectively navigate their health and life options through a comprehensive network of resources. Sourcewise MyPlan , a collaboration between GoMo Health and Sourcewise, provides support to caregivers and ensures a timely connection to case managers that can help connect caregivers to resources such as respite care and Medicare. By bringing needed resources that they can access in their lived environment, the program gently guides the caregiver and addresses their psychosocial needs.
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SOURCEWISE
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PROGRAM DEMOGRAPHICS MyPlan Includes Family Caregivers Who Are: 18 to 59 years old
Socio-emotional Status: Caregivers 89% indicated high-stress levels with 92% directly related to caregiving responsibilities 30% indicated depression
Multicultural
U.S. based
Social Determinants of Health (SDoH): Persons Served or Members 70% have a lack of reliable transportation that prevents access to care 15% experience food insecurity
15% live alone
What Sourcewise caregivers are saying:
“I can’t express how much of a difference your program has made in my life. Please continue the program.”
“The GoMo Health program has hugely reduced my stress levels and the educational portal has taught me so much.”
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SOURCEWISE
PROGRAM GOALS An all-in-one care coordination solution for caregivers and care managers to:
Reduce the time between the first intake and the first interaction with care manager by 33%
Increase client satisfaction by 20%
Improve caregiver outcomes: PHQ 2; fatigue; stress; unmet needs
Improve net promoter score by 20%
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Key Program Outcomes and Results
Key Program Outcomes and Results
90% overall program retention rate
Improvement in Caregiver Physical and Emotional Health:
100% decrease in average length of hospital stay 76% decrease in number of overnight or extended stays in the hospital 73% decrease in rate of caregiver isolation 47% decrease in ED visits that did not result in admission 29% decrease in rate of caregiver depression 13% decrease in rate of caregiver stress Improvement in Persons Cared for SDoH: 45% decrease in number of ED visits that did not result in an admission 20% decrease in a lack of reliable transportation preventing access to care 10% decrease in food insecurity
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CASE STUDY 5
Made Easy Meals Chronic Condition Management Program
Integrating Food and Nutrition into Healthcare for Vulnerable Populations
Bright HealthCare, a tech-enabled Medicare Advantage carrier, delivers healthcare benefits to more than 720,000 consumers across 14 states. Core to its mission is ensuring integrated care that meets members where they are, reduces barriers to access, and drives improved outcomes. In partnership with Hea!thrageous, GoMo Health designed the uniquely integrated Food as Medicine solution. The program combines nutritionally balanced meals from Hea!thrageous with a personalized and interactive Healthy Eating Score and virtual health concierge. Designed to provide a nurturing and seamless support experience, the program improves member health for individuals with qualifying chronic conditions and enhances an integrated approach to serving these vulnerable populations.
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BRIGHT HEALTHCARE
PROGRAM DEMOGRAPHICS
Bright HealthCare serves vulnerable populations to address social determinants of health in addition to chronic conditions, with 80% of enrollees between the ages of 60-79.
PARTICIPATING PLANS
Medicare Advantage Members Chronically Ill
Chronically Ill Special Needs (CSNP)
Dual Special Needs (DSNP)
QUALIFYING CHRONIC CONDITIONS
Type 2 diabetes
Congestive heart failure
Chronic kidney disease
High cholesterol
Hypertension
The program is offered in both English and Spanish with 38% of members selecting Spanish as their primary language.
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“Bright HealthCare is committed to transforming healthcare by combining our innovative technology model with the knowledge and expertise of local partners. The Made Easy Meals program has developed a strong clinical model of care designed to serve member populations with complex conditions and improve outcomes to deliver an even better experience for our members.”
Mike Mikan, Chief Executive Officer and President, Bright HealthCare
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BRIGHT HEALTHCARE
PROGRAM GOALS:
Medicare Advantage Star Ratings Enhance member experience
Improve quality measures
Health Outcomes Empower members to live healthier lives
Address food insecurities
Improve individual blood pressure, cholesterol, weight, and HbA1c
Care Management, Joy in Practice, and Operations Provide member services and
resources more effectively, offloading day-to-day tasks
Enable care management team members to focus on high-impact activities
Cost-effective Scalability Increase member retention and growth
Reduce ED visits, hospital stays, and readmissions Reduce cost of care and utilization
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Key Program Outcomes and Results
Successfully Managing Chronic Conditions for a Healthier Lifestyle
97% program participant retention 90% of survey respondents say this program makes them feel more supported by their health plan 88% of survey respondents say
80% of members reported satisfaction with meals 71% of members who submitted 10 or more glucose readings via at-home monitoring recorded lower A1C from baseline
their ability to manage their health has improved since joining the program
“The program has been great! I have lost a few pounds, and my diabetes and A1C went down so I only need to take one metformin per day now.”
“The program keeps us very conscious about our health. Our doctor is very happy with our progress on maintaining our sugar levels!”
Bright HealthCare Member
Bright HealthCare Member
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AT A GLANCE: DEI IN ACTION
BRIDGEWAY EHOST PROGRAM Program goal: Improve behavioral health outreach for at-risk youth 26% of participants identify as LGBTQ
66% of participants indicated they are homeless or at risk of homelessness
COLGATE CONNECT Program goal: Enhance Colgate’s oral health
products with mobile-based engagement, empowering youth with resources to encourage healthy dental habits Content is available in both English and Spanish to expand program reach and access Program is curated specifically for youth to keep children resilient and actively engaged in a brushing routine
MENTAL HEALTH ASSOCIATION IN NEW JERSEY (MHANJ) CONCIERGE CARE PROGRAM
Program goal: Connect high-risk residents with the tools to manage mental/behavioral health challenges and navigate COVID-19 95% of participants are extremely satisfied with the program Increased call specialist productivity with less time spent on phone calls due to virtual care coordination
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OPTIMUS CONCIERGE CARE, AN ACO ORGANIZATION Program goal: Increase medication adherence for patients with diabetes, hypertension, and high cholesterol 33% of patients enrolled indicated Spanish as their primary language with content automatically changing to Spanish based on browser In 2021, program saw a 10% improvement among Spanish speaking patients new to a condition PARTNERS HEALTH PLAN HEALTHY CONNECTIONS PROGRAM Program goal: Engage and nurture members/ caregivers with diabetes and/or hypertension to increase activation of member’s health and wellbeing Increase in HEDIS measures
Improved HbA1c: 55% increase
Controlled BP: 21% increase
Lowered hospital admission rates: 15% decrease
THE AGA KHAN HOSPITAL MATERNAL CHILD HEALTH PROGRAM Program goal: Virtual care coordinator to remotely support prenatal/postnatal women in a rural area where healthcare is not easily accessible 98% of prenatal participants said the content helped better manage their pregnancy 93% of postnatal participants said the content helped better manage their baby’s care
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Schedule a 1:1 Consultation
Get in touch with a GoMo Health representative to receive a demo of these programs.
Visit gomohealth.com/demo or text GOMO to 51684
GET IN TOUCH
1 (848) 467-4560
gomohealth.com
info@gomohealth.com
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