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Achieving the Triple Aim with Chronic Pain Medicaid Patients
Reducing Costs, Improving Outcomes, and Increasing Satisfaction
Table of Contents
Overview ................................................................................................................... 3
Background ............................................................................................................... 5
Why the Positive Outcomes? .................................................................................... 7
Learn More ............................................................................................................. 10
TABLE OF CONTENTS | ACHIEVING THE TRIPLE AIM WITH CHRONIC PAIN MEDICAID PATIENTS
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“This program is not about text messaging. It is about the science of motivation, activation, and human resiliency using the BehavioralRx ® evidence-based behavioral and cognitive methods. BehavioralRx uses a proprietary AI behavioral modification machine learning technique called CARBS (Cognitive Action Response Behaviors) to create resiliency to stay on therapy.”
BOB GOLD Chief Behavioral Technologist GoMo Health
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Overview
I. Introduction
This document describes the outcomes from the OPENtext program, made available to the Rhode Island Medicaid Communities of Care. The program used the GoMo Health behavioral science and Personal Concierge™ to help Medicaid patients with chronic pain who are high utilizers of the Emergency Department (ED) proactively managing their needs and reduce unnecessary ED visits. The study was funded through a PCORI (Patient Centered Outcomes Research Institute) grant. A unique and fascinating variable in this study was that GoMo Health and patient navigators each engaged their own randomized group of high-volume ED patient utilizers experiencing chronic pain for the purpose of comparing a behaviorally-based mobile technology vs. a human intervention. In most of our commercial programs, GoMo Health acts as a virtual care coordinator while integrating with, reinforcing utilization of, and escalating to human care coordinators. This approach provides a seamless digital and human care delivery model where each component complements the other.
III. BehavioralRx ®
This program, in fact, is not about text messaging — it is about the scientific discipline of motivating, activating, and creating human resiliency using BehavioralRx evidence-based behavioral and cognitive methods, specifically, a propriety AI machine learning technique called CARBS. Just like all care plans and treatment protocols are not identical, neither are all technology solutions. The behaviorally-based technology platform used in this research, created by behavioral scientists, is designed from the ground up to work in harmony with the day-to-day changes in a person's emotional and physical states.
II. ResearchGate Summary Report
This includes a third party published summary report by ResearchGate (January 17, 2019) covering the background, methods, and results of the OPEN research initiative. ResearchGate is a professional network for scientists and researchers with over 15 million members worldwide who use it to share, discover, and discuss research.
IV. Program Demo Registration
Register for a 1:1 educational session to learn more about the OPENtext program and BehavioralRx by visiting gomohealth.com/behavioralrx .
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Background
The following published report can be found on ResearchGate. ResearchGate is the professional network for scientists and researchers. Over 15 million members from all over the world use it to share, discover, and discuss research. They are guided by their mission to connect the world of science and make research open to all.
www.researchgate.net/project/OPEN-Comparative- Effectiveness-Randomized-Control-Trial-RCT
RESEARCHGATE REPORT
Chronic pain is a debilitating condition that affects the most fundamental aspects of patient quality of life. Yet effective chronic pain management is clinically challenging. As part of an innovative solution, the Rhode Island Medicaid program introduced the Communities of Care initiative in November 2010 and a focused chronic pain initiative (CPI) in June 2012. The CPI targets 1500 members who are high emergency department utilizers suffering from chronic pain and offers: case management team, patient self-help, behavioral healthcare, and traditional and complementary therapies (massage, chiropractic, and acupuncture). However, retention and engagement are known challenges in this setting. One way to address these challenges is through the use of mobile technology (using GoMo Health Personal Concierge: a two-way BOT with a behavioral modification engagement science; called OPENtext for this research program), which has been at the forefront of patient self-management across a number of health problems. Patient navigation interventions also show promise for engaging marginalized populations in care.
OBJECTIVES
1. To better understand the challenges of engaging in the CPI program.
2. To develop and test a 12-week text-message intervention (OPENtext) compared with a patient navigation approach (OPENnav) to increase patient engagement and self-management of chronic pain.
METHODS
An advisory board guided the study, conducting 48 qualitative interviews with patients, providers, and health system administrators to understand facilitators and barriers to CPI engagement and define content, delivery, and functional specifications of an optimal text-message intervention for enrollees. Based on these findings, incorporating elements of existing evidence-based chronic pain self-management content, and employing behavior change theories, we developed and pilot tested a text message intervention for CPI enrollees. Finally, in a randomized controlled trial with 197 CPI patients, we compared the effectiveness of OPENtext to OPENnav
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in increasing patient's self-efficacy, readiness to self-manage their chronic pain condition, and engagement in CAM (chiropractic, acupuncture, massage) at 6 months. Secondary outcomes examined changes to quality of life, self-reported pain, opioid medication use, emergency department use, and aberrant opioid use behavior. We also analyzed intervention effects by gender and minority status. Both longitudinal and latent growth curve modeling approaches were applied to test effects.
RESULTS
Qualitative interviews identified key barriers to CPI engagement: inconsistent communication, lack of CAM familiarity, poor patient social support, low health literacy, and logistical challenges. The OPENtext intervention was developed and finalized into a tailored program with over 3000 messages and resources addressing identified gaps. The RCT enrolled 197 patients, attaining 98% through 6-month follow up.
Compared with OPENnav, OPENtext participants reported greater increases:
Activation: Participants enrolled in OPENtext were more likely than participants enrolled in OPENnav to engage in the intervention itself (98% v. 71%). Mental State: Contemplation scores and a trend for increases in maintenance scores reflecting improved readiness to contemplate making changes (b= 0.31, p=0.001) and to maintain made changes (b=0.08, p=.07) in self-management of chronic pain. Pain: Reductions in bodily pain (i.e., pain severity (b= -1.42, p=0.001 at 3 months, b= -0.78, p>0.05 at 6 months and b= -1.65, p=0.001 at 9 months) and pain interference in daily living that impact quality of life (b=5.88, SE=2.80, p=.04 at 6 months). ED Visits: Reductions in healthcare plan-verified emergency department visits (p=0.001), and a trend in self- efficacy to self-manage chronic pain (b=14.31, SE=8.43, p=.09). Resiliency: OPENtext recipients were also more likely than OPENnav recipients to exhibit patterns showing continued moderate CAM engagement over time (p=.03). Resiliency: Both study arms experienced similar overall increases over time in non-medicine-based treatments (CAM) service engagement. Mental State/Activation: Secondary outcomes also showed reductions in depressive symptoms, pain catastrophizing, and increased over-the-counter analgesic use across both groups.
CONCLUSIONS
A text-message intervention (using GoMo Health Personal Concierge: a two-way BOT with a behavioral modification engagement science) can help support self-management of chronic pain, elevate pain-related quality of life, and alter care engagement in CAM among patients heavily affected by health and social disparities who are living with chronic pain. Offering non-pharmacological therapies to patients on Medicaid resulted in alleviation of pain experience, reduced narcotic and opioid use, and better behavioral health outcomes at six months regardless of study arm.
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Why the Positive Outcomes? GoMo Health BehavioralRx evidence-based science develops, fosters and strengthens resiliency that leads to more resilient humans. It is the science of human motivation, activation, and resiliency for personalized patient and medication therapies. 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 that enable a person to adjust their lifestyle to stay on therapy.
BehavioralRx Machine Intelligence uses evidence-based scientific principles from:
GoMo Health Concierge Care ® , the cloud-based software implementation of the BehavioralRx methods and algorithms, is delivered to people and can engage in a two-way dialogue, considering participant needs in-the-moment, and preferred time of day and day of week. It is personalized and within their lifestyle; consistent with their day-to-day behaviors and cognitive processes. Concierge Care, the deployed brand name for the implementation of BehavioralRx, gives time back to patients and clinicians and works within their lifestyle.
Behavioral Psychology Focused on human motivation and
activation; highly correlated to emotional attributes such as trust, credibility, outlook, reciprocity. Cognitive Neuroscience Focused on cognitive human factors engineering; highly correlated to brain functions such as short and long-term memory encoding and movement, learning and memory storage and persistence, and in-the-moment memory retrieval and recall.
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BEHAVIORALRX HUMAN ENGAGEMENT ALGORITHMS
1.. Concierge Care Goes to the Person • Creates bonds • Creates feeling of belonging
4. Simple and Highly Directed Stimulates AHA! moments and memory recall.
5. Enables Patients to Influence Based on Their Life at that Moment Responsive to human need: patient can interrupt current regimen and have Concierge Care go into triage mode to handle their episodic event/issue. 6. Optimizes Human HCP Talent, Minimizes Costs and Adverse Events Programs are based on algorithms that optimize the use of human care coordinators as part of a seamless conversation flow with the patient, thereby increasing efficiency, effectiveness/impact, and joy in practice of clinical care team.
2. In the Moment •
Preferred time of day and day of week influence message timing • Typically, one thought/question/action at a time • Snackable bites of information 3. Is and Feels Personal – Creates Intimacy • Immediately responsive • Provides reciprocity, therefore stimulates same in return • Patient can initiate “conversation” flows
APPLIED BEHAVIORAL AND COGNITIVE SCIENTIFIC PRINCIPLES, METHODS, AND ENGAGEMENT ALGORITHMS For purposes of orienting the reader, we will select 5 of the BehavioralRx CARBS (Cognitive Action Response Behaviors) methods that were applied in this pain management and substance use disorder (SUD) research program to produce the outcomes. 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. See chart on page 9.
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BehavioralRx CARBS Science
Applied to Chronic Pain (and SUD)
Behavioral and Cognitive Effect
Influence Technology Activation through shared decision making
Participants set their goals, communicated their immediate symptoms, and got immediate affirmation and reciprocity when receiving custom program content to support their health journey.
Enabling patients to share in the formation and modification of their care plan produced a 3-5x increased level of activation; they felt more personally invested in program. Built participant resiliency through believability in their ability to self- manage; increases trust and credibility in the program and in themselves to carry out the steps necessary to stay on program; modified participants'
Environment of Need Technology Intervening at the right moment
Participants who indicated pain, stress levels, and feelings related to social isolation were immediately responded to with appropriate mental and physical activities in the moment and environment of need. Participants were able to interrupt the regimen 24/7 when they felt a specific need by texting in keywords (ex: breathe, calm, peer, mood) to request specific support, with resources immediately delivered back to them in response.
believability in their capacity to perform the tasks significantly increased activation.
Wander and Wonder Technology Activation by increasing memory persistence and recall via mental and physical activities that stimulate contextually relevant neuroreceptors
Participants received a variety of activities that utilized different senses; these activities were both pro-actively sent and delivered on-demand at participants' request.
Emotions can be a catalyst or an impediment to learning. It has been estimated that 95% of our reactions are unconsciously driven by the amygdala and only modestly impacted by the executive centers of the cerebral cortex. Although the brain is considered a rational entity, it is an emotional brain, where feelings receive first priority. Engaging the emotional regions of the brain vs. the rational cortex alone engenders higher degrees of activation and increased likelihood the desired network of neurons will fire in unison in future like circumstances. Outlook is a huge trigger or inhibitor of activation and resiliency. Participants, like all of us, live their day-to-day life in a series of mini events throughout the day. BehavioralRx methods simplify and contextualize complex information into digestible, snackable bites of information that enable a person to accomplish those activities and begin to change their outlook in their own ability to self-manage. Removing feelings of social isolation and helping the person to feel comfortable to express their feelings and receive helpful and supportive guidance when and where they want it is a powerful contributor to reducing stress and other mood disorders. This creates positive behavior modification that produces more sustainable habits, ultimately increasing a person’s resiliency.
Participants occasionally received a virtual “fortune cookie” that offered surprise and delight.
Reduction Technology Activation through simplifying
Participants received one thought, action, or question at various times throughout the day based on their preferred times of day and schedule. The cadence, tone, and content varied based on a number of personalization variables and their specific responses.
Nurturing Technology Guided motivation
Participants were guided based on their perspectives in the moment and provided with positive reinforcement for participation; when participants did not respond a BehavioralRx algorithm was able to ask again (based on a relevant time interval) and change the way the question was asked. This supportive technique is capable of acting on a null action. Participants received certain messages with different tones of voice; some messages were written as a healthcare professional providing guidance and others were written as a peer who was experiencing a similar issue.
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Learn More
To learn more about BehavioralRx and schedule a 1:1 online consultation, visit: gomohealth.com/behavioralrx
GoMo Health ® is a leader in population health management and patient engagement solutions that support the continuum of care, improved patient satisfaction and MACRA value-based reimbursements. GoMo Health Concierge Care ® personalizes patient interactions using our proprietary science, BehavioralRx ® , The Science of Precision Health, building trust and credibility to motivate higher levels of activation and resiliency. In partnership with health care organizations worldwide, GoMo Health delivers a highly scalable and cost-effective solution for the management of high-risk, chronic, and complex conditions, enabling better self-management, healthy decision making and improved outcomes.
GET IN TOUCH
1(848) 467-4560
gomohealth.com
info@gomohealth.com
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