Care Evolution

From HIMSS 2023 Interoperability showcase

Medicare Advantage and CMS MSSP patients of a leading community health system in Massachusetts can enroll in an innovative program to receive over-the-counter wearables and devices such as health trackers and pulse oximeters to better connect with their health system. A 67-year-old COPD enrollee, Mrs. Davis, signs up to receive these devices and agrees to share her passively collected wearable data. While going about her daily routine she periodically responds to highly personalized short assessments enabling her care team to monitor her COPD status by combining her responses with the wearable data via the team’s digital app. About a month after starting the program Mrs. Davis starts feeling under the weather. The app allows her to report these new symptoms and request at-home COVID and Flu tests, which she receives the next day. The app guides her through taking the tests and sharing the results with her care team. In addition to her COVID results being shared with the care team, the system also shares her results with the Association of Public Health Laboratories AIMS platform so that her tests also inform the public health system. Using this surveillance system, the care team decides to dispatch EMTs from an available community pool who are already strategically positioned for a wellness check and helps obtain a Paxlovid prescription before she suffers a COPD exacerbation and must call 911 for a visit to the emergency department. Overall, this demo shows how leveraging at-home diagnostics, remote monitoring using over the counter devices, and use of proactive EMT dispatch to deliver home based care improves management of the health and total cost of care of a capitated population.

Value
At-home monitoring informed by clinical, claims, and wearable data enables earlier interventions, enhances patient engagement, better informs care teams and public health, and lowers the burden and cost of acute care.