This project aims to utilize a mixed method learning model to host bi-monthly “events ”. The Million Hearts Learning Lab is a bi-monthly learning series focused on cardiovascular disease prevention and management topics. The series is open to clinicians, quality improvement, and other interested staff across the country, but with a focus on community health centers. Clinicians may earn 1.0 CME credit per session through the American Medical Association’s Ed Hub. All pre-work and live event links are hosted on NACHC Learning Lab Platform –Confluence –with a link pointing to AMA’s Ed Hub to apply for CME Credit. The format of these events will include:
Pre-Work: 12-minute podcast (video w/ slide or audio only)/review of onepagers/submit questions for expert faculty.
Day of event: 15-minute review and 30-minute live Q&A with expert faculty. https://nachc.zoom.us/webinar/register/WN_RQgExu1jTAOecmqeNTUeTQ#/registration
Total time per event: 60 minutes
The expert faculty will be from the AMA team and the Health Center Controlled Networks (HCCNs)/health centers in Discovery projects.
The Million Hearts Learning Lab is a bi-monthly learning series focused on cardiovascular disease prevention and management topics. The series is open to clinicians, quality improvement, and other interested staff across the country, but with a focus on community health centers. Clinicians may earn 1.0 CME credit per session through the American Medical Association's Ed Hub.
This project aims to utilize a mixed-method learning model to host bi-monthly “events”. Please watch the videos below, then select “Take Quiz” to earn CME.
The Million Hearts® Learning Lab focuses on cardiovascular disease prevention and management. In this video, participants receive an overview of how bi-directional text messaging can be used as an evidence-based communication tool to improve hypertension and cholesterol outcomes.
The Million Hearts® Learning Lab focuses on cardiovascular disease prevention and management. In this video, participants will learn about how bi-directional text messaging can be used as an evidence-based communication tool to improve hypertension and cholesterol outcomes. Key communication strategies and phrases that successfully engage patients in chronic disease management using bi-direction text messaging software will be reviewed and discussed.
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Cardiovascular Disease (CVD) Prevention Education from the AMA is part of an effort to prevent and even reverse the effects of the most threatening chronic health conditions.
To help improve the quality of its educational content and meet applicable education accreditation requirements, the content provider will receive record of your participation and responses to this activity.
AMA CME Accreditation Information
Credit Designation Statement: The American Medical Association designates this Enduring Material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:
1.0 Medical Knowledge MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program;
1.0 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.0 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program; and
1.0 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program;
1.0 Lifelong Learning points in the American Board of Surgery’s (ABS) Continuing Certification program
It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.
CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.
If applicable, all relevant financial relationships have been mitigated.
Video 1: Using Bi-Directional Text Messaging to Engage Patients in Chronic Disease Management
Amy Zarr: [00:00] Welcome. Today we'll be talking about using bi-directional text messaging to engage patients in chronic disease management. My name is Amy Zarr and I am the Associate Director of Population Health for the Michigan Primary Care Association. I work with FQHCs across the state to help them optimize their utilization of health IT tools and platforms to improve patient health outcomes and meet value-based performance targets. MPCA has integrated Azara Drives with the Luma Health patient outreach and engagement platform for bi-directional patient text communication that 24 of our 40 FQHCs subscribe to. I have a background in clinical quality improvement, working in community health settings for the past eight years.
Tracy Angelocci, MD: [00:53] Hi, I'm Dr Tracy Angelocci. I'm the Chief Medical Officer at CareMessage. CareMessage is the largest patient activation platform built exclusively for federally qualified health centers and free and charitable clinics, and is used by more than 400 safety net health care organizations. I'm an internist and pediatrician, and before joining Care Message last year, I served for 11 years as the Chief Medical Information Officer at a large FQHC in Central Texas. We know that effective management of chronic conditions requires many touch points beyond visits with a primary care provider. The average American has four PCP visits and well under two hours of face time with their health care provider annually. So more time is needed for education and to build confidence in disease self-management skills. There is an increasing movement towards omnichannel engagement in health care and away from offering a call center as the only form of communication accessible by the patient.
But as digital health interventions and increasing technology make their way into our practices, community health centers need to be aware of the digital divide. Mobile apps and patient portals, both of which require broadband access or data plans, as well as some degree of technical literacy, will leave a segment of our patients behind. This is where SMS texting can become a great equalizer. The latest Pew research shows that 97% of Americans now own a cell phone. Smartphone ownership has risen to 85% and is now equivalent across racial and ethnic groups. But that doesn't mean that 15% of the general population and likely a much higher percentage in FQHC patients can interact with us only by SMS texting and cannot use mobile apps. And the importance of texting becomes more critical with those over age 65, as nearly 40% do not own a smartphone. And we see a similar dependence on texting in those at lower income and education levels. There is a growing body of evidence that texting can be effective in driving healthy behavior.
I'm sure you're all familiar with the USPSTF, the Preventive Services Task Force that independently reviews evidence for clinical preventive services and develops recommendations. But you might not be aware that there is a related community preventive services task force. This is an independent panel established by DHHS more than 25 years ago. And it reviews the evidence on community-based health promotion and disease prevention approaches. The task force publishes their findings and recommendations in an online forum called the Community Guide. And the available evidence on texting shows that it is a helpful intervention in some specific situations that have been studied by the CPSTF. That is medication adherence in chronic conditions, smoking cessation interventions and reminders for cancer screenings.
At Care Message, we're building our own body of evidence for texting by conducting randomized controlled trials with university and FQHC partners. I've included a link to those studies, but I'll just quickly highlight one here. We studied the effectiveness of a 12-week diabetes text messaging program with low-income Latino patients at two FQHC centers in Los Angeles. The diabetes text program is bidirectional, sprinkled with questions throughout, and then branching logic incorporates patient responses to those questions to further personalize the education program for each patient. In the end, the intervention group had an average HbA1c reduction of 0.4 percentage points compared to the control group. But the subset of patients that were more highly engaged in the text program, who responded to more of the question prompts, experienced a significant mean reduction in A1c of 2.2 points.
Zarr: [04:41] As we just heard, there is mounting evidence that text messages are an effective means of communicating with patients to manic chronic conditions, particularly those most vulnerable to poor health outcomes. Directly engaging with patients one-on-one provides more personalized care and support to patients while sending messages en masse as one-to-many or broadcast messages with educational information, community resources, and screenings and assessments save staff time.
Depending on the system used, there are types of communication that can be sent through an automation process, including broadcast messages, appointment reminders, and medication adherence and refill reminders. This allows for more focused time on one-on-one communication with higher risk, higher need patients with chronic conditions. When texting patients to help them better manage their chronic conditions, it is important to take into consideration many factors that can either enhance or detract from the effectiveness of the message. Respecting patient preferences and sending personalized text messages, they will understand in their native language and account for different learning modalities can ultimately lead to positive interactions with patients. They will more likely respond to messages you send because it signals to them that my care team wants to see me improve my health status. Patients will then be more receptive to future messages you send, collaborate on goals to achieve better health and become champions of their own health.
However, one must be cautious as to not bombard patients with messages. Being strategic and following an outreach calendar of types of messages to send will, and when, will reduce the likelihood that patients will ignore or opt out of receiving messages in the future. It is also strongly advisable not to use nagging or fear tactics when encouraging patients to make behavior changes that lead to improved health outcomes. Rather, meeting patients where they're at in the stages of behavior change and using techniques such as motivational interviewing to guide patients to taking steps that will improve their chronic conditions when they're ready will be more effective.
Angelocci: [07:09] Amy touched on the importance of understanding the theories of behavior change and incorporating that into your messaging. And that's a topic we could devote an entire webinar to, but I'll just give a quick overview here. Multiple theories, I've listed a few here, have been extensively studied in health care and evidence shows that a person's readiness to engage in health-related behavior is determined by their perception of a handful of common variables that we see across the models. The first is perceived susceptibility. That is, me as the patient, do I believe I'm actually at risk of getting the condition or the complication that you're messaging me about? It's important here to know that people tend to underestimate their risk for disease as compared to others, a phenomenon known as optimistic bias.
The second is perceived severity. If I believe I'm at risk, how serious do I think the consequences are? The first two together are sometimes referred to as the threat analysis. I need to believe both that I'm at risk and that the consequences are serious in order to motivate me to take action.
The third is perceived benefits, sometimes called response efficacy. That is, do I believe the action you want me to take is actually beneficial and will reduce my risk? And the fourth factor is all about barriers. These can be real or structural like transportation or cost barriers, where they can be perceived or internal and refer to things like discomfort, embarrassment, the time, cost, or the hassle factor of completing the action. Some theories include the factor of self-efficacy that refers to the patient's belief and whether they can follow through on the recommended action and overcome the barriers. And others point to the influence of subjective norms. This refers to a patient's belief about whether most people approve or disapprove of the behavior. I'm more likely to follow through on the suggested action if my peers or people of importance to me think that I should engage in the behavior.
And then finally, cues to action are important. The more prompts or nudges I receive, the more I pay attention and begin considering the action. In our case, we're talking about text messages as that cue, but this can be any sort of outreach through any communication medium, including mass media. So the best practice in text messaging is to be aware of these factors and incorporate them into your campaigns. This points towards a strategy of using a series of related text messages about a given topic as there is obviously no way to incorporate all of these factors into a single message. Even if you choose not to address each factor, remember that the simple reminder text that is used most often, that is the you're due for this thing, call us to schedule, is really only going to be effective for a small segment of your population. It will only prompt those who already believe the threat is real, believe the proposed action is effective and who are not facing any significant barriers.
Zarr: [10:03] When texting with patients, taking a team-based care approach with various clinical and non-clinical support staff and integrating them into patient communication workflows allows for better managed patient outcomes. For example, community health workers can use texting platforms to send one to many or Care Gap broadcast messages, requesting patients schedule an appointment with their provider. Some population health outreach platforms have self-directed patient scheduling features that allow patients to easily pick a time that's convenient for them without even having to call the clinic back.
As noted in a previous slide, it is important not to bombard patients with too many messages. Otherwise they could ignore or opt out of the texts altogether. Instead, focus on one to two care gap messages per month and send to patients without upcoming appointments if no other actions are needed on the patient's part to prepare for their visit. Another example of using staff available to you is incorporating nurse care managers into patient engagement workflows for monthly or bimonthly direct texting to provide educational and or community resources they may need to better manage their chronic conditions. Automation is key. The more use cases you can automate, the more free time staff will have to provide more direct support to the patients who need it the most. It can be difficult to determine a cause and effect relationship between patients receiving text messages and improvement in clinical outcomes due to reporting limitations, but certain inferences can be made. And improvement in chronic condition and chronic disease quality measures month over month from the time texting campaigns began can be attributed to its effectiveness.
However, it may take several months or more before you start to see any improvement in some clinical measures, but you can also look to process measures such as reduced no-show rates and increased number of office visits as indicators that text messaging is effective. Some texting platforms are more sophisticated than others. For example, if you are using a Zara patient outreach, reporting on the effectiveness of the messages is part of the add-on feature. We hope this pre-work session has been informative and provided actionable steps you can take to provide bi-directional communication with your patients to better manage their chronic conditions. We look forward to seeing you during NAC's live session, March 15th, where we will answer any questions you have and elaborate on the content presented in this video.
Video 2: Using Bi-Directional Text Messaging to Engage Patients in Chronic Disease Management
Elizabeth Breitenbach: [00:08] Hi, good afternoon, everybody, and welcome. My name is Elizabeth. On behalf of NACHC, thank you so much for joining us. It is 3.01 Eastern. I'm going to go ahead and give it about 15 seconds or less, letting Zoom connect all of our attendees that were in the waiting room into the "main room." You should be able to hear my voice right now, should be able to see slides on the front of your screen. If you're here for the Million Hearts Learning Lab, you're in the right place. So we'll get started in about 10 seconds. Thank you so much.
[00:50] All right, in the interest of time, let's go ahead and get started. Good afternoon, everybody, and welcome to this session, our next session in our Million Hearts Learning Lab series, using bidirectional text messaging to engage patients in chronic disease management. My name is Elizabeth Breidenbach. I'm a meeting and event specialist based in our clinical affairs division here at NACHC, and I'm pleased to bring you this event along with my division colleagues.
Before we get started, we would like to review a few housekeeping announcements. First things first, you have joined this online event. Zoom is recording this event and will be available for playback at a later time. Automatically joining this event automatically consents you to this recording. If you do not feel comfortable being in this recorded session, we ask that you kindly leave at this moment. We also wanted to inform you that all attendee lines have been muted as well as video. So again, your line has been automatically muted and video has been disabled for this session. No need to fret. Like I said, those will be disabled for the entirety of this session.
And a little bit later on throughout the session, we'll also talk about survey in regards to CMEs and things of that nature. And last thing we wanted to mention to you folks is chat has been disabled, but we do have the Q&A open and the Q&A boxes will be located. You may either have to take your cursor, wake, as I like to say with Zoom is take your cursor and wake it up over top of Zoom, either at the top of your windows or might be at the bottom of your windows. If you finally simply find the Q&A box and expand that panel, you can send your comments, questions, or concerns in this box at any time. You can also upvote questions that you find from your colleagues that you would like us to answer as a priority. And you can also comment on those questions. So we do encourage you to do those things today. At this moment, I'd like to turn things over to Dr Sterling, who's going to be kicking off today's event. Dr Sterling, the floor is yours.
Dr Sterling: [02:40] Yeah, thank you, Elizabeth. And on behalf of our Million Hearts team, Million Hearts partners across the nation, AMA, and NACHC. I'm very honored today to open this Learning Lab number four. It's a critically important topic we'll be discussing today. It's hard to see in this photo, but I'm wearing a white coat, and so I'm a clinician in addition to the executive director of the Million Hearts Initiative. And today's topic, trusted communication and partnered care, is truly at the heart of the clinician-patient relationship, and so we'll be learning today about bi-directional text messaging to engage patients in chronic disease management. I look forward to learning a lot during today's session, and we'll be looking to all of you to be engaged, involved. We heard that over 700 were registered, and I see the numbers continuing to climb, approaching 300 already participating. So with that, I'm going to hand it off to Meg to give you a sense of today's plan and agenda. And thank you again. I look forward to doing a lot of learning today.
Meg Meador, MPH, CPHI: [03:50] Thank you so much, Dr Sterling. So just wanted to do a quick review of how our Million Hearts Learning Labs are structured. So the total time for our learning lab is 60 minutes, the same as a traditional webinar, but it's packaged into three pieces.
So we have a pre-work video recording. We have a pre-work survey to gather your questions, and then combine those two things with today's live event, and that will give you the 60 minutes. So today is actually 45 minutes, and then we're going to be sharing at the end how you can apply for CME credits. Our learning objectives for today, so we're going to get into the nuts and bolts of what two-way text messaging is and how it can be used in an evidence-based way to improve cardiovascular health outcomes. We're going to outline some key communication strategies and phrases to engage patients successfully. And we're going to talk about and discuss how text messaging can be integrated into your workflows and the various roles that your different care team members can play in those workflows.
So I'd like to introduce our two speakers today. You should recognize them from their pre-work. The first is Amy Zahr. She's the Associate Director of Population Health at Michigan Primary Care Association. And in her role, she works with federally qualified health centers across the state to help them optimize their use of health IT tools and platforms to improve patient health outcomes and meet value-based performance targets. Michigan PCA has integrated the Azara Drives Population Health Management system with Luma Health Patient Outreach and Engagement Platform for that bi-directional text messaging communication. And they have 24 out of their 40 member health centers subscribing to this. So Amy knows a lot with that practical experience running that program. She has a background in clinical quality improvement and also working in community health settings for the past eight years.
We're also going to hear today from Dr Tracy Angelocci, and she is the Chief Medical Officer at CareMessage. CareMessage is the largest patient activation platform built exclusively for federally qualified health centers and free and charitable clinics. And it is used by more than 400 safety net health care organizations. Dr Angelocci is an internist and pediatrician. And before joining CareMessage last year, she served for 11 years as the chief medical information officer at a large health center in Texas.
So we're very excited to have both Tracy and Amy with us today. We'd like to move now right into a couple of introductory slides that Tracy's going to share with us. And then after that, we'll slide into our Q&A segment. So Tracy, over to you.
Tracy Angelocci, MD: [06:47] Thanks, Meg. So we know, we all know that effective management of chronic conditions requires many touch points beyond visits with a primary care provider. The average American only has four PCP visits a year, so well under two hours of face-to-face time with their provider. So obviously more time is needed for education and to build confidence and disease self-management skills. And as digital health interventions and increasing technology make their way into our practices, community health centers need to be aware of the digital divide. Mobile apps, patient portals. Both of these require broadband access or data plans, as well as some degree of technical literacy, and they will both leave a segment of our patients behind. But this is where SMS texting becomes a great equalizer. The latest Pew research shows that 97% of Americans now own a cell phone. Smartphone ownership has risen to 85%. And interestingly, smartphone ownership is now equivalent across racial and ethnic groups. But that does mean that 15% of the general population and probably a much higher percentage in FQHC groups can interact with us only by SMS texting and can't or will not use mobile apps.
And then smartphone ownership is even lower if we look at those over age 65 as nearly 40%. Older adults do not own a smartphone and we see similar numbers in those at lower income and education levels as well. So there is a growing body of evidence that texting can be effective in driving healthy behavior. I'm sure you're all familiar with the US Preventative Services Task Force that independently reviews evidence for clinical preventive services and gives us recommendations. But there is a related community preventive services task force. This is an independent panel established by DHHS more than 25 years ago, and it reviews the evidence on community-based health promotion and disease prevention approaches, and they publish their findings and recommendations in an online forum called the Community Guide.
The available evidence on texting from that guide shows that it is helpful as an intervention in some specific situations that have been studied by the task force. Those are medication adherence in chronic condition, chronic conditions, smoking cessation interventions, and reminders for cancer screenings. Now there's a big meta-analysis of studies using texting for meta-adherence and they show that text reminders double the odds that a patient will be adherent, but those studies tend to be short-term with a median duration of intervention of about 12 weeks, so more needs to be done to study the sustained effects of texting. At CareMessage, we're working on building our own body of evidence for texting by conducting randomized controlled trials with university and FQHC partners. And I'll just quickly highlight one of those studies related to diabetes management. We studied the effectiveness of a 12-week diabetes education text messaging program with low-income Latino patients at two FQHC sites in Los Angeles. Now, the diabetes text program was bi-directional. It was sprinkled with questions throughout, and then it used branching logic. And based on patient responses to those questions, it would further personalize the downstream education content delivered to each patient. In the end, the intervention group had an average HbA1c reduction of 0.4 percentage points as compared to the control group, but the subset of patients who were more highly engaged in the TEXT program who responded to more of the question prompts experienced a significant mean reduction in A1c of 2.2 percentage points.
Meador: [10:34] Thanks, Tracy. And so I want to move over to the Q&A portion, but I also want to just say we had such rich questions come in from the pre-work survey. We've done our best to kind of compile the top themes and share back with you today those things we think will be of most value. But I'm going to lead off with a question that I think is best supported with a slide. So this one is for Amy. You shared some really great like text communication strategies, some very granular things about ways to phrase text messages, some best practices for reading level, other kinds of things. And people want to know about that. So if you could share some of those, and I think we have them on the screen, that would be really helpful. >>
Zarr: Absolutely. So it's best practice to send any message regardless of what the content is at or below the sixth grade reading level.
And the frequency of messages will depend on the type of message you're sending. So if you're sending a care gap message or a general broadcast messages, those are best sent to large groups of patients at a time. So it's best to send those as general messages that don't contain specific PHI, which would require an extra level of encryption. And when you're looking at care gap messages specifically, you'll want to send maybe two to three different types of care gap messages over the course of a month and spread them out. As long as there's no prep required on a patient's behalf. You can also send those to patients who don't already have scheduled follow up appointments. And doing it this way will eliminate patients from receiving too many messages.
As more patients then schedule their visits in response to your Care Gap message, in particular, especially if it's bidirectional and allows the patient to use their phone to set up that appointment that you're requesting, A care team should be reviewing patient care gaps prior to their visits. So, this way, when a patient who then becomes scheduled doesn't receive subsequent care gap messages, the idea is that in reviewing those care gaps with care teams, that they are addressed at the same visit. and you're not asking patients to come back for multiple follow-up visits to address each individual care gap.
When it comes to appointment reminders, we found that it's best practice to send more than one appointment reminder. So one suggestion would be to send the text message at seven, three, and one day before the appointment. And as the patient confirms the appointment, which is also done directly in response to the message if you're using bi-directional text messaging, then the patient will fall off the appointment reminder list and will also not receive those additional appointment reminders once they confirm their appointment.
And then to address the question about individual messaging. That's best reserved for a smaller subset of patients who may have a specific follow-up need such as reviewing care plans or remote patient monitoring and medication management. That way your staff are working with a much more manageable list of patients. We don't recommend messaging about a single topic or care gap just once in the year. You want to make sure that these are reemphasized throughout the year, especially if these patients don't close their care gaps or if they have chronic conditions and they need more patient education. That's something you definitely want to reinforce multiple times throughout the year in order to receive better results.
Meador: [15:32] Thank you, Amy. This is so helpful. I mean, you just have a wealth of knowledge about sort of how to implement this in practice. You know, what are the things that are going to resonate best with people? Very human-centered. I just want to point out a couple of comments that are in the Q&A that, you know, Rosina Lalji also said, "We use text messages "to provide appointment reminders and wellness "to close care gaps as well." So just reinforcing, yes, it works and we use it.
And then Meg Bowen from OCHIN says that, "We use preferred name in the documentation "as it is more personal "and also takes into account SGM patients." So love that. So I want to move on to you, Tracy. Also in the pre-work, you talked about the importance of using theories of behavior change, of getting a little nerdy public health on you because that's my background, to craft those messages. Can you share any resources that would be helpful in crafting text messages or messaging templates that people can use?
Angelocci: [16:41] Yeah, I think, you know, the theories of behavior change is a huge topic. I spent the first several months at CareMessage just really diving really deeply into that. But I think this is where it's really important to select a vendor who's supplying not just the texting platform, but is really partnering with you as a content provider, but also a partner who's able to advise on workflows and process redesign to best incorporate texting. CareMessage users have access to a library of hundreds of text messages that we've created that are written at the sixth-grade reading level or less. They're in English and Spanish and they do take into account the theories of behavior change. Luma also has pre-written messages in English and Spanish and I think Arabic also. But again, back to the vendor search, you really want to look for things not only like a content library, but dedicated customer service managers who stay with you after kickoff to ensure long-term success with texting, a vendor with clinical leadership that's involved in building out the content and has a true demonstrated understanding of FQHC workflows and priorities, and vendor produced white papers or other best practice guidelines that really take you step by step once you implement in texting into outlining a real communication strategy that will set you up for success.
Meador: [18:07] Super, very helpful. Thank you, Tracy. Moving back to Amy. So you mentioned, I think the Luma Health Set had three different languages and CareMessage at the current time has two, English and Spanish. What recommendations would you have for dealing with language barriers sort of beyond what the capacity of the system is?
Zarr: [18:31] So we definitely recommend that whenever possible use preferences for patient language. So if their primary language is in a language other than English, you'll want to use that language. So whether it's through your texting vendor or using Google Translate or other software vendor, you'll want to be able to translate and send messages to patients in their native language in order to get an uptake of patient engagement.
Meador: [19:14] Super, that's very helpful. One of the themes that emerged from our pre-work questions was concern about how bi-directional text messaging would work in rural places with rural people. And so Tracy, we'd love to aim this one at you. Do you have any examples of how bi-directional text messages have worked in rural health centers with older patient populations?
Angelocci: [19:40] Yeah, well, I think we all saw the rise of telemedicine during the pandemic helped increase access to health care for those in rural areas. Bidirectional texting helps bridge those gaps in a very similar way. As we covered in the pre-work, we see texting now used for so much more than just broadcast campaigns to drive preventive care or close care gaps. That's a big piece of it, but it's increasingly used for remote patient monitoring, medication adherence and refill reminders, and a lot of one-on-one communication between a patient and care team extenders, like case managers, dieticians, clinical pharmacists, and that sort of thing. Now, while telemedicine did help drive access in rural areas and with the older population, it also helped highlight the digital divide that we've been talking about. We just talked about how smartphone ownership in the US is at 85%, but that drops down to 80% in rural areas, 61% for those over age 65 and around 76% for households with incomes under $30 000. Rural Americans have made big gains in adopting digital technology. Home broadband adoption is up nine percentage points just over the last five years. It's currently at 72% compared with 77 to 79% for urban and suburban areas. And 80% of adults in rural areas say they use the internet on a daily basis, but they are less likely than urban adults to own traditional or tablet computers and rely more on their phone as their only access to the internet.
And we know that although rural areas are more wired today than in the past, in many areas, the current infrastructure still just does not support consistently dependable broadband. So, like we were saying, SMS texting bridges the gap where access to broadband is problematic. As you, as your clinics move towards communication avenues beyond just a call center, we think it's important that texting is the base level of communication as opposed to using only apps or portals because it acts as an equalizer. It's the least common denominator. One other thing in regard to older population, there's some interesting research, some bright spots around increasing technical literacy that I saw published by AARP. The increase in tech use in the over age 50 population has tech spending in that group is up more than 200% since 2019, even in the over age 70 age group. 44% of older adults view tech far more positively as a way to stay connected than they did before COVID. And more than 80% say they rely on technology as a way to stay connected to family and friends. One quarter of older adults have ordered groceries online. One third have attended a virtual event since 2020 and three quarters have adopted video chat. So there are still disparities there, but the gap has been lessening since the pandemic started.
Meador: [22:41] Super helpful. So one of the silver linings of the pandemic is I guess increased digital literacy and use of those technologies. But I think, you also highlight how important it is to be mindful of exacerbating disparities or creating health inequities in certain populations. And it certainly speaks to making sure that we are asking patients what their preferences are for communication before making that assumption. But I love that we should be shifting our mindset to text messaging possibly as that lowest common denominator. I want to just pull a question from the Q&A just because it's relevant. in terms of patient preferences, do either of you have a sense of how many people prefer the sort of the opt-in versus the opt-out messaging options? Does that make sense? Or do people like to--
Angelocci: [23:35] Federal regulations require you to offer opt-out. You have to be very clear with the messaging, text stop at any time, and to periodically send opt-out instructions. with every message, but for sure it should be in the initial welcome message to patients.
Meador: [23:55] Super, good to know. Okay, so let me move forward on the questions that emerged from our pre-work. We just talked about sort of reaching older and rural patients. This is a question that's really for both of you. We can start with you, Tracy, and then move to Amy. So you shared your research on how bi-directional text messaging has led to improved chronic disease management, particularly in that medication adherence realm. Is there also data on how it impacts patient engagement or operational measures like no-shows? I'm thinking here like we're trying to make the case to the leadership to buy this. What are some examples that you can share?
Angelocci: [24:33] Yeah, I think Amy has some information on appointment reminders and no-shows, so I'll save that part for her and I'll highlight a couple other examples. Texting can also drive ROI by helping you engage with payer assigned members who've not yet established care with your health center. So you can find texting platforms that can ingest, for example, your monthly patient attribution files that you get from Medicaid MCO or Medicare Advantage plans. And then some of them are able to automatically scrub those lists for you to separate known patients from members. And then you can create a messaging campaign that is specific to those members to encourage them to establish care and schedule that first appointment with you.
I think next to appointment reminders, one of the primary uses for texting is closing care gaps. Important from a clinical standpoint, but also improving performance on clinical metrics is becoming so much more important as we move further along the path into value-based care. And those value-based contracts also weight patient satisfaction very heavily. So we see a lot of customers using text platforms to send patient satisfaction surveys to highlight areas that need work or to even pinpoint particular clinic locations or providers who are outliers. I think it's important to note here that your texting strategy, of course, you're going to be focused on metrics, on clinical and operational metrics, but don't lose sight of the need for a text strategy that focuses on workflows, processes, staffing ratios, like that, like where are all the places in your operation that you could insert texting?
Make a list of every situation that currently involves staff making outbound calls. So that's like appointment reminders and no-show follow-ups, members without visits, scheduling, relaying instructions like for procedures, transitions in care, closing care gaps, processing referrals, you know, the list just goes on and on. And we know how frustrating outbound calls are, there's a really low return on that effort. Only about 50% of calls are answered, and then frustratingly, only a small fraction of the answered calls actually end up with a satisfactory outcome with the patient complying with whatever you're calling them about, whatever your request is. Yet we pay staff to do that really inefficient work. So we encourage health centers to move those functions to texting, so you can get equal or better results with just a fraction of staff time.
And I will say it's rare for any of our customers to add staff just because they've added a texting platform. And that all goes back to the high-level strategy. As you transition some of your phone-based communication volume to texting, you transition the roles of the staff in your call center. At the FQHC that I was at, our patient navigation center actually created a career growth plan from call center patient service rep to population health team. And positions on that team were really highly sought after and staff satisfaction ratings were far higher for those who communicated with patients all day long via text versus those who were on the phone.
Meador: [27:38] Wow, super. Amazing answer, just in terms of my brain thinking about all the innovation that's waiting to happen and flipping things on their head because of text messaging. So super exciting. You answered a lot of questions, but I also want to give Amy an opportunity to share some of those operational ways that text messaging might help?
Zarr: [27:58] Yeah, absolutely. So I think what I would just add is that, yes, bi-directional text messaging does help impact patient engagement and operational measures in addition to clinical measures. And when thinking about adopting a platform, you definitely want to be thinking about the return on investment and consider whether the platform you are going to be adopting, whether it integrates with your EHR and other population health tools that you may use and whether the platform can offer as much automation as possible to help with some of the staff, free up some of the staff time, but text reminders can certainly increase the volume of patients scheduling appointments for things like annual wellness exams, chronic disease management appointments and well child visits.
And then as you layer on appointment reminders, in comparison to not reminding patients about upcoming appointments, any reminder system is going to definitely have an impact on reducing the no-show rate. It can even cut the no-show rate by as much as 50%. So, if you're already using reminders through one method like your EMR, you might want to consider a more automated process if your EMR doesn't allow for that in order to make bidirectional communication more efficient.
You're muted, Meg.
Meador: [30:03] I'm muted. … I'm muted. So I'm going back to Amy. I want to circle back to a question that came in in the Q&A that's related to what you were talking about, sort of the operations and, you know, you were sort of describing how, you know, the workflow of making sure that, you know, patients aren't reminded after they've already scheduled an appointment, for example. This question says, "For appointment reminders, is there a way to configure the texting so that people who have confirmed will still get the reminder if they choose to do so? So, meaning there's an option for them to confirm, 'I don't need any more reminders' versus confirm, 'I would like to be reminded.' Are those settings, like, even available?"
Yeah, so I think that depends on the vendor you go with. Speaking from personal experience in using LumaHealth, actually just today I was on a call with one of our LumaHealth customers, and they had their—as a center, their own specific settings for how often a patient was reminded about an upcoming appointment. And once it was confirmed, they had their settings set up that the patient would still be reminded two hours before the appointment, just to make sure and help further reduce the no-show rate. So I don't know if it's possible, and certainly Tracy can speak on the behalf of CareMessage. I don't know that it's possible for on a patient-by-patient basis that they still receive some sort of reminder closer to the appointment.
But it is possible for in the case of Luma Health customer to have the setting configured so that even if a patient confirms their appointment, they'll still get that last minute reminder in case the patient needs to make last minute alternate arrangements for transportation or things like that, or if they need to call the clinic to reschedule at last minute.
Angelocci: [32:29] Yeah, definitely depends on the vendor, but typically lots of different types of customization possible, including like different types of messages based on the appointment template. So different messaging for a telemedicine visit or behavioral health, you know, versus a well child check or something like that. Lots of customization. One benefit that we found at the health center that I was at before I came to CareMessage is our EHR had been doing appointment reminders for us and they were charging us on a per text basis. And so we tried to be really cheap and we would send a reminder out just two days ahead of time whereas, you know, once we transitioned to CareMessage, it's, we're not charging on a per text basis. So we could do the appointment confirmation reminder and then a couple of days out and then, you know, the day of without tripling our cost.
Meador: [33:19] Super helpful. So we're, this is what is, you're not your father's Buick, it's not your father's text messaging, something like that. We're definitely in 2023 when it comes to the sophistication and customization capability. So another question for Amy, one of the things that's so interesting about your role is you're sitting up at sort of a layer beyond health center. So for those who aren't familiar with the safety net structure, Amy's part of the state primary care association that's kind of overall the health centers in the state of Michigan. So speaking to that, what role can sort of regional or state organizations play in helping care delivery organizations set up these kinds of bidirectional text messages at the clinic level?
Zarr: [34:06] Right, so primary care associations and health center control networks can play a pivotal role in helping clinics set up by directional text messaging platforms.
In our role, we're in a position where we can fully vet vendors for high quality products and whether those products will meet the needs of our member health centers. And we can also better negotiate group purchasing agreements. So the cost, which also came up in the pre-work questions, costs will depend on what vendor you choose, but senior leaders are able to negotiate for a lower cost as part of the purchasing agreement through the PCA or HCCN.
In addition, we were able to use funding through the HCCN in Michigan to help support the implementation costs of LumaHealth. So we were able to offer the product at a discount for our organizations, our health centers that chose to subscribe to that product. And another benefit of if you're able to go through a PCA or an HCCN is we work directly with the vendors. So if a product has a feature that you think it should have but doesn't, or if there's an enhancement that you'd want to see, we're able to work directly with the vendors to help bring those enhancements to fruition and help support the health center needs to maximize utilization of a text messaging platform.
Meador: [36:14] Super, thanks, Amy. I love that sort of economy of scale and sort of the power of numbers that you bring to the table. Several questions in the Q&A around HIPAA. So our next question is pretty timely. Tracy, this one's for you. And feel free if you have a moment, you could answer the questions in the Q&A if you have time or pick them up in part of your response. Are there HIPAA concerns with using text messaging and how would you address those?
Angelocci: [36:44] Yeah, super, super good question. Your vendors will be up to speed not only on HIPAA but also TCPA, which is the Federal Telephone Consumer Protection Act, which there are some health care exemptions for that, but there are still pieces of TCPA you need to be aware of. And there's also some regulations that vary from individual cell carrier to cell carrier. But in regard to HIPAA, patients can request that their PHI be transmitted by electronic means, even if that transmission exposes the PHI to a third party. In a related manner with email, DHHS has written guidance that says that covered entities are permitted to send patients unencrypted emails if they've advised the individual of the risk. And you know, HIPAA is as much about the policies and the culture that guide your staff as it is about technology. So texting can be considered HIPAA compliant if certain safeguards are taken with your policies, even if it's not considered HIPAA secure from a technology standpoint, because texts by their very nature are not encrypted. So the legal and regulatory guidance that we've received that we share with our customers is that covered entities are advised to let their patients know that unsecure texts could be read by a third party. And when a patient is given this kind of light warning and still prefers to receive information and by text, the covered entity is not in violation of HIPAA.
So we recommend that you leverage the texting platforms initial welcome message. So before a patient gets any other text, they get a welcome message that includes this light warning. I can say something as simple as caution, text messages are not secure. And then relay the opt-out instructions like text stop at any time to stop receiving messages. It is advisable to send opt-out messages at regular intervals, but it's not required to be sent with every message. And so instituting a policy that combines this light warning with an easy way to opt-out is a strategy that we think balances an individual patient's right to both privacy and access. And of course, you're going to want to run, you know, all of this past, your internal legal teams, because so much of it is policy driven, you know, like your internal policies.
Meador: [38:56] Very helpful. I think that's really, we tend to think of the platform and not necessarily the policy, but they really, the policy culture and platform all go together. So super helpful. I think we have time for just one more question. So I'm going to go to our, so always we have a last question, sort of asking both speakers, you know, what one piece of advice would you give on our topic? And so today's question is, what one piece of advice would you give to an organization who's wanting to get started with bi-directional text messaging?
Zarr: [39:28] Sure, so I can answer this first. So I think having a plan in place to notify patients that you will be adopting bi-directional text messaging will serve you in the long run. Promoting the service will give patients an awareness of this new practice and get them comfortable and get them ready to expect messages.
Another thing you'd want to be aware of is if your patient forms don't already include patient communication preferences by text message and the types of information that patients are okay with you sharing make sure that you update your forms and have patients sign these forms indicating their contact preferences. And as Tracy mentioned in the last question about a welcome message, I've worked with a health center that started sending broadcast messages to patients. And what they did was create message zero is what they called it and alerted patients ahead of time that this is something that they would be doing going forward. So they could make sure that patients had a chance to opt out of receiving messages if they weren't comfortable receiving bidirectional text communications. But the opt-out rate was pretty low because, as we've heard, bidirectional text communication is becoming more commonly applicable and used by health centers and health clinics and patients are receptive to that.
Meador: [41:18] Thanks, Amy. To you, Tracy?
Angelocci: [41:21] Yeah, so I would say the critical factor, especially in showing a return on your investment starts with C-suite buy-in and setting a very clear strategy and an all-encompassing strategy for texting so that it's used to its fullest potential. Like otherwise it's just seen as just another tool like a phone that overburdened staff can use to reach patients. And just one example of that, like say we're talking about texting campaigns for closing care gaps, which is only one of the many uses for texting. It would be very important to have a clinical leader in Pop Health or the quality team set a calendar for messaging content and hold people accountable to sending those messages because it's so easy just to get in the weeds of your day-to-day work and look up and realize a month or two has gone by and haven't sent a campaign. But more importantly, think about the process piece of that too. So when you create the content calendar, how does that team then pull the associated care gap list from the EHR to know like, "Hey, who's overdue for mammograms?" Because today it's time to message about mammograms. You don't want a data access roadblock or barrier to slow down that team. But our most successful customers think of texting proactively, meaning every new project, every workflow redesign that they engage in, they think, how does texting fit in here? It's not an afterthought.
Meador: [42:39] Love it. It's strategic, it's intentional.
Really appreciate all the rich information that you both have shared today. We're going to move on to our resources slide. Gosh, so many good questions. I wish we could have spent the whole hour answering more questions, but rest assured, the recording will be available. You'll get to hear that, you'll also be able to have access to these slides afterwards. You can see on this slide some great resources for you. If you want to dive in a little bit more, if some of the questions that you had weren't answered, I bet you can find those answers here. Next slide. Also want to mention that last month, the Million Hearts Initiative launched the 2023 Hypertension Control Challenge. And this year's challenge identifies and recognizes individual clinicians, practices and health systems that achieve hypertension control rates of at least 80% in 2022. The deadline to apply to become a 2023 hypertension control champion is April 14th, so just about a month away. And the link to learn more about the challenge and access the application is provided in the chat. So we welcome all qualifiers and appreciate your help in spreading the word about this opportunity to recognize those top performing care teams across the country. I'd like to turn it over now to my AMA colleague, Rupi Hayer, and she's going to share a little bit more information on claiming CME and also talk about our new on-demand option for the Learning Lab. Rupi?
Rupi Hayer: [44:11] Thank you, Meg, and thank you to the speakers for a very insightful discussion on bidirectional text messaging. Here is the information on how to claim CME credit for today's session. We will share this information via email too, but just so you guys know, we will ask you to click on the link that's provided and then go ahead and sign into your AMA Ed Hub account. If you do not have an account, you can go ahead and create one by hitting create an account and from there you'll be directed to click the start button which will take you to a quiz. Once you complete the short quiz you'll be able to claim the appropriate amount of CME. And then just a reminder for this activity today, the last day to claim your activity is April 26th, so make sure you do it before then. After that, you will be unable to be able to claim your credit. Also, note how you can download your certificate of participation. There should be a link on the top right-hand side, which allows you to select transcript and from there be able to select a certificate to download. Next slide. Here is a reminder that we do move our CME, our live CME activities to enduring after the 45 days. So, oh, sorry, the 30 days. So here, the last two learning labs are available. The first one is treating patients with hypertension, what's the RX and then managing cholesterol using technology.
So both of those that we previously presented live are now going to be available on the Ed Hub site in an enduring format. And then our most recent one, which was a motivational interviewing for medication adherence that is also available, will be available coming early April. So more details to come there. We will send these links out after, after today's session. And the next slide here is just a friendly reminder about the SMBP forum, which is scheduled for tomorrow. I believe we're popping some information in the chat on how to access the forum tomorrow. And then last but not least, wanted to share a friendly reminder about the upcoming learning labs. Our next one is scheduled for May 17th, and the one after that will be on July 19th. You can go ahead and scan that QR code to make sure you're registered so you can get more information about it in the upcoming month.
I think that wraps us up all for today. Thank you all for joining. We really appreciate you taking the time to attend today's session, and we look forward to seeing you all at our upcoming sessions. Thank you.
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