Creating virtual “health neighborhoods” to promote patient education & reduce readmissions

HealthCare Access Maryland (HCAM) is dedicated to ensuring that all Marylanders have equal access to health care and services. Each year, HCAM serves more than 125,000 Marylanders, including children, pregnant women, parents, childless adults, immigrants, homeless people, youth in foster care, people with substance use disorders, individuals recently released from jail, and many others.

HCAM’s pilot program focuses on creating post-discharge patient-centered “health neighborhoods” that addresses both medical and healthcare related needs by engaging discharged patients with health tips and reminders, targeted chronic condition education, and local outpatient healthcare resources, to help ensure the best possible outcomes and to reduce readmissions.

CLIENT OVERVIEW
Website	healthcareaccessmaryland.org
GoMo Health Solutions	Personal Concierge™

Our Goal

Maryland has one of the highest readmission rates in the country. Our goal is to reduce readmissions by addressing the 5 most prevalent conditions and procedures that have resulted in readmissions in the Baltimore community.

GoMo Health leveraged its proprietary emerging science, BehavioralRx, the science of precision health, to build the program and determine the engagement strategy, approach and content delivered.

The following behavioral and cognitive techniques were applied:

Anchoring Technology / Cognitively connecting the desired action with an existing everyday activity.
Tailoring Technology / Persuasion through customization.
Nurturing Technology / Guided persuasion
Conditioning Technology / Reinforcing target behavior.

Enrollment through an online HRA form

Using the GoMo Health Concierge Care® platform and select condition-specific health content, St. Agnes Hospital sought to reduce readmissions through patient-direct follow up, education and outreach. Discharge Nurses working within the St. Agnes Healthcare system enroll patients at the point of discharge, using an online HRA survey developed specifically to support patient health post-discharge.

Continuing patient engagement post-discharge

Coordination of care in these new patient-centered “health neighborhoods” will enable St. Agnes Care Coordinators to motivate, oversee, remind, and supervise patients for up to three (3) months post-discharge.

This Personal Concierge program consists primarily of middle age adults having undergone specific procedures and/or with chronic conditions relating to: Hypertension/Heart Disease, Diabetes, Asthma, and COPD.

The Concierge Care difference

GoMo Health Concierge Care® integrates program-aligned, condition-specific multimedia educational content, care regimens, reminders, and local resources with pre-determined mobile engagement protocols, that include message stratification (by condition and/or co-morbidities) and HIPAA compliant live text chat. Platform infrastructure supports the development of program stratification to deliver relevant content to each individual patient based on survey answers at the point of enrollment.