Live Better

Reducing readmissions in cirrhotic and post-liver transplant patients

Opportunity

In 2015, approximately 30 percent of cirrhosis and liver transplant patients were readmitted to the hospital within 30 days at an additional cost of more than $21 million to Penn Medicine. Readmissions are inconvenient and dangerous for this patient population, as morbidity and mortality risk is increased in the hospital.

Intervention

Live Better is an automated hovering program designed to keep cirrhosis and liver transplant patients out of the hospital. Powered by Way to Health, the program prompts recently discharged patients to report highly predictive indicators of readmission for this patient population - daily weight, mental function, medication adherence, and temperature - via text message. 

Patients are enrolled in the 30-day monitoring program by nurses before discharge and receive a scale and thermometer to support biometric tracking. Live Better's lean staffing model leverages patient liaison and nurse oversight to monitor daily patient-reported outcomes, only escalating information to physicians if necessary.

Impact

Live Better's implementation resulted in a 43 percent reduction in 30-day readmissions in the initial pilot population, with only four percent of cases requiring escalation to a physician. During the pilot, the total program cost per patient remained under $50, including equipment and staffing. These results are projected to lead to an annual reduction of $8 million in expenses related to 30-day readmission among this patient population.

The team has tested this intervention further in a pragmatic trial and is currently evaluating the results.

Phase 2: It does work
Collaborators

Vandana Khungar, MD, MSc
Kimberly Forde, MD, PhD
Colleen Cook, BSN, RN
Diane Peyton, BSN
Ann Huffenberger, RN, DBA
Asim Viqar

Innovation leads

Christina O'Malley, MHA
Matt Van Der Tuyn, MA
Shivan Mehta, MD, MBA, MSHP

Platforms
Funding

Innovation Accelerator Program

Awards

UPHS Quality and Patient Safety Award, 2018

Innovation Methods

Vapor test
A vapor test offers a product or service that does not yet exist. Vapor tests will help you answer the question, "Does anyone want this?" and generate credible evidence for demand.
 
Vapor tests require carefully designed soft landings to protect against poor user experience. An example of a vapor test would be showing a product or service on a website to see how many people express interest by clicking on it.
 
In this case, a soft landing would involve showing an "out of stock" or "not accepting new clients at this time" message when users click on the offering. 
Vapor test

We used a vapor test to identify the communication mode most preferred by cirrhotic and post-liver transplant patients.

During pilot enrollment, patients were offered email, text message, and telephone call options, even though a communication channel for the program had not yet been determined. Based on the responses, we decided to move forward with developing a text message communication protocol.

Fake back end
It is essential to validate feasibility and understand user needs before investing in the design and development of a product or service.
 
A fake back end is a temporary, usually unsustainable, structure that presents as a real service to users but is not fully developed on the back end.
 
Fake back ends can help you answer the questions, "What happens if people use this?" and "Does this move the needle?"
 
As opposed to fake front ends, fake back ends can produce a real outcome for target users on a small scale. For example, suppose you pretend to be the automated back end of a two-way texting service during a pilot. In that case, the user will receive answers from the service, just ones generated by you instead of automation.
Fake back end

To prove the efficacy of a post-discharge monitoring program with this complex population, we first designed a low-risk fake back end pilot that did not require the time and expensive commitment of an automated solution.

Instead of developing a bot to sift through and escalate patient responses, the clinical team, composed of a physician and discharge coordinator, sent a subset of patients daily check-in messages and performed a manual review of all patient responses.

This exercise allowed the team to test the frequency and content of patient check-in messages and elicit feedback from patients on the program before building a more permanent solution.

The concierge
A concierge provides hands-on, efficient, and proactive services for customers.
 
Similar to the concept of walking in someone's shoes, a concierge walks alongside someone and helps them get things done.
 
Acting as a concierge or high-touch helper for a small sample of people will enable you to get deep into the reality of their journey and learn about the barriers they face, because like a real concierge, you'll help them navigate those barriers. You can also test solutions in real time as you explore the problem space in context.
The concierge

As an expansion on the initial solution offering, the project team launched a concierge pilot with walk-in appointment availability.

The underlying assumption was that we could catch patients before readmission if we allowed them to call us or come in with any questions or needs. Through this high-touch pilot, led by the project team's clinical champion, we identified the need for closer coordination with caregivers. We also confirmed that the low-cost automated hovering pilot was sufficient for identifying readmission risks.

Videos

Pitch Day 2017