JMIR Publications

ABSTRACT

Background:

Smartphone-accessed digital tools can promote chronic condition management, reduce disparities in health care and hospital readmissions, and improve quality of life. However, whether digital care strategies can be implemented successfully on a large scale with traditionally underserved populations remains uncertain.

Objective:

As part of a randomized trial comparing care delivery strategies for Medicaid and Medicare-Medicaid beneficiaries with multiple chronic conditions, our stakeholders identified implementation challenges, and we developed stakeholder-driven adaptions to improve a digitally delivered care management strategy (High-Tech care).

Methods:

We used four mechanisms (Study Support Log, Patient Partners Work Group Log, Case Interview Log, and Implementation Meeting Minutes) to capture stakeholder feedback about technology-related challenges and or solutions from nine patient partners, 129 participants, and 32 care managers and used these data to develop and implement solutions. In order to assess impact, we analyzed High-Tech care exit surveys and intervention engagement outcomes (video visits and condition-specific remote monitoring pathways sent via text at varying intervals) before and after each solution was implemented.

Results:

Challenges centered around two themes: (1) difficulty using both smartphones and High-Tech care components, and (2) difficulty using High-Tech care components due to connectivity issues. To respond to the first theme’s challenges, we devised three solutions: in-person technology support visits (Tech Visits), participant-facing technology user guide (Tech Packet), and tailored condition-specific remote monitoring pathways. During the first 20 implementation months, 73 participants received at least one Tech Visit. We saw a 15 percent increase in video call completion for participants with data pre- and post-Tech Visit (n=25) and a 7 percent increase in pathway completion for participants with data pre- and post-Tech Visit (n=59). Of the 379 participants given a Tech Packet, 179 completed care during this timeframe and were eligible for an exit survey. Of the 96 survey respondents, 76 percent found the Tech Packet helpful and 64 percent actively used it during care. To support condition-specific remote monitoring pathway completion, we allowed for adaption of day/time of the text message with 31 participants changing the time they receive condition-specific remote monitoring pathways, and change in standard biometric parameters with 13 physicians requesting personalized parameters for participants. To respond to the second theme’s challenges, Tech Visits or phone calls were made to provide education on how to connect a smartphone to the internet, schedule video calls and or condition-specific remote monitoring pathways location with broadband/internet, and or disconnect from the internet.

Conclusions:

Having structured stakeholder feedback mechanisms is key to identifying challenges and solutions to digital care engagement. Creating flexible and scalable solutions to technology-related challenges will increase equity in accessing digital care and support more effective engagement of chronically ill populations in the use of these digital care tools. Clinical Trial: ClinicalTrials.gov NCT03451630