EXECUTIVE SUMMARY
Technology can help extend case management, improving efficiency and costs when managing large populations of at-risk patients.
- A chatbot tool can send patients daily text messages that provide information on self-care behaviors and ask them about their current health status.
- The technology can analyze responses and flag patients who need medical attention or follow-up.
- Case managers can review the tool’s patient data and target interventions based on what they find.
The nation’s increasing focus on value-based care and population health has led to a greater need for case managers. But the economics of paying for these positions remains challenging. One health system found a way to extend and improve case management through a technological solution.
It is hard to hire enough managers to handle all the patients who need longitudinal care management, according to Mark Schario, MS, RN, FACHE, vice president of population health and president of the University Hospitals (UH) Quality Care Network, UH Coordinated Care Organization, and UH Accountable Care Organization, Inc., of University Hospitals Health System in Cleveland.
Collaboration with a technology company can provide solutions and tools that help case managers extend their reach and work with patients more efficiently. Technology enhances communication between nurse case managers and patients.
Technology can add a lot of extra power to one individual case manager, Schario notes. The health system’s technological tool is a chatbot that sends daily text messages to patients with specific diseases and chronic conditions. These messages educate patients on self-care behaviors and ask them about their weight, blood pressure, and other health factors.1
Chatbot Aids Disease Management
The chatbot outreach and educational messages are sent to thousands of patients with congestive heart failure (CHF), chronic obstructive pulmonary disease, pneumonia, acute myocardial infarction, stroke, generic post-acute issues, asthma, type 2 diabetes, and hypertension. Each chatbot message includes a short educational message.1
Schario and colleagues found chatbots interact frequently with patients, communicating asynchronously so patients can manage these on their own schedule. The chatbot enables case managers to spend more time on high-value interactions where clinical judgment is necessary.1
“We have a large population with many folks with chronic disease,” says Carol Bahner, BSN, RN, CCM, study co-author and manager for care management in population health with University Hospitals in Cleveland. “When we enroll someone into one of our chronic disease [categories], the chatbot will automatically text or email the patient daily or every few days, depending on their disease state. It asks them how they’re doing, how is their breathing, and what is their blood pressure.”
The chatbot also provides information on why it is important for CHF patients to weigh themselves daily and eat a low-sodium diet.
“Their responses are sent out to nurse case managers,” Bahner says.
Risk Levels
The technology analyzes patients’ responses and divides them into categories of green, for patients who are doing well with managing their condition; yellow, for patients who need a little intervention or follow-up to prevent a crisis; and red, for patients who need medical attention through a 24/7 nursing hotline.
If a rising or elevated risk is detected, nurse case managers contact the patients. “They might say, ‘I see your blood pressure was a little elevated today; let’s talk about that,’” Bahner says.
Yellow also might indicate the patient did not refill a prescription. The nurse case manager would ask why the patient did not take the medication.
“If there is a green response, it means the patient is doing great and doesn’t need outreach or a phone call that day,” Bahner explains. “Red is the highest escalation and means the patient has a concerning response. The patient is either directed to call the 24/7 nurse advice line, or the nurse could call the patient to help them problem-solve.”
The chatbot would send the patient the nursing hotline number the patient could automatically dial by clicking on that number if he or she receives chatbot messages via cellphone. If the patient receives email messages, the chatbot will provide them with a number to call. Whenever patients call the nursing hotline, the technology records how the patient made the call. Nurse case managers also can see whether patients visited a provider or were seen in the emergency department (ED).
“We do not get very many red responses,” Bahner says. “We view chatbot as a screening and educational platform.”
The chatbot’s helpful educational tips include reminding patients to weigh themselves each day and to wear the same clothing for a more accurate weight. “We want to reinforce the habit of weighing and reporting weight,” Bahner notes.
The chatbot program began in late 2019 and provided some unanticipated benefits during the COVID-19 pandemic’s initial national shutdown. For instance, some patients who received daily chatbot messages reported this was their only daily connection in a world of isolation.
“It was a positive consequence,” Schario says. “Even if the chat sequence would end, they wanted to re-enroll because they kept engaged with someone about their care.”
The chatbot technology continues to serve patient populations well, he adds.
Asynchronous Communication a Plus
Patients and case managers also have liked the tool and the asynchronous connection aspect of chatbots, Schario and Bahner say. What this means is the technology sends messages and records patients’ responses whenever the patient wants to respond. The patient might respond at 2 a.m. or 6 a.m., and the response is not dependent on a case manager’s hours and timing of the follow-up phone call.
“Care managers can be very frustrated by leaving outreach call messages. Trying to connect at any moment in time is very difficult,” Schario explains. “If someone wants to engage at 3 a.m., the computer is waiting for them, and they could do this.”
Initially, the case management team expected red messages in the middle of the night. This did not happen.
“That’s one of the powerful parts of the chatbot that has gone beyond traditional care management,” Schario says. “Whether one person is trying to do outreach at one moment in time or trying to connect with patients between 9 a.m. and 5 p.m., it’s not always convenient for patients.”
The chatbot always is convenient. “Patients say they feel so much safer because they know a nurse will call them if something happens,” Bahner says. “In the beginning, some of our staff said, ‘No one will want to talk with a machine. They want to talk to us.’ But they were surprised. We’re in a society that wants to text right now, and we had a lot of people who engaged more readily through text than through a phone call.”
Even older patients have enjoyed using the text messages or emails. “When you study research, you see that people into their 80s are well engaged in mobile technologies,” Schario says. “Clearly, people who don’t have the cognitive ability can’t do it, but people in their 80s are fully involved with some level of technology.”
Chatbot technology might not work in all cases of older, at-risk patients. For instance, it might not be the best approach for follow-up of patients in nursing homes because they could mistake the messages as coming from staff in the facility.
The goal is for the technology to help case managers and providers identify at-risk patients before a health crisis. If the chatbot indicates patients are in the yellow zone, or even the red zone, then case managers can intervene and potentially prevent a crisis.
“A patient just may need one little change, and that could be done by having the case manager talk to the primary care provider about making a small medication change,” Schario explains.
Nurses can quickly identify the person with concerns and help them manage their care and receive services.
“Nurses are able to reach out to the right people at the right time,” Bahner says. “The nurses love it. Even those who were skeptical in the beginning love the technology that lets them see what’s happening with patients. Our nurses are all about wanting to help people feel better and manage self-care, and this helps them do it.”
REFERENCE
- Schario ME, Bahner CA, Widenhofer TV, et al. Chatbot-assisted care management. Prof Case Manag 2022;27:19-25.
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