Abstracts

Rationale: The goal of this project is to develop and implement a novel patient-centered population health management (PHM) outreach delivery model that capitalizes on mobile health information technologies (mHIT) for chronic epilepsy care in Northeastern Illinois. A community-based PHM coordination center has been established to facilitate access to community resources, mHealth-linked subspecialty expertise, and 'on-demand' web-based animated patient education. mHIT, as used in our model, is defined as bidirectional coordination of 'HIPAA-compliant portable video-conferencing, wearable sensory technology, and coordination of community resources. Such a community-based healthcare management mechanism is necessary for accommodating a markedly increased patient throughput following implementation of healthcare reform. This initiative aims to reduce hospital admissions while improving the co-morbidity patterns and healthcare-use behavior of individuals in the rural community living with refractory epilepsy. The clinical implementation of this strategy hinges on the scalability of a networking approach that coordinates near real-time matching of community psychosocial services, and specialized medical care of patients with a remote urban-based tertiary care medical center (RUMC).Methods: The methodology combines the following five innovative components: (1) a HIPAA-compliant portable video-conferencing communication protocol for remote access to specialists at RUMC and community-based healthcare providers, (2) wearable ambulatory body sensor technology borrowed from the animation industry for detecting body movements anywhere, (3) a custom-designed web-based networking technology employing a relational database for accessing and tracking allocation of all community-based resources, (4) computer-intensive streaming of an animated education series and immersive 3D educational website targeting epilepsy and mental health (http://www.synapticom.net/videos/), and (5) an independent community-based PHM coordination hub (EFNCIL) facilitating the above components.Results: Preliminary data demonstrate a four-fold increase (n=351) in specialist referrals at the distant tertiary care center (RUMC) of children and adults evaluated between 2012-2015. ‘On-demand’ community psychosocial resources were matched with all patients using our networking provider database. Several mood (NDDI-E, GAD-7), family-management, patient and provider assessment tools were used.Conclusions: The mHIT-intensive PHM-based outreach delivery model overcomes barriers preventing such coordinated care from being implemented. The model significantly expands the geographic reach of a distant tertiary care medical center to an underserved geographic region. Preliminary data suggest that a community-based coordination hub can efficiently maximize patient access to community resource, medical expertise, and customized patient education. Progress of our mobile health-intensive care delivery model can be followed at: http://www.synapticom.net/outreach/.