Abstracts

Rationale: The goal of this initiative 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 rural Northeastern Illinois. There is a critical need to identify and treat psychiatric co-morbidities in individuals with refractory epilepsy. Furthermore, a large proportion of the approximately half-million children and adults in the United States living with refractory epilepsy are more likely to have lower socioeconomic status, to be illiterate or marginally literate, and to live in medically underserved rural communities. Nearly 70% of this group will require mental health access to social services. While about 20% of Americans live in rural areas, only 9% of the nation's physicians practice in these areas. Our community-based PHM mechanism is necessary for accommodating a markedly increased patient throughput in rural Northern Illinois 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 a rural community living with refractory epilepsy. The clinical implementation of this strategy hinges on the ability to coordinate 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: Mood disorders screening measures for depression (NDDIE) and anxiety (GAD-7) in the rural EFNCIL clinic were compared with those seen in an urban-based setting (RUSH Epilepsy Center, Chicago, IL). The methodology combines the following 3 innovative components: (1) a HIPAA-compliant portable video-conferencing communication protocol for remote access to specialists at RUMC, and community-based healthcare providers, (2) a custom-designed web-based HIPAA-compliant electronic health record (EHR) for accessing patient medical data, and tracking allocation of all community-based resources, and (3) an independent community-based PHM coordination hub (EFNCIL) facilitating the above components. Results: 'On-demand' community psychosocial resources were matched with all patients using the rural community PHM EHR and the patient cohort followed at RUMC. Two mood (NDDI-E, GAD-7), and a family-management assessment tool were used. A two-fold increase in clinically significant mood disorders were seen in patients followed at the rural PHM hub compared with urban based patients followed at RUMC (p< 0.05). Those rural patients symptomatic on visit 2 were over 3-times that of the urban cohort (43% v 13%). 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 co-occurring clinically significant mood disorders in patients with refractory epilepsy are twice that compared with a quasi-matched cohort followed at a large urban-based Level 4 Comprehensive Epilepsy Center. The elevated NDDI-E and GAD-7 measures are consistent with major and sub-syndromic mood disorders. A rural community-based coordination hub can efficiently maximize patient access to community resources, medical expertise, and customized patient education. Progress of our mobile health-intensive care delivery model can be followed at http://www.synapticom.net/outreach/. Funding: 1. Illinois Children Healthcare Foundation 2. Mental Health Board of McHenry County 3. Upsher-Smith Pharmaceuticals 3. Community Development Block Grant Program