Heather Sobko, PhD, RN is president and CEO of IVR Care Transition Systems, Inc. of Birmingham, AL.
Tell me about yourself and the company.
I started out in psychology and sociology. I got advanced degrees in those and I decided that I really did not want to be a psychologist. I went into nursing and ended up getting my doctorate degree in nursing, with a focus on comparative effectiveness and outcomes research.
I lean towards geriatric populations just because I’m enchanted by geriatric patients. I think they’re delightful and I enjoy working with them. Adults with chronic illness became a passion of mine.
After working in clinical settings, both in acute care and then in long-term care, I realized that wow, we can do a much better job helping folks transition. This was long before bundled payment rules came out or before Affordable Care Act was implemented with penalties for readmissions.
Looking at what patients faced going through care transitions, I realized there is a lot that we can do. Using technological tools, we can do a way better job. It doesn’t have to be expensive. It doesn’t have to be difficult.
That’s where the idea for IVR Care Transition Systems came from. Intentionally, we chose a phone-based system. Alabama is very rural. We have patients who live in sections of our state that just don’t have Internet access. We’re just not there.
We decided to use something really low tech — the telephone. Everybody knows how to use one and everyone has one. It doesn’t require any special training or any special equipment to be able to participate.
The technology folks get excited about smartphone apps, but only a small percentage of patients will ever use them, mostly those who were already motivated anyway. Do you think IVR systems get overlooked because they’re not as cool sounding as an app?
Apps are very trendy. I think that right now there are about 12,000 different health apps available. People download the apps, they use it a couple of times, and then they realize it’s a lot of work to keep up with them and they don’t want to do that. That one falls by the wayside and they’ll just download another one and try that for a couple of weeks. That’s just a pattern, a trend.
There is no research that shows a link between long-term successful outcomes and the use of any of these apps. There are so many available it’s almost like what we go through in the inpatient setting with alert fatigue. I get the sense that there is a trend coming down the pipe that is app fatigue. There is just so much available.
IVR is unique and especially helpful for individuals who are older, who aren’t tech savvy, from a previous generation. Therein lies my passion for geriatric patients. Patients like to get a phone call. Our system is not a computerized voice — it’s a real person’s voice. It’s me, actually, because I’m a real nurse. Who else should talk to a patient than a real nurse?
Because we schedule calls when the patient likes to be called, in pilot testing with 540 patients, we had an 86 percent response rate for patients completing 28 different surveys getting them through that 30-day critical period for risk for readmission and emergency department visits. They like the system. They like it. They look forward to talking to the system or getting feedback from the system. The system’s name is CATHE — your care transition helper.
Did people push back like they might against PBX or telemarketing? How did you get them to participate in a survey that’s delivered by telephone?
Patients know the call is coming. We ask for the patient. We have the patient list for CATHE to address them when she calls. For example, you might like to be called Tim. When CATHE calls, she will say, “Hello, this is CATHE, your care transition helper. I’m calling to speak with Tim,” but it’s Tim voice the way you recorded it.
The person knows who it is. There is caller ID that identifies it that it is part of the healthcare plan you’re participating in, so it’s the hospital or the clinic calling to check up to see how you’re doing. I think that does make a difference.
The system also has built-in empathy. If someone says they’re feeling worse, the system says, “I’m sorry you’re feeling worse today. These next few questions will help me learn more about that.”
We really try to keep it focused on what is meaningful from a clinical perspective. Cold calling patients and having a conversation with them — first of all, it’s hit or miss. You might catch them on a great day, and if you’re lucky you catch them on a day they’re having some problems, you can do some problem solving and a help guide the patients to appropriate steps. But chances are it’s hit or miss. Even if you catch them within one week post discharge, if they’re not having the problem, you’ve lost an opportunity to do an early intervention when it arises.
The CATHE calls less lasts less than four minutes each. They’re all logic-based, so if a patient reports they’re not having a symptom, we don’t ask any more questions about that symptom. We go to another topic. That keeps it fresh.
The questions are not the same every day. Patients learn very, very quickly that a real person is behind this looking at a very comprehensive dashboard. If red flags are triggered, someone in person follows up to help you with your medicines, to help you make that follow-up appointment with your community provider, or to help you with diet and exercise or symptom recognition before it becomes an urgent situation.
If you gained 2.5 pounds in 24 hours as a heart failure patient, for example, that’s an early sign that you’re holding fluid. A quick adjustment in the medication can fix that, and then you can monitor. But if it becomes five pounds, 10 pounds, 15 pounds, which can happen so quickly, now you’re forced to go to the hospital and have an IV drug administered so you can get rid of that extra fluid.
The biggest value of this system in general is that it captures patient-provided data. We’ve spoken to numerous payers. The bundled payment all cause readmissions is really not a very good measure. As a clinician, I could have zero patients readmitted to the hospital, and on paper, I look like superstar. But in reality, what if all my patients died? That’s not a very good measure.
The data does belong to each hospital that uses the system. It’s their patients, so it’s their data, not ours. They can trend and track what’s going on. If a patient on Day 17 needs to come back to the hospital, now they have a whole database full of information that says, here’s what happened with this patient each day. Here’s how we responded, and then it became important that we brought the patient back. We believe, based on this data, that you should reevaluate and perhaps reimburse us even though it’s within 30 days. Insurance companies are saying, well, if you have data, OK then — we’re willing to take a look.
That’s very, very meaningful. Hopefully, over time, we may be able to change that policy and make it a little bit more appropriate, a better measure for what’s really happening with these patients so they’re not all put into the same box for all cause readmission. Some readmissions are appropriate and necessary, and right now, hospitals and doctors and nurses are being penalized for doing the right thing. That’s just the wrong incentive.
Most technologies don’t scale up to the number of patients that need to be monitored. Some just try to predict readmissions or provide analysis after the fact without involving the patient.
Correct. We were gearing up towards looking at Meaningful Use Stage 3, which is going to require patient-provided data. It’s very important that the patient is engaged. Engaged patients, regardless of their level of illness or number of co-morbid condition, simply do better, period. If you have an engaged patient, you can already anticipate that that patient is going to do better. This system is just a tool that allows the patient to engage with you.
The other thing is that it overcomes the barriers to external providers. Within the system, there are automatic links to every external provider that that patient is involved with. It’s a whole team approach. If you have a patient who is triggering red flags and you would like to share that information with a community provider, you can click on a link. The system automatically sends them a message that says, please log on to the system and review patient XYZ for changes.
Now that communication takes place automatically with a click of a button. You never have to log out of the system and go searching for information. Most patients have five, six different providers. You can keep everybody in the loop through one strategy. They have a read-only view and they can look at the information and participate in figuring out what is the best thing for the patient. That’s also very, very beneficial.
Many of our older patients that live in rural communities also have very low levels of literacy, many of them only sixth-grade education. Having something talk with them rather than have them have to read something is also advantageous.
Patients can get a call at five in the morning or eleven o’clock at night. It doesn’t matter. Whatever they want can happen. We’re available through the system 24/7. We don’t have someone sitting and making a telephone call and trying to reach a patient. If the patient would like to be called at six in the morning, it automatically calls at six in the morning and they are ready for that call.
It does leave a nice message if it misses you and will call back in 30 minutes. After two tries of that, it will leave a message saying, “I’m so sorry I missed you today. I’ll try again tomorrow.” A patient who doesn’t respond in three days will automatically trigger a red flag that something is amiss and we can call a family member and find out is everything OK.
But the main thing is lots of patients don’t understand the difference between side effects of their medications and symptoms of their illness. By engaging with a patient over a 30-day time period, you capture the opportunity to teach them and to help arm them with tools to be their own advocates. For example, asking a patient, “What will you say when you call the doctor?”
Shortness of breath is a good example. Patients may believe the main symptom is, “I can’t sleep at night.” They’re going to tell the receptionist at the doctor’s office, “I can’t sleep at night.” That person, who is not a clinician, is going to take down a note: Mrs. Johnson is having trouble sleeping.
That’s not a triage. That’s a priority. Someone eventually will get to that phone call and may recommend a sleeping medication. What the patient probably should have said is, “I’m a heart patient. I’m sleeping with four pillows and I can’t breathe and therefore I can’t sleep.” That’s a whole different scenario.
We try to teach patients how to communicate with their providers to really speak to them about what’s very, very important. We coach them, “This is what you need to say. Let’s practice” and then we follow up with them and see how it went after they make that call.
We don’t intervene. It’s not a rescue system. It’s really designed to help the patients engage and learn how to better manage for themselves, because there’s not enough of us to go around and patients really appreciate the fact that we’re reaching out.
It also doesn’t matter what kind of insurance the patient has. They could have terrific primary and secondary insurance or no insurance. All patients get the same quality of follow-up regardless. That has meaning in and of itself because it’s leveling the playing field. We are very proud of that component –that all patients, regardless of what kind of insurance they have, are going to get the same high quality follow-up care.
As a PhD nurse, informatics expert, and researcher, it’s clear that you get excited about patients, while most of the companies out there are more excited about the technology or the business aspects of what you do. Are enough nurses working in healthcare IT or using the approach that your company is taking?
We have several nurses on our team. Believe or not, the TIGER Initiative and HIMSS and the American Medical Informatics Association — particularly the Nursing Informatics working group — the Association of Nurse Executives, everyone is really starting to catch on to the value of informatics in general. It can never take the place of clinical expertise, but there are tools that can help us do a better job and help us measure what we’re doing so that we have some evidence that shows what’s working, what’s not working, and what are the very best practices.
If we’re not measuring our outcomes, then we’re just playing a guessing game. Informatics is critically important to being able to capture and measure and evaluate what we’re trying to improve with the patient.
Do you have any concluding thoughts?
Our team is very, very diverse. I never, ever could have put something together like this all by myself. There is 40 of us — engineers and business people, lawyers and IT specialists, and physicians and surgeons and social workers. Everyone has something very valuable to contribute. That’s how we put the whole system together — lots and lots of different types of data specialists.
I am sitting in a happy seat that I get to be surrounded by these stellar individuals. But really, this group of people … I just can’t even begin to describe how fortunate I am to work with these folks. It’s just remarkable to me and it’s very synergistic. We don’t have room for egos. There is no chip on the shoulder. There is none of that.
We have a corporate philosophy. We have all read Guy Kawasaki’s book Enchantment and decided that that would be our mantra. In everything we do, we try really, really hard to be enchanting. That’s our core philosophy of how we conduct ourselves among the team and with our potential customers and collaborators — that we want to be enchanting.