Patient Support & Advocacy

How are patients really doing? One way to find out: Send a text

Sara Berg, MS , News Editor

AMA News Wire

How are patients really doing? One way to find out: Send a text

Apr 11, 2024

A single mother of three young children who was working hard just to make ends meet was a frequent visitor to a local emergency department in the Sanford Health system for depression. The care team enrolled her in a low-tech, text-based remote patient-monitoring program at Sanford Health. It saved her life. 

“One day, she sent a text saying, ‘I’m having a one out of a nine kind of day’ in response to a prompt we sent checking in on her. We were able to immediately reach out to her in time to make a difference,” said Jeremy Cauwels, MD, an internist and chief physician at Sanford Health.

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“I’m happy to say we got her engaged in the right kind of care and she’s now back to being fully functional and taking good care of her kids,” Dr. Cauwels added.

This is a free service that allows patients to self-report symptoms through a phone call or by text message. As part of Sanford Health’s initiative to advance virtual care, the text-based technology enhances the patient experience and allows physicians and care teams to intervene sooner to better manage certain health conditions. Patients can be in the program for as little as one month, but the average patient is in the program for eight to 10 months.

Patients with chronic obstructive pulmonary disease (COPD), congestive heart failure, depression or diabetes are in the program for longer in order to support the management of their chronic conditions. Patients can “graduate” from the program when their condition is properly managed. There is also a post-discharge program for patients.

“The way it works is we can choose different chronic diseases, so we’ve chosen depression, COPD … and congestive heart failure. We also use it for some diabetes management, specifically trying to maintain their blood-glucose levels,” explained Erica DeBoer, chief nursing officer at Sanford Health, which is a member of the AMA Health System Program that provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“Once the patient engages in the program, we send out short symptom-based questionnaires via text message or phone call in a personalized cadence,” DeBoer said. “We developed this program because we recognized an opportunity to promote better preventive health intervention.

“Improving the patient experience is an important tool to build trust, promote shared decision-making and ensure better care coordination,” she added.

Through the first year of the remote patient-monitoring program, “we’ve seen fewer emergency department visits and fewer in-patient visits for those who have chronic conditions,” DeBoer said. “We attribute this to the more consistent communication between caregivers and patients. It also helps us to identify those patients who aren’t showing up for their clinic visits to manage their chronic disease too.”

The AMA Remote Patient Monitoring Implementation Playbook offers a step-by-step process to help guide your practice through the implementation of remote patient monitoring. It is part of the AMA Digital Health Implementation Playbook Series that includes a Telehealth Clinical Education Playbook and a Patient Access Playbook

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“What’s amazing about it is that it’s low-tech. Sometimes people want all the gizmos and gadgets and that can be incredibly overwhelming to a patient,” DeBoer said. “Two-thirds of our patients live in rural areas, and sometimes access to broadband or limited financial resources can be a challenge. Our patients just need a regular cellular phone to enroll in this program. It doesn’t even have to be a smartphone—just one that can receive text messages, or phone calls.”

“In some cases, we’ve been able to reduce barriers for patients with limited resources by providing a low-tech phone that doesn’t require minutes so our teams can support the patient and their disease management,” she said. The Sanford Health initiative can be like having an accountability buddy, something to nudge a patient to stay engaged and attentive to how they’re feeling and how they’re managing their chronic disease.

“The part that our doctors love about this system is it is automated, so they receive notifications in real-time when a patient with congestive heart failure may need immediate intervention,” Dr. Cauwels said, noting the augmented intelligence (AI) technology checks on the patient “every week and gives them information when they need it at the point of care.”

That, he noted, “is a huge difference when you compare it to many of the wearable devices that we all have that give us lots and lots of information, but may not actually tell us when we need help.”

“I call it the signal-to-noise ratio, but when that signal comes through and says, ‘Hey, Jeremy’s really fallen off the rails here and you can tell because of this text message,’ that’s a much higher-definition signal that gives us the ability to take action more quickly.”

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Institutions in this article have been honored by the Joy in Medicine™ Health System Recognition Program.

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“Physicians want to see their patients doing as well as possible and this is exactly the type of work that gets us to heading something off at the pass before it gets bad—rather than waiting until somebody ends up in your emergency room or ends up in your clinic and needs to be sent directly to the ER,” Dr. Cauwels said. “Those are never good days for a doctor, for a nurse, for anybody in that clinic staff because they know if they would’ve known something a little earlier, they probably could have headed it off.”

“For our physicians, it really gives them the ability to understand what’s going on when their patients aren’t in their office and can help direct them back to their office sooner if needed to make sure you are indeed providing the best care you possibly can for your patients,” he added.

“If we can manage a patient’s chronic disease remotely and proactively engage with them in between medical appointments, it gives us an opportunity to have a more meaningful conversation with that patient while they’re with us for 15 minutes during a clinic visit,” DeBoer said.

“And on the flip side, that also allows us to personalize care for that patient and maximize their time and the provider’s time during visit,” she added.

The key is keeping patients engaged while in the program. And it is working. Patients are responding to text messages and interacting with the care management team. For example, of the 400 patients with COPD who are enrolled in the program, “82% are highly engaged and activated,” DeBoer said. “It makes a big difference.”

For patients with “heart failure, about 75% are connecting with us on a regular basis,” she noted, explaining that “if they don’t connect, that’s a trigger to our front-line teams—those care managers—to proactively reach out and customize the engagement program to fit their need and lifestyle.”

AI is used “to help us engage at the right times and then if there is some trigger based on the questionnaire for chronic disease … it actually will then escalate and trigger a phone call to that care manager who then connects with the patient to make sure that they’re doing OK and have what they need,” DeBoer explained. “We have an opportunity to really try to understand our patients better, understand what barriers are getting in their way so that they can manage their chronic disease more effectively.”

Since launching the program, Sanford Health has sent more than 82,000 automated text messages, more than 8,300 automated phone calls and has received more than 2,300 proactive alerts, including more than 1,800 for depression alone. Care teams have made 91 crisis hotline connections. 

“I would encourage any health system that’s looking at this to jump in and say, ‘This is how we help those folks who find it hard to navigate health care,’” Dr. Cauwels said. “Rather than them coming to health care, we bring health care to them and they can get connected in a way that makes sense patient to patient.”

This low-tech, text-based remote monitoring program “really does a good job of energizing those patients to help take care of themselves,” he said.

The Substance Abuse and Mental Health Services Administration has launched the 988 Suicide and Crisis Lifeline, which replaced the National Suicide Prevention Lifeline. Calls to 988 can trigger immediate dispatches of mobile crisis teams—24/7—to anyone experiencing a mental health crisis, if needed.

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