Location: Hattiesburg, Mississippi

Size: A walk-in and appointment-based primary care and occupational medicine clinic with one staff physician and a nurse practitioner serving approximately 5,291 patients annually.

Affiliation: None

Southern Medical Care was recognized as the most engaged participant in the HeartCare Channel program. The program was funded by the COSEHC Quality Impact Practice Transformation Network (PTN) through a cooperative agreement under the CMS Transforming Clinical Practice Initiative (TCPI) and was designed by the American Heart Association and The Wellness Network to deliver targeted and customized video and print patient education to a rural population.


The Challenge
Southern Medical Care operates in a rural area, where up to 80% of patients have diabetes and hypertension and a majority are on Medicare or Medicaid. Its lead healthcare provider, Dr. Lara Otaigbe, is a certified diabetes educator. As the healthcare environment rapidly shifts from a volume-based to a value-based model, Southern Medical Care needed a measurable tool that would aid in maintaining consistent care, engaging patients in understanding and managing their conditions through effective patient education, reducing readmissions, and improving patient satisfaction.

Southern Medical Care is a small facility without the resources to launch a large patient education program. Hoping to gain support, Southern Medical Care’s Dr. Otaigbe responded to an open call for participants from the QualityImpact PTN.

QualityImpact provides technical assistance to more than 5,000 care providers throughout the Southeast United States. The group deploys “transformation solutions” to help care providers transition to a value-based model and alternative payment methods. “Each transformation solution is individually tailored to the provider’s needs,” said Harshini Parvatha, the practice facilitator who worked with Southern Medical Care. In Southern Medical Care’s case, the clinic wanted to “focus on patient and family involvement” through increased patient engagement and education.

QualityImpact’s support is funded through the CMS TCPI cooperate agreement at no cost to participating care providers.

The Requirements
In their initial meetings with Quality Impact, Southern Medical Care identified several key goals. They wanted to provide more comprehensive patient education, and importantly, they wanted to extend patient education initiatives to the patient’s family members. The practice identified that patient and family participation was a crucial factor in improving patient outcomes, especially in chronic care management, where patients are often dealing with overlapping chronic conditions that require long-term care. They also wanted a program that would be easy to manage and easy to use for patients, including patients with limited access to computers or smartphones.

The Solution
Working under QualityImpact guidance, Southern Medical Care teamed up with The Wellness Network and its long-time partner the American Heart Association (AHA) to create the Southern Medical HeartCare Channel, a custom video and print library with over 284 videos and 111 PDF resources. The library, whose resources were developed at a 5-7th grade reading level, was designed to directly address Southern Medical Care’s needs.

“Given the clinic’s population and specific patient needs, we customized the library to include resources on heart failure, high blood pressure, stroke, diabetes, COPD, and health and wellness, among other key topics,” said Gloria Catha, senior manager of Patient Content Strategies for the AHA.

The Wellness Network team also created a series of collateral materials to help explain and promote the tool to Southern Medical Care staff and ultimately increase patient engagement. There was onboarding training, a resource checklist, and a simple 3-step promotion created to engage staff and provide a simple process for integrating use of this resource into clinical workflow. Posters and table tents were used to increase patient awareness while specially designed bookmarks informed patients how to access the online library from home and steered them toward videos specific to their needs.

The Implementation
The goal was to reinforce face-to-face education and encourage extended learning, so the team focused on patient involvement beginning with their first interaction. As soon as patients made an appointment or walked into the Southern Medical Care clinic, they were encouraged to access the HeartCare Channel library. New patients making appointments were sent an email with registration and log-in information for the HeartCare Channel library, plus a recommendation to view relevant videos.

When patients came into the clinic, they were again prompted to access the library. The receptionist handed each patient a HeartCare Channel library bookmark with a recommendation to view the American Heart Association’s Life’s Simple 7-video series on their smartphone. If they didn’t have a home computer, tablet or smartphone, the clinic loaned them a tablet for use in the waiting room. Once in the clinic exam room, Dr. Otaigbe reinforced the healthy lifestyle messages from the videos. After their appointments, patients were given a checklist with more recommended videos.

“Patients reported that they found the information useful and educational,” Lara Otaigbe, MD Southern Medical Care

A key element in the program’s success was the presence of a strong internal advocate, Ember Ahua, Southern Medical Care’s office manager. One of the challenges with this type of program is participation from the clinic itself. Southern Medical’s HeartCare Channel library resource was designed to be as minimally invasive as possible, but its success still depended on getting buy-in from the clinic staff. Fortunately, Southern Medical Care quickly recognized the value of the program and made a dedicated effort to incorporate this resource into daily clinic life. “It was really simple on us and the patients,” Ahua said. “That was important.”

Lessons Learned

In a rural area with a high percentage of Medicaid and Medicare patients, access to technology can be an issue. Thanks to the clinic’s use of tablets, however, it didn’t matter if a patient had access to a computer, tablet or smartphone—they could still access the library in the waiting room and view the videos and PDF resources. For patients who already had online access, the HeartCare Channel made it possible to provide comprehensive patient education before, during, and after the clinic visit, both with the patient and his or her family, across the continuum of care. “Patients often need to hear things three or four times,” Ahua said.

In fact, the level of overall patient engagement was a pleasant surprise—it turned out that patients were hungry for education. Over 20 videos were viewed for each unique log-in, meaning that patients weren’t just watching the videos assigned to them but were taking advantage of the library’s wide-ranging content to learn more. Engagement held steady with an average number of 190 videos viewed each week. The result was a more informed patient base.

As Medicare and Medicaid funding rapidly shifts toward a value-based payment model, and away from a volume-based model, it’s essential that care providers of all sizes find ways to measurably and cost-effectively reduce hospitalization rates and improve patient outcomes. A growing body of research shows that patient education positively affects patient outcomes, which in turn will affect reimbursement and provider payment. The Southern Medical HeartCare Channel resource directly met that need.

“Telehealth strategies like this one include digital and mobile health technologies that can support the work of doctors and their teams to reinforce health, promote lifestyle changes and to make managing chronic diseases easier for their patients,” said Eduardo Sanchez, MD, MPH, FAAFP, Chief Medical Officer for Prevention and Chief of the Center for Health Metrics and Evaluation, American Heart Association.

From QualityImpact’s point of view, the program was carefully designed to satisfy the goal of engaging patients in understanding and managing their own care. To make sure its enrolled practices are making progress, Quality Impact holds biweekly calls and continually updates the action plan. “Southern Medical has been recognized as a highly engaged practice within our PTN,” Parvatha said.


About the HeartCare Channel
In 2015, The Wellness Network and the American Heart Association/American Stroke Association (AHA/ASA) launched the HeartCare Channel, a cardiovascular disease and stroke-focused library available online, on tablet, via in-hospital TV channel and EMR integration services that was designed to empower heart and stroke patients to live healthier, longer lives. This collaboration offers a unique opportunity for enhanced educational engagement between patients and caregivers at bed-side in the hospital, at a time when they’re most in need of key information and highly motivated to take action to improve their health.

This resource is designed to provide actionable and trustworthy heart- and brain-health patient education that encourages discussion among patients, their families and their doctors. Those discussions can improve understanding of the patient’s condition, steps to improve their recovery, reduced risk of readmission, and live healthier, longer lives.

About The Wellness Network
The Wellness Network (TWN) is dedicated to delivering life-enhancing wellness information to motivate patients to take action, aid hospitals in meeting accreditation and improve overall quality of health care. TWN’s award-winning library of over 5,000 video and print resources is available via the most comprehensive health network in the US, including 2,300 hospitals, 300,000 tablet and TV screens, and online with a monthly engagement of 550,000 people.

This resource is designed to provide actionable and trustworthy heart- and brain-health patient education that encourages discussion among patients, their families and their doctors. Those discussions can improve understanding of the patient’s condition, steps to improve their recovery, and reduced risk of readmission.

About the American Heart Association/American Stroke Association (AHA/ASA)
The American Heart Association/American Stroke Association is devoted to saving people from heart disease and stroke—the two leading causes of death in the world. We team with millions of volunteers to fund innovative research, fight for stronger public health policies and provide lifesaving tools and information to prevent and treat these diseases. The Dallas-based association is the nation’s oldest and largest voluntary organization dedicated to fighting heart disease and stroke. To learn more or to get involved, call 1-800-AHA-USA1, visit heart.org or call any of our offices around the country.

Quality Impact is supported by Funding Opportunity 1L1CMS331443-02-00 from the US Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided is solely the responsibility of the authors and does not necessarily represent the official views of HHS or any of its agencies.

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