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, mobile health-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 the inaugural year in which healthcare reform has been implemented. This initiative aims to reduce hospital admissions while improving the co-morbidity patterns and healthcare-use behavior of a majority of individuals in the rural community 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 individual 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) a wearable ambulatory body sensor suit 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 targeting epilepsy and mental health (http://www.synapticom.net/videos/), and (5) an independent community-based PHM coordination hub (EFNCIL) facilitating the above innovative components. Results: Preliminary data demonstrate coordination of 17% of the community expected to be diagnosed with refractory epilepsy. These individuals receive the above wraparound services via mHIT and community-based ambulatory services. Several mood, family-management, patient and provider assessment tools were used. Individual predictors included insurance status with potential need for facilitating healthcare coverage, age, ethnicity, co-morbidities and medications (both anti-epileptics and antidepressants/neuroleptics). 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.