Digital Health@Home

Tech breaks down barriers for hard-to-reach patients and boosts digital skills to better manage chronic and self care 

Digital Health@Home (H@H) is a project funded by the Health Forward Foundation, and developed to cross-train health workers with connected devices, remote monitoring tools, and digital literacy basics. It leverages trusted caregivers to deliver edge care at home to select high risk and priority patients, and embeds digital tool training with care delivery to help patients manage their care across telehealth, remote management and in-person care. The addition of digital literacy training boosts health workers’ digital proficiencies, and increases patient digital engagement that leads to better ongoing communications and better health outcomes.  

This project expands upon the work that came out of our 2020 project – Digital Equity for Community Health Workers – that reinforced the vital role community health workers (CHWs) play as empathetic peer consultants, and the reality that CHWs and the clients they serve often lack important digital skills. One of the outcomes of the 2020 project included a modular curriculum co-designed with CHWs to boost their own digital literacy and train-the-trainer tools to further engage their learning to share with their clients. 

The role of ‘home facilitator’ is atypical for many health workers, and is an indicator of the new innovative approach the H@H project brings to the delivery of care. The project has partnered with Swope Health to train up three licensed practical nurses (LPNs) in this new role, and identify a cohort of 20 hard-to-reach patients to receive these new home-based care and digital literacy training sessions. 

We believe that new methods and care modalities like H@H can greatly enhance equity in patient access and engagement and dramatically improve Federally Qualified Health Centers’ patient engagement, no-shows and missed appointments. Digital Health@Home aims to 1) improve overall engagement rates for a cohort of 20 patients; 2) improve patient digital engagement through a patient portal; and 3) train patients with new digital skills to better manage, monitor and impact their care long term. 

What success looks like:

  • Swope Health outcomes – change in engagement, no shows rate; staff feedback 
  • Patient outcomes – change in digital and care scores; feedback
  • Health worker outcomes – change in digital literacy proficiency; feedback 

Pre and post surveys will be distributed to the patient cohort, Swope staff and health workers to assess changes over time, and to collect qualitative feedback on the effectiveness, impact and success of the project. 

The problem this project addresses

Telehealth gives providers an important platform for addressing missed appointments, gaps in care, and other factors that contribute to negative health outcomes. The situation is particularly important for federally qualified health centers (FQHCs) and community health centers (CHCs) who deal with a large underserved population that keeps growing as the coronavirus pandemic continues to strain our health systems. FQHCs and CHCs face an uphill battle when it comes to patient engagement, particularly with patient no-shows which average a rate of 30% nationwide, and is often directly linked to low-income patients and Medicaid recipients. Low-income patients often delay care or avoid it entirely due to transportation issues, insurance availability, mobility, home life, and school and work pressures – all of which can play a part in whether someone does or does not visit the doctor. 

FQHCs and CHCs will serve an all time high of close to 30 million patients within the next year, according to the NACHC. The demand for health centers is growing exponentially, reflecting a widespread need for more affordable and more flexible care options. 

Swope Health serves more than 43,000 patients across 14 centers located throughout the bi-state area including Kansas City, Belton, Independence, Kansas City North, Hickman Mills and Wyandotte County, KS. Of those patients, 64% live below the federal poverty level; more than 2,800 were experiencing homelessness; and almost seven out of 10 were Black or Hispanic.

Based on a McKinsey survey of physicians who serve predominantly Medicare fee-for-service (FFS) and Medicare Advantage (MA) patients, it estimates that up to $265 billion worth of care services (representing up to 25 percent of the total cost of care) for Medicare FFS and MA beneficiaries could shift from traditional facilities to at-home care by 2025 without a reduction in quality or access. 

In February 2021, the use of telehealth was 38 times higher than pre-pandemic levels. A combination of remote monitoring, telehealth, social supports, and home modification enables more patients to receive some level of care at home. 

If you’re interested in learning more about H@H, or how to get involved, or if you’d like to know more about our health innovation projects and initiatives  – please contact John Fitzpatrick, Community Health Strategist, at jfitzpatrick at kcdigitaldrive dot org,