How might we reduce hospital (re)admissions by orchestrating more seamless and effective post- and chronic care journeys for patients?
Ineffective post-care and a lack of compliance with ongoing care for chronic illnesses render many medical interventions obsolete. This leads to an increased rate of hospital readmissions and a greater likelihood of ongoing health complications. In turn, all of this translates to high financial burdens for both the patient and the healthcare system as a whole. ($564 million is spent because of hospital readmissions each year, and $290 million is spent because of ignored medical advice each year.)
Over the course of our 7-week Introduction to Design Planning course in Spring 2018, our team developed a platform to solve this problem. Noting that the first issue with administering appropriate post-care comes at the moment of discharge—when patients are typically handed over a long, disorganized document of “instructions” for their at-home care—we started looking at holistic, tech-driven ways to deliver this care that fit more seamlessly with the patient’s lifestyle and routine once they are out of the hospital.
Phase 1: Secondary research blitz
Due to the condensed timeline of this project, we were asked to build most of our context through secondary resources. Luckily, between several recent Institute of Design projects focused on discharge instruction redesign and the plethora of articles about this topic available on the internet, we were able to piece together a robust view of the problem at hand.
“In the old days, when we discharged patients from the hospital, you had this: ‘Good bye and good luck. Nice knowing you. Hope everything is great. Drop us a postcard sometime.’ The future is that we are still responsible for that patient. Whether you own the facility, operate it, or not, you are now financially accountable.”
Discharge instructions from several Chicago-area hospitals
Key insights
Effective post-acute care can offer significant potential for savings and quality improvements. Nearly all of the articles we surveyed cited the fragmented state of post-acute care. With fragmentation comes variability, which can mean wide differences in cost, utilization, and quality.
Many hospitals and physicians have only a rudimentary understanding of post-acute care services and give little thought to where their patients are heading after discharge, as long as it does not extend the acute length-of-stay.
Most health systems have a limited understanding of and relationships with post-acute providers. Regulatory requirements of operating a post-acute care facility can be quite nuanced, suggesting that partnerships may be a faster and more affordable option for most health systems.
Home health is poised for new market opportunities powered by emerging technologies, monitoring services, and patient preference to remain at home. This is a market ripe for exploration.
Here are a few of our favorite articles:
Phase 2: determine the value web
Based on our research findings, our team (under the guidance of Doblin’s Larry Keeley) developed a platform that helps connect post-acute and chronic patients to appropriate holistic care paths. The following diagram showcases the value web we created for all of the stakeholders involved in the ecosystem.
Phase 3: Develop the UI/UX for chronic care
Carlos Ramirez is a 27-year-old hispanic man who lives in the Cicero neighborhood on the southwest side of Chicago. A few weeks ago, he was diagnosed with Type II Diabetes and has been feeling quite overwhelmed by the news and his new daily routine—there are just so many things to remember! Because Carlos has Humana insurance through his job, his doctor referred him to TangoCare to help him manage his disease.
Here is how TangoCare might work for Carlos:
Carlos can log into his TangoCare app and see his daily program at a glance. All of his medication is listed, adjusted around his other events in his Google Calendar, and his recommended exercise is based upon machine learning from past days.
After Carlos’s Amazon Alexa reminds him to check his glucose levels with his smart, connected monitor, his dashboard is automatically updated. Because his levels are improving, he is prompted with a notice that he can enjoy a special treat today!
Disease-focused modules, all authored and submitted by clinicians or researchers in exchange for royalties, appear toward the bottom of the home screen. These help patients manage their own symptoms and care at home on their own.
Carlos’s dashboard will automatically adjust to reflect the new data received from his glucose monitor. As you can see, now his progress has been rated as “excellent” and he is even served a recipe for a special shake as his treat.
When Carlos turns his phone sideways, his patient dashboard opens. This dashboard tracks his progress and benchmarks it against others with his diagnosis, provides adaptive recommendations, and serves Carlos with metric readouts from his wearables.
Using criteria from the Joslin Diabetes Center and cross-referencing with Carlos’s current levels, the nutrition module serves him a list of recommended meals that can be easily delivered by TangoCare’s partner, UberEats, with the click of a button.
Phase 4: develop the UI/UX for post-acute care
Greta Ericksson is a 72-year-old woman who lives in Wilmette, a northern suburb of Chicago, IL. She recently had hip replacement surgery and has been managing her Stage I Hypertension for the past 12 years. After her surgery, her doctor recommended that she use TangoCare to manage her post-care because it would be able to blend recommendations for her needs with the surgery with those for her Hypertension as well. Although she lives with her husband, her daughter Jane is registered as her care partner through TangoCare and has been granted permission (HIPAA-approved) to access her account at any given time.
Here is how TangoCare might work for Greta:
When Greta opens her TangoCare app, she is served with her daily program. This schedule pulls in recommendations not only pertaining to her hip replacement, but also her Hypertension as well. It is a one-stop-shop for managing her healthcare.
When Greta turns her phone sideways, her patient dashboard opens. This dashboard tracks her post-surgery recovery progress, provides adaptive recommendations, and serves Greta and her care partner with metric readouts from her wearables.
Every time Greta books an at-home appointment with a holistic care provider through the TangoCare app, she is asked to leave a review for her care. This helps TangoCare ensure that it partners only with the best providers for its patients.
Greta’s smart pillbox ensures she is taking her medications on time. In the TangoCare app, Greta can see instructions for each pill she is expected to take, as well as an image of the pill so she can confirm she is taking the correct one.
Greta is asked to report her current pain levels. These reports are then sent to her physician so they can be aware of her progress. If Greta ever reports higher pain levels, TangoCare is able to adjust her regimen based on physician-specified parameters.
Greta’s daughter, Jane, is able to log into her own TangoCare portal to help her mother manage her care. In this instance, Jane is able to book a follow-up appointment with a nurse practitioner for an at-home visit on behalf of her mother.
As Greta scrolls down her homepage, she finds tailored modules, all authored and submitted by clinicians or researchers in exchange for royalties. These are designed to help patients manage their own symptoms and care at home on their own.
Since physical therapy is a major part of the post-care routine for a hip replacement, this module will be prioritized within Greta’s app. Here, she can find daily at home therapies based on her recovery schedule and can book at-home appointments with a local PT.
Because of Humana’s upcoming partnership with Walmart, TangoCare patients are also able to schedule follow-up appointments at certain Walmart stores nationwide. If a patient selects this option, they can also receive a ride through UberHealth at a discount.
phase 5: final pitch
In early May, all 10 teams in the Introduction to Design Planning course presented their final platforms. Some of the pitched platforms included:
More seamless ways to connect with volunteer opportunities
A rental service for your unused “stuff”
Gig economy-driven party planning/party kits
A club for lonely elderly people to meet others and stay active
Crowdsourced food production and delivery by marginalized women
Special Thanks to the whole team
IIT Institute of Design Students: Pooja Chaudhary, Vinod Kizhakke, Fanny Tan
IIT Institute of Design Adjunct Faculty: Dan Chichester, Larry Keeley
We were so wrapped up in the work that we never took a team photo—so enjoy some photos of our process instead!
