Helping individuals in Colombia manage chronic illnesses between healthcare visits through telehealth

Living Lab door

U-M ‘Healthy Call’ partnership assisting local entities in developing sustainable programs with plans to extend platform throughout Latin America 

 

Improving healthcare delivery doesn’t have to rely on complicated or expensive technology.

But to make healthcare better and reach more of the people who need it most, delivery innovation concepts require rigorous evaluation, adaptation to thrive in diverse environments, and support from providers and insurers to ensure long-term viability.

Perhaps most importantly, they must be responsive to the needs of the people they serve.

One notable program utilizes mobile health tools to empower people in Colombia living with diabetes and depression to take greater control of their own health, while also connecting them with sources of follow-up care. The program has found success through a number of public-private international partnerships – and in building on decades of experience refining the model of delivery across a variety of healthcare settings around the world.

The Llamada Saludable program (or “Healthy Call”), as it is known in Colombia, is part of a platform of mobile health self-management assistance tools developed through a program of research at the University of Michigan and Ann Arbor VA led by John Piette, Ph.D., a professor of health behavior and health education in the School of Public Health, a professor of internal medicine at the Medical School, and a research career scientist in the VA Center for Clinical Management Research (CCMR).

Here’s how it works: program participants receive brief, weekly automated calls that prompt them to respond to questions about their health and self-care, such as whether they’ve been taking their medications, if they’ve experienced symptoms of low or high blood sugar, and how they’re doing emotionally. Answers that prompt concern trigger alerts to healthcare professionals for follow up to prevent acute complications.

The system also provides reminders to patients about the complex tasks that are required to manage chronic illnesses between visits to the doctor. For diabetes, these can include glucose monitoring, carefully watching diet and exercise, and taking prescription medicines as prescribed.

This year, as part of an implementation and evaluation program, Llamada Saludable is enrolling thousands of patients with diabetes and depression who receive services either through Savia Salud, a large public insurer serving more than 1.5 million socioeconomically vulnerable people in the region of Medellín or Sura, one of the largest private insurers in Latin America.

U-M students involved in implementing the Healthy Call program
U-M students involved in the Healthy Call program implementation, in Medellín

While some program participants live the urban center of Medellín, others reside outside the city in housing constructed by people displaced by conflicts in the region. Still others live in small towns in agricultural areas up to four hours from the city center. Telehealth can offer important resources in a place like Medellín and its surrounding areas, where people live quite far from hospitals and other sources of care, often don’t have access to necessary specialists, and where safety concerns may prevent ambulances from entering some neighborhoods.

One key factor? Cell phones are plentiful in Colombia, and – relative to the United States – inexpensive to maintain.

For Piette, who has been working in the field of “telehealth” for most of his career, it’s all about accessibility: bringing healthcare services to the most vulnerable patients with the most limited access to care through technological means that are readily available, even in low-resource and rural areas.

“We’re really serving as a bridge to develop these cutting-edge interventions in this environment that has much more limited resources,” Piette, who directs the U-M Center for Managing Chronic Disease (CMCD), says. “At the same time, we’re learning an awful lot from them about how to develop mobile health programs that are helpful for vulnerable populations throughout Latin America and our own country.”

In Colombia, Piette’s group collaborates with the Living Lab, an organization co-supported by the University of Antioquia Schools of Medicine and Public Health in Medellín, and by the Medellín local government. The Living Lab serves as an economic and scientific incubator to grow programs intended to improve public health, become self-sustaining, and provide jobs and an economic boost to the region.

In establishing the telehealth platform, U-M and the CMCD provide technical assistance and support to their Living Lab partners, along with advice on strategic planning, conducting quality management with large programs, and other knowledge that can help them become a self-sustaining service delivery, education, and research environment. Now the team in Antioquia is developing other self-management assistance programs using mobile health tools for suicide prevention, heart failure management, and other conditions.

In 2016, the research team on the U-M side included first-year medical students participating in the Global Reach Program of U-M’s Medical School, as well as a student from the U-M School of Information. This summer was the second year of student involvement in the Colombia program implementation. The students were involved in further testing and developing the platform, including adding content around smoking cessation strategies.

For U-M student Angeline Sawaya, now immersed in her second year of medical training back in the U.S., it was a rare opportunity for hands-on experience in helping improve healthcare delivery and access in a different environment. “This project helped me realize how a technology like Llamada Saludable can be so powerful in developing sustainable programs that can reach so many people in such an efficient way.”

Long-term, Piette sees the project in Colombia blossoming into an international referral center, with potential support from insurers who serve individuals across Latin America, and other international companies that provide self-management assistance for people with chronic illness.

“We’re primarily focused for the next couple years on strengthening this platform in Colombia, which I think could play an important leadership role for their region of Latin America and maybe all of the Americas, and, hopefully, they’ll be a point of reference for the Spanish-speaking world.”

U-M has a suite of chronic disease management telehealth programs running throughout Latin America, which build on and adapt decades of work in chronic disease management through the Ann Arbor Veterans Administration. As a population, Veterans can benefit from telehealth services in similar ways, since they may live far from their nearest VA healthcare facility, and are often contending with multiple chronic illnesses – in fact, most people over the age of 50 in the general population have more than one chronic condition. The VA reported that its national telehealth programs served more than 677,000 veterans during fiscal year 2015, and telehealth is one of the areas the agency has identified for growth and improvement.

For the rest of U.S. healthcare, although the Affordable Care Act includes a number of provisions to encourage opportunities to advance telehealth services, only Medicare has implemented  this at the federal level, while individual states vary greatly in their laws around coverage and reimbursement of telehealth services under private insurance, Medicaid, and state employee health plans. Meanwhile, 20 percent of the U.S. population lives in areas with physician shortages and could potentially benefit from greater access to care, treatment, and monitoring through telehealth.

Having family and loved ones involved in chronic disease management can also be enormously helpful. Other versions of the self-management programs developed by Dr. Piette and colleagues include caregiver support, although integrating that into the projects in Latin America will requires consideration of local views on family and illness.

Piette says another priority in the Latin American program development is to integrate community health workers – who are frontline public health workers who are either part of the community they serve or have an intimate understanding of it – into the models of care; health workers already play a major role in the program for depression management being developed by Piette and colleagues in Bolivia.

He also notes that designing these programs to address multiple chronic conditions remains challenging, but that ongoing work at the VA and U-M on managing multimorbidity will offer great guidance and hopefully some self-management models that can be exported to other settings around the world.