COMMENTARY

Text Messaging-Based Platform Helps Improve Health Behavior Among Lower Income Patients

November 11, 2016
Thomas Morrow MD

I have talked a lot about how we need to change behavior in this country to avoid catastrophic health care costs. I have also talked about some pretty advanced technology on both ends of the spectrum. Most of the time, the technology is incredibly advanced:  electronic medical records (EMRs), predictive modeling, smart phones, computer tablets, cell-connected pill dispensers, etc.

But, a significant portion of our population and a disproportionate percentage of the underserved population do not have access to smart phones or continuous access to computer technolog—and they are in the sickest of the sick populations in the United States.  In fact, although about 94% of all adults have a mobile phone, only about two-thirds of those phones are smart phones. Also, significantly more adults use their smartphone for texting (97%) than for apps (60%); a difference that is even greater if you focus on lower income groups. Costs also comes into play; the lower income groups typically have mobile plans with significant data usage restrictions but unlimited texting.

Agile Health, an emerging company out of Nashville, Tennessee, has looked at these statistics and spent the last five years embracing and perfecting SMS/text messaging as a modality to deliver personalized coaching support that helps people improve their health and practice self-care more effectively. Agile is led by healthcare veterans Gary Slagle and Scott Werntz, who served in executive positions at some of the nation’s leading behavioral management care and prescription benefit management companies. After years of experience building and deploying interventions designed to inform and drive targeted behavior change among patients and providers, they decided to form Agile Health. They recognized the game-changing potential that mobile technology had to dramatically and cost-effectively improve the impact of health engagement and behavior change at the individual level—as well as the extendibility, scalability, and efficiency of patient engagement and health management operations at the institutional (payer/provider) level.

Agile’s approach is simple. They use two-way SMS texting to push messages directly to the user’s native phone interface, establishing a personal and private coaching dialogue designed to produce sustained behavioral change. It is a low friction approach that is widely available across the population, and is less cumbersome because it does not require the use of an app.

Each of their programs focus on the individual behaviors proven to affect clinical, utilization, and cost outcomes that are increasingly relevant to payers. These include foundational behaviors such as healthy eating, exercise, medication adherence, and self-monitoring, as well as more targeted behaviors like adherence to evidence-based guidelines, following hospital discharge instructions properly, managing medication therapies, and properly utilizing healthcare resources.

To effectively achieve behavior change, Agile uses the Information, Motivation, Behavioral Skills Model of Behavioral Change (IMB) prompted by Fisher and Fisher. This model revolves around three essential components:

  • accurate information about the behavior;
  • motivation to do the behavior; and,
  • a set of skills needed to implement the behavior. 

The IMB model follows a precept that for complex behavior requires all three of these items to be present simultaneously and none is sufficient alone.

Agile teaches using evidence-based content and guidelines.  They provide proven motivational strategies tapping into one’s intrinsic motivation to do and feel better. And they build behavioral skills, helping people set achievable goals, arranging their environment for success, establishing social support, tracking their progress, and celebrating accomplishments every step of the way. Importantly, Agile ensures that program participants continue practicing these skills—day in and day out, one text at a time—until they ultimately become lifelong habits.

Core to Agile’s approach is its technology. They have built a sophisticated platform called SHERPA that leverages secure, HIPAA compliant health care messaging to drive a wide range of highly automated engagement programs, each coupled with a companion integrated web site. But Agile does not rely only on technology. They also use human coaches to seamlessly intervene when additional support is needed, something many app-based programs have not done. 

Eligible participants can enroll either by text, web, or telephone call, and continue to get the personal support they need for the life of the program. Once enrolled, participants receive a structured text-messaging curriculum, tailored to their personal health objectives. Some of the messages contain hyperlinks and encourage them to use the secure website to enhance and personalize their text messaging experience. There, participants can adjust the timing of their messages, create their own personal text reminders, connect personal remote monitoring devices, access relevant health content, obtain social support, and access other tools designed to support sustained engagement.

Agile’s programs include on-demand, automated, interactive support when a live coach is not needed, and offers live health coach support via text when they need it. The health coaches monitor program utilization and participant data and initiate dialogue via text when appropriate. As care teams use the text platform to engage patients, they gain real time insight to individual needs, so they can be proactive and prevent problems before they occur.

The SHERPA platform captures and compiles data from a variety of sources. It records all inbound and outbound message activity and assimilates data gleaned from messaging interactions, web usage, third party data provided by the sponsoring organization, and data from personal remote monitoring devices such as weight scales, activity trackers, glucometers, and blood pressure cuffs.

This data is then used to support additional ad-hoc text based dialogue and to trigger rules-based virtual coaching messages and alerts. The data can also be used for reporting requirements such as HEDIS, STAR, ACO, etc.

Agile Health caters to health plans, hospital systems, large physician groups, third party care management companies, large self-funded employers, and wellness/population health management companies.

Importantly, Agile’s programs have clinically proven results. A recent clinical trial published in the Annals of Emergency Medicine demonstrated that Agile’s diabetes self-care program decreased emergency department use by 30% and showed trends toward improvement in HbA1c, quality of life and medication adherence; findings that were magnified in the Spanish speaking group. Another study published in The Lancet demonstrated their tobacco cessation program resulted in improvements in biochemically verified continuous tobacco abstinence at 6 months; more than double those in the control group.

Agile Health is simplifying the participant experience, improving health engagement, and reducing costs in the process. Their sophisticated SMS based behavioral improvement model makes wellness, chronic condition management, and transitions of care programs accessible to some of the most vulnerable in our population.  For that, I commend Agile Health!