What is the problem within the the two opportunity areas we are seeking to solve and the evidence we have that this is a real problem?
The problem we are seeking to solve is patients and their family caregivers lack information, time, and money to find, make a decision, and access the right care, especially in-home care, for older adults. In particular as the population ages, there are many research/survey or newspaper articles pointing to this problem. Due to lack of assisted living and nursing home beds and cost of such care, "age-in-place" will be one of hallmarks of senior care in the 21st century. The burden of "age-in-place" will fall squarely on the 65 million or more affected families. This concern has been reinforced for me as I conducted focused group surveys, and had conversations with potential individual users, long-term care organizations, prospective partners, and even doctors for chronic diseases. It is not only a real problem in the U.S. that most people run into at some point in their lives, but also a growing problem worldwide.
The solution in the case of "Healthy Bone Health Aging"
An individual recovering from a fracture is particularly vulnerable when transitioning from hospital or skilled nursing facility to home care. This transition can be difficult for both the patient who finds her life and home disrupted and any family caregivers who are anxious to help but are uninformed and uncoordinated.
Especially in the case of patients diagnosed with osteoporosis, the care plan created after a fall needs to promote the range of actions for minimizing bone loss and strengthening weak bones. These include nutrition, exercise, mineral and vitamin supplements, and specific medication for treating the condition.
When I was taking care of my parents’ osteoporosis condition, I found adding all these actions into their “usual daily living” plan very challenging because these new actions made their “usual” daily living routine a lot more complicated as well as created even more stress in the lives of both patients and caregivers.
This personal experience inspired us to create a solution that not only supports healthy bone and healthy aging but also ensures the care experience is as positive as possible for everyone involved.
A Cloud-based CareXc Solution
The CareXc (www.carexc.com) platform is a new health care platform designed to transform the chaotic daily routines for caregivers and older adults in need of care into a streamlined, patient/caregivers-centered resource.
It enables patients and family caregivers to easily lay out and follow step-by-step instructions for managing, the recovery process, including connecting to support resources for caring for osteoporotic bone fractures or other health conditions (e.g., stroke, diabetes) that might exist before the fall or have developed during recovery.
By laying our solution on the CareXc platform, it can be used for investigating the cause and connecting dots, identifying people at risk, and be able to Intervene for prevention.
As an Internet based solution, the CareXc platform’s capabilities are available to authorized caregivers and healthcare professionals, local or remote, so all information, including past and current health records can be integrated & made accessible for investigating the cause, connecting the dots, and planning an intervention.
This solution consists of three modules built using CareXc: 1) curating and providing access to a library of care plan templates specifically for bone health conditions and fall prevention, 2) customizing care plans and forming a personalized team/community of people to carry out the plan, and 3) enabling various ways for patients and caregivers to easily acquire a list of products/services associated with the personalized plan.
The library of care plan templates, organized by health conditions, is sourced from medical and in-home care experts and institutions. Some are augmented with the direct input of individuals who have experienced similar conditions. We believe patients and caregivers connecting with others can achieve better outcomes when they gain information and recommendations from other individuals who have faced similar situations.
All templates are information rich, containing a list of tasks, with a description section, the allotted times and cost estimates, a list of products for each task, and a discussion board to post questions and answers among the team members who can be medical professionals. All are displayed on one web-page with three tabs to create a “one-stop-shop” style user-interface so users do not have to switch to other web-pages to further navigate for the information or products they need. The description section can contain additional research, data, or examples provided by healthcare system's experts. They may be directly included if space permits or a direct link is provided to their organization’s page. In either case, users do not lose the CareXc page that they have been on. The following screen shot gives an example of this information-rich page.
These templates can be augmented easily by a medical professional, a case manager or other caregivers who have the privilege to change templates; for example, incorporating new treatment options can be done by using the Edit Care Template capability in CareXc.
A care plan template can be adopted and customized by using the Customize Plan capability to create a personal care plan. A plan is the foundation for forming a personalized "care team" comprised of, everyone involved in a patient's care, from doctors, nurses, therapists, coaches, and case managers to family caregivers. Their skills and availability are captured and used to create schedules for carrying out the tasks they agree to do; for example, take the patient to her physical therapy session between 11:00 to 12:00 by car. The following is an image of the "Customize Plan" capability.
Each patient’s care plan is evergreen because it can be revised as needed; for instance, to address health issues which arise because of an adverse drug interaction. This Customize Plan capability enables a healthcare provider to intervene promptly, accessing the plan remotely from the convenience of his office. The revised plan can be used immediately by the patient or her caregiver at home.
Patients have or develop multimorbidity are very common in adults with osteoporosis. Our Merge Plan capability can be used to have one plan including tasks of preventive care for other diseases and improve the quality of life with Osteoporosis.
Merge Plan function can be very useful for coordination and we marked it on one possible time of using it on the Journey map uploaded.
Each plan includes links to qualified product suppliers. Integrated sourcing of equipment and supplies saves time, reduces stress, and can lower costs. The discussion board can be used for rating products, tips and tricks of carrying out plan tasks to save more time and cost, etc. These capabilities as well as making requests to alert caregivers in situations like supplies are running short can be further automated with AI. All these are built in to motivate users to return to the solution even after they already found a care plan when they first used the solution.
Devices that enable voice activation, or telehealth sessions can easily integrate with this platform to lower the barrier for a patient to use the solution. With these devices plugged in, the care plan’s tasks can be carried out by patients at home with family, coaches, and health aids, or with doctors at a remote location for ensuring care plan adherence.
Since osteoporosis is not recoverable as older adults continue to age, a solution like CareXc is already valuable for managing medication to reduce bone loss. Maintaining a personalized community even after the patient is recovered from the fall will significantly help in preventing falls from happening again.
We believe this level of flexibility in helping people living with a disease like osteoporosis makes our solution an extremely strong response from the following perspectives:
- Any health condition can change over time, and even the same condition, such as osteoporosis, varies from person to person. No one size fits all or is of fixed length. Consequently, any solution offered needs to be flexible in multiple dimensions which is built into the platform. For example, with a remote device, the patients can feel much more assured that someone is there for them even if no one is staying with them, especially in the initial period after discharge.
- For patients and caregivers who lead busy lives and aren’t “into” computers, reducing the burden of tracking and managing all the variables (e.g. time required, cost, etc.) encompassed in a care plan is paramount. CareXc will provide the intelligence to automate some of these tasks to reduce the burden. For example, when a change is made to a patient’s care plan, e.g., a new medical supply item is added, CareXc queries designated 3rd party websites for pricing and, using cost parameters previously defined by a patient/caregiver enables patients to still meet their financial constraints.
- CareXc has been designed in a way which recognizes that the world doesn’t stand still, and more ideas combined makes an even better idea. We expect other companies and healthcare consortium to create tools, solutions, and data repositories to enhance caregiving. The open architecture of our platform enables integration of 3rd party tools and the sharing of data collected through those tools. This capability extends to the ideas included in this Challenge. CareXc solution can grow and get upgraded without having to build more capabilities only by ourselves.
How We Tackle Bone Fracture and Osteoporosis
The following illustrates a time based journey of daily living.
We also added the CareXc care plan modules from the "In Hospital" period to "Out-patient Experience", and then to "Reestablishing Routines" period of the Health Bone Health Challenge Journey Maps included below.
However, if people already have been using CareXc for their daily living plan, their in-home care records would have been stored in the CareXc data repository. and the health systems' ER can be granted to have access for determining if the fall is indeed caused by an osteoporosis condition.
We plan to simultaneously work with other solutions that are focusing on each of the three above mentioned missions to constantly elevate the quality of healthy aging life and reach a higher degree of falls prevention and unite a strong community of people with the same health concerns and similar circumstances to be the most accessible, understandable and inexpensive approach to solve the "first fracture is their last" challenge.
Additional details of where CareXc touches the Challenge Journey including the "Living in Community phase (with CareXc)" is in the uploaded Journey map.