1. HAWAI‘I ISLAND CARE COORDINATION SERVICES
OUTCOMES REPORT
September 2013
Complex Care
Coordination for Private
Practicing Physicians

2. Executive Summary
 Enrolled a total of 78 patients of private Primary
Care Physicians (PCPs)
 Double-digit improvements in health outcomes
including HbA1c, cholesterol, triglycerides, blood
pressure and weight
CONCLUSION:
Care Coordination WORKS!

3. Patient Enrollment
 78 patients with complex care needs due to
chronic diseases such as diabetes
 High-cost, high-risk patients identified by PCPs
and Health Plans
 High use of emergency departments and
inpatient care
 Average age 69.8
 83% overall enrollment rate / 79% completion rate

4. Physician Participation
 29 Physicians Participated
• 13 PCPs in East Hawaii
• 16 PCPs in West Hawaii
 Physician Role
• Active participation in selecting and enrolling their
patients into the program, intro to care coordinator
• Availability for care coordinator questions
• Longer appointment visits if necessary
• Access to PCP records by care coordinator

5. Care Coordinator
Participation
 Registered Nurse (RN) assigned
to each patient to create a
service plan to improve
his/her health
• Provided education about his/her
complex conditions
• Assisted with access to
specialists, keeping track of
prescriptions and appointments
• Health Coach provided support to
make lifestyle changes

6. Use of Monitoring Technology
 42 patients received, at no charge, use of
Ho‘okele’s iHealthHome® in-home monitoring
technology for one year.
 Enabled patients to take biometric readings at
home for blood pressure, blood sugar and
weight, which was submitted to the R.N.
 Empowered patients to
log their own food,
exercise and activities
and to communicate
with the R.N via video calls.

7. HICCS HbA1c – 36% Better
IMPROVED HEALTH
Mean
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
Baseline Post Sustained
HbA1C
Baseline 7.80
Post 5.04
Sustained 4.99 36.0% PctImprovement
6.63 t-value
0.00 p-value

8. HICCS Ttl Cholesterol – 19% Better
IMPROVED HEALTH
Mean
0.00
20.00
40.00
60.00
80.00
100.00
120.00
140.00
160.00
180.00
Baseline Post Sustained
Total Cholesterol

9. HICCS LDL – 10% Better
IMPROVED HEALTH
Mean
70.00
72.00
74.00
76.00
78.00
80.00
82.00
84.00
Baseline Post Sustained
LDL Level

10. HICCS HDL – 13% Better
IMPROVED HEALTH
Mean
36.00
38.00
40.00
42.00
44.00
46.00
48.00
Baseline Post Sustained
HDL Level

11. HICCS Triglycerides – 37% Better
IMPROVED HEALTH
Mean
0.00
50.00
100.00
150.00
200.00
250.00
Baseline Post Sustained
Triglycerides
Baseline 193.22
Post 145.52
Sustained 122.00 36.9% PctImprovement
6.75 t-value
0.00 p-value

12. HICCS Systolic BP – 11% Better
IMPROVED HEALTH
Mean
110.00
115.00
120.00
125.00
130.00
135.00
140.00
Baseline Post Sustained
Systolic BP

13. HICCS Diastolic BP – 13% Better
IMPROVED HEALTH
Mean
64.00
66.00
68.00
70.00
72.00
74.00
76.00
78.00
80.00
82.00
Baseline Post Sustained
Diastolic BP

14. HICCS Weight – 9% Better
IMPROVED HEALTH
Mean
165.00
170.00
175.00
180.00
185.00
190.00
195.00
Baseline Post Sustained
Weight
Baseline 190.77
Post 185.09
Sustained 173.99 8.8% PctImprovement
2.74 t-value
0.00 p-value

15. IP Admits – 29% Reduction
IMPROVED HEALTH

16. ER Visits – 25% Reduction
IMPROVED HEALTH

17. Physicians See Changes
Patients who were calling or
coming in to the office frequently
were able to reduce their visits to
every 3-4 months.
PERSPECTIVES

18. Patients Feel the Difference
It seems that healthcare is a pile of jigsaw pieces My
care navigator helped to show me how the pieces fit
into a map of health. It helped to prioritize these, that
allows my family and I to make better choices for me.
87% of patients agree that
My RN Navigator helped me to better
understand my medical condition and what
I needed to do to take care of myself.
PERSPECTIVES

19. MAHALO
Dew-Anne Langcaon, Ho‘okele Health Innovations
dewanne@hookelehealth.com
Ken Ono, West Hawai‘i Home Health Services
kenono@hawaii.rr.com
Susan Hunt, Hawai‘i Island Beacon Community
susanbh@hawaii.edu