The first step we take with any partner is to develop the priority Chronic Disease states that we should target.
of healthcare costs are a result of the treatment of Chronic Diseases.
Source CDC, 2015
Once we have identified our target diseases clusters, we go through a 5 step process
Building an outreach strategy to targeted populations who match the priorities of each partner and encouraging them to apply to join OTS
Deploying our readiness assessment model to work with the referred populations and ensure they are ready for the OTS intervention
Ensuring that all participants who have been accepted are both onboarded to appropriate OTS programs, and show up for the 1st in-person session
During the OTS intervention, 12 main metrics for engagement are tracked to ensure that targeted health outcomes are achieved
Critical to the OTS approach is ensuring that as many participants reach a state of self-management of their condition during the OTS program
While existing Wellness platforms are addressing some of the needs of low-risk, pre-chronic populations, they are not tailored for the rising risk. The OTS program fills that void with a high intensity, high frequency program to slow, stop and reverse the progression of chronic diseases.
The OTS program's methodology is built from practice-based delivery across Group Exercise, Nutrition Education and Behavior Change.
Combining these three disciplines into an integrated program helps to drive real lifestyle change, which is critical to overcome unhealthy habits that have often been built up over decades.
The OTS program has been built with over 2 years of research and program development in partnership with:
Progressive Engagement to Reach Self Management
OffTheScale offers a comprehensive, progressive engagement 12 month program, combining an intense 3 month intervention with a 9 month maintenance period. The majority of participants will get to a self management state over this 12 month period. After this period, OTS offers an ongoing sustainability program for those that need additional support.
3 Month Intervention
For the first 3 months, OTS combines 1 hour, weekly in-person group meetings & weekly check-in call, with remote monitoring and engagement through the OTS mobile app and activity band.
9 Month Maintenance
After 3 months, the program continues with a less intensive curriculum of monthly meetings, lifestyle improvement surveys and data collection from a range of digital tools.
Once participants have graduated the 12 month program, they can sign-up to attend additional in-person group meetings as needed to support their goals. Graduates remain part of the OTS community for life and can access fellow graduates for support through their app and community platform.
It is well documented that changing lifestyles is often hard. We agree its hard, but not impossible. The key is working on the root causes of poor lifestyle, and not just dealing with the symptoms.
To maximize engagement and drive positive health outcomes, OffTheScale's platform seamlessly blends high intensity in-person group sessions, with digital tools for high frequency engagement. The multi-channel platform allows the program to be delivered to the group, but still tailored to the individual.
Our participants meet for 1 hour, once a week in a group environment. These group meetings are lead by our professionals who deliver our multi-disciplined program. The group environment helps drive engagement, teamwork and a sense of community.
Each participant joins a general OTS community at large, but also has access to a private social group just for their program. This allows each participant to share questions, ideas, motivation and access important program content and updates in a safe and secure manner.
Once a week there is a group call, where participants review progress, share questions and concerns, and are provided with updates and new content from the program.
At the core of the platform is a suite of mobile applications that support all aspects of the program. The OTS participants use their app to support the program remotely, in-between their group meetings.
The app's key features include:
tracking meal & nutrition consumption
access to lifestyle content, tips and alerts
visualization of activity, sedentary behavior and sleep
habit tracking and personalized dashboard to show progress
messaging with professional and community
The OTS Professional uses their mobile application to:
tracking group and individual progress
review meal pictures in real time, and provide personalized feedback
monitor participant activity goals and trends
respond to comments and questions related to program content
complete program and session admin
Engagement Dashboard & Reports
All of the information and data gathered by the platform is combined into a simple to use dashboards for each stakeholder. This dashboard is used by participant to track their own progress during the program. It is also used by our Professionals to steer the group focus, and to tailor content to individuals as needed to achieve their health goals.
The platform also provides customized reports to provide partner regular updates to its partners, physicians and other key stakeholders. These reports contain key data that tracks referrals, refinement, onboarding, engagement and self-management status.
To be able to deliver a community-based intervention program with any partner, OTS has developed a recruitment and training methodology to build a program delivery workforce. OTS Professionals are credentialed and trained at the highest level to be able to earn the trust of health systems, and fill the continuum of care angagement gap. Having the ability to receive and relate to referred patient, payer, and underserved populations is critical to healthy systems in their value-based transformation journey and for positively impacting the communities served.
OTS Change Agents are the workforce essential to the successful delivery of the OTS intervention programs. OTS has partnered with Exercise is Medicine (EIM) to provide credentialed professionals with the baseline knowledge for coordinating community-based chronic disease care of referrals, chronic disease exercise prescriptions, and lifestyle behavioral change strategies. These professionals are then further trained in the delivery of specific chronic diseases and disease cluster intervention programming. Education continues with updates for nutritional guidance, exercise options, and behavioral change methodologies. Annual compliance courses provide OTS Change Agents with HIPAA and other safety and security clearances.
As an essential community care component, designated OTS places are part of a community network that provides access to safe and convenient environments to participate in OTS intervention programs. Most importantly, OTS places must be viewed as a point-of-care for health system referrals that invite partcipation compliance and engagement to complete their chronic disease intervention care plan.
The OTS places have convenient parking, security, lighting, and easily accessible entrances and exits. The OTS spaces are always dressed the same week-to-week offering familiarity for the group to settle in and begin their new week of behavioral change and health improvement.
The designation of OTS place includes various types of locations that includes clinical facilities or shared-spaces like community centers, library multi-purpose rooms, church facilities, schools, corporate board rooms or other appropriate spaces.
Payment reform is reshaping chronic disease care at a breakneck pace. The healthcare services map for health system strategy and payer business development (employers, insurers, Medicaid and Medicare) has shifted to value based-care payment models for chronic disease care. What used to be management of chronic conditions by specialty - diabetes, obesity, hypertension, hyperlipidemia, etc - has now shifted from that "horizontal" specialty specific orientation to a vertical approach with population health management leading the entire care range of chronic conditions by stratified population groups.
CMS seeks to have 30 percent of Medicare fee-for-service payments in value-based purchasing categories 3 and 4 by 2016 and 90 percent by 2020.
OTS has mapped its payment triggers to critical components of delivering community care:
Set-up defined population
Stratification and refinement support
Enrollment and onboarding
Intervention engagement and completion
Transition to maintenance program
Maintenance program engagement and completion
As health systems share a higher percentage of chronic disease risk for defined payer populations, payment for chronic disease care is tied to the success of risk reduction interventions to slow, stop and reverse the progression of chronic diseases. OTS is aligned with the new value-based payment contracts that achieves health system goals to replace volume revenue with value revenue. OTS sees its role as reducing health system risk while at the same time increasing the health system presence and reach into the communities served.
Based on current and future value-based contracts with payers, OTS has a flexible payment model that is customized to match health system needs. OTS believes that health systems must minimize the barriers for their chronic disease population groups to participate in community-based intervention programs. This will improve health, minimize healthcare cost and maximize the patient-centered care experience.
The science is clear that increased activity and exercise is critical to creating a healthier lifestyle. OTS reviewed the wearable marketplace and picked Garmin(r) as its activity band partner. OTS uses a band that has a 12 month battery life so users do not have to charge it, and that is waterproof so it does not have to be taken off. These features help to maximum the amount of activity data that is captured over the life of the program.
In addition, the bands are branded OTS aqua to make them stand out. Our participants are changing their lives, and wearing the band is a positive symbol that represents the commitment they are making to themselves.