In 2012, a group of UNTHSC faculty were approached with a unique opportunity. Millions of dollars had suddenly become available through Medicaid to fund innovative health care delivery projects for low-income and uninsured patients. The catch? Funding was performance-based, awarded as successful progress was proven. The Health Science Center could lose money if the projects did not meet their goals.
Dr. Scott Walters, UNTHSC Professor and Chair of Health Behavior and Health Systems in the School of Public Health, was asked to design a project focused on behavioral health.
“This was really unlike a traditional grant where the funder thinks you have a good idea and gives you money to conduct the project,” he said. “Not only did UNTHSC front millions of dollars, but it also had to take the risk that the projects would go well. Nobody had ever seen anything like this before.”
|“I pay more attention to my health now. I stopped smoking and started exercising. Every morning, I would get a text reminder to take my medication and go for a walk, and that kept me motivated. I had been eating a lot of junk food at night, but the reminders made me think twice about reaching for cookies, so I would get a piece of fruit instead. Now I feel like I can continue on my own.” – Sidney Taylor
In partnership with Dr. Emily Spence-Almaguer, UNTHSC School of Public Health Associate Professor and Associate Dean for Community Engagement and Health Equity, Dr. Walters’ team designed m.chat, a technology-assisted health coaching program for people residing in permanent supportive housing (PSH) in Fort Worth.
About 75% of PSH residents have a chronic health condition; two thirds have active substance use, and more than half have active mental health symptoms. PSH residents tend to have substantially higher health care costs compared to the general population.
The m.chat program matched PSH residents with a health coach, who met with them monthly over 18 months to set goals around diet, exercise, substance use, medication compliance and other areas. The program’s special software and system for reminders helped clients stay motivated and track progress along the way.
The project enrolled 653 clients over four years. Most people chose to work on diet (62%) and exercise (60%). About 41% wanted to make changes in substance use, and 26% wanted to improve their level of social support.
The pace of the project and performance-based reimbursement pushed the team to constantly adapt to new challenges.
“In our first year, part of the funding was tied to enrolling 300 people fitting a certain profile. In a typical project, if you are meeting 80 or 90% of your goal, that’s a success. Under the Waiver mechanism, though, we were required to meet the full 100%,” Dr. Walters said.
|“Being able to stop smoking has been my biggest accomplishment. I had tried to quit before but was struggling. My coach didn’t judge me. I was able to be very honest with him, and it helped to have someone to talk to. I worked on meal planning and lost weight, and the text messages reminded me to go walking twice a day. In the fall I started working on my associate’s degree online. I know I can do it now. Even if it gets hard, I don’t want to quit.” – Sharon Simon
Despite many barriers to improving health, people who participated in m.chat showed substantial improvements: over 12 months, 23% increased their fruit and vegetable intake, 40% decreased sweet intake, and 49% decreased fat intake.
People who set a goal to improve physical activity had far less sitting time and far more activity over 12 months, nearly doubling their number of active minutes per week.
Depression scores went down by one-third, and more than one-third of substance abusers quit.
“The unique impact of m.chat was in the way it addressed a broad range of behaviors affecting people’s health,” Dr. Walters said. “We demonstrated that people can improve their overall health, sometimes in more than one area, despite very difficult circumstances.”
From a funding standpoint, the project was also a success, fully meeting its metrics each year. Projects like m.chat demonstrate UNTHSC’s ability to innovate quickly in response to a unique funding mechanism, resulting in win-win situations for the university and the community.
|“Through different activities, I collected enough ‘Chat Bucks’ to buy things I couldn’t afford, like a mattress, groceries, laundry detergent. It makes you feel better about yourself and gives you something positive to look forward to” – Pamela Wilson
In 2018, the m.chat team will merge and be funded through UNT Health, with broadened responsibilities for health coaching and patient advocacy.
The team will retain many of its original goals of helping people improve diet, exercise and substance abuse cessation, and will also coordinate with UNT Health providers to deliver the best comprehensive health care available.
In collaboration with UNTHSC’s INCEDO continuing education division, the team will also oversee training efforts around motivational interviewing and other evidence-based patient communication strategies to improve the overall experience of UNT Health patients.