1. ! YOUR AUDIENCE IS EVERYWHERE, SHOULDNT UBI? ! UNDER PRESSURE Hospitals today are under tremendous pressure to improve patient outcomes and, at the same time, reduce costs. One of the best ways to achieve this goal is to make patients and their families part of their own care team. In a systematic review of research on the links between patient experience and clinic safety and effectiveness, British researchers noted positive associations between the quality of clinician-patient communications and adherence to medical treatment in 125 of 127 studies analyzed [which] showed the odds of patient adherence was 1.62 times higher where physicians had communication training. They also observed evidence of impacts on resource use of primary and secondary care, such as hospitalizations, readmissions and primary care visits.1 To this end, electronic communications via email, social media and the hospitals website can effectively augment and reinforce in-person communication to improve patient education, compliance and outcomes. The ideal approach is to be in regular contact with the patient (and a family member or caretaker when appropriate) beginning as early in the process as possible. One-to-one channels of electronic communication are ideal for this purpose. Even the majority of the senior population (age 65+) is online and more than 90% of adults ages 1849 use the internet.2 Internet users already go online when they have health concerns: 72% have conducted a health-related search, according to the Pew Research Center.3 Email communication provides the most efficient means in terms of time, effort and costof sustained connection with patients to educate and encourage adherence to hospital recommendations. However, as noted by Betsy Weaver, Ed.D., CEO of e- communications solutions provider UbiCare, to stand out in the queue of emails in the patients inbox, messages must be concise, of high value, contain reliable content and be precisely timed to coincide with what is happening in the recipients healthcare life at the time of delivery. And the message must be worth taking action onnow!4 Hospitals are finally finding ways to routinely collect patients email addresses. For example, classes educating prospective patients about an elective surgical procedure represent an opportunity to obtain email addressesfrom the prospective patient as well as family members. These contacts should be entered in a database, labeled as class attendees, and uploaded into a software platform with customer relationship management (CRM) capabilities. This enables the hospital to stay in touch The result is patients who are more educated about the whys behind their care instructions and are therefore more compliant. This, of course, fosters better outcomes and increased patient satisfaction.

2. ! 2!YOUR AUDIENCE IS EVERYWHERE, SHOULDNT UBI? ! with this target population on a regular basis, sending out additional information and positioning the hospital as the expert health resource in the community. Once a prospective patient schedules a surgery, the hospital has an opportunity to begin sending regular email messages related to the surgery dateand the multiple benefits and cost savings of timeline-specific email messaging begin to accrue. Each message walks the patient through important steps from pre-op through the procedure itself and then the stages of post-op rehab. By including FAQs, information on selected diagnoses and the hospitals resources, as well as links to additional details, these email messages reinforce the in-person communications between healthcare providers and patients. The result is patients who are more educated about the whys behind their care instructions and are, therefore, more compliant. This fosters better outcomes and increased patient satisfaction, which (measured by HCAHPS) has been shown to be more highly associated than any clinical measure with reduced avoidable readmissions.5 And that is money in the bank. SELLING IT TO THE C SUITE This sounds like the right thing to do for patients, but how can the need for this be best explained to hospital executives in charge of a clinical departments budget? In order to determine the return on investment (ROI) of implementing targeted patient messaging, it is helpful to look at avoidable readmissions. Last year (2012) was the first year for Medicare hospital readmission penalties with a maximum penalty of 1% of Medicare payments to the hospital. In 2013 the maximum penalty goes up to 2% (and again in 2014 to 3%). Furthermore, additional measures including hip and knee replacement surgeryhave been announced for 2013. Here are a few thoughts about ROI that may prove helpful when discussing the financial benefits of implementing a new process at the hospital. ! Preventing Blood Clots Blood clots are normally not a problem after spine surgery, but when they do occur they can be serious. So we take special precautions to prevent them, which may include prescribing blood-thinning medication. In the hospital, you will be fitted with special elastic stockings while you are in the holding room prior to surgery. Before being put to sleep in the OR, you will be fitted with plastic boots that surround your lower legs with air and inflate and deflate to aid circulation. After surgery, we will teach you leg exercises that will keep your blood circulating, prevent blood clots and strengthen your back. Sample support section from UbiCare's Spine Surgery email!

3. ! 3!YOUR AUDIENCE IS EVERYWHERE, SHOULDNT UBI? ! ROI can be divided into hard dollars and soft dollars. Hard dollars are direct cost savings, while soft dollars are generally time savings (which free up staff to do other tasks) or improvements in patient and/or employee satisfaction leading to recommendations (bringing in new patients), reduced staff turnover (savings in hiring/training costs) and improved perception of the hospital as a great place to work (thus attracting the best applicants for positions). Whenever possible, try to assign some dollar value to the soft dollar ROI items to obtain a more accurate picture of the true value of adding a new process. This is often not done, making the up-front cost of a new process look too expensive. Implementing change is a challenge for everyone, so the ROI needs to be demonstrated to be worthwhile and have a positive effect on as many departments as possible. Here are examples of ROI for an email patient education and engagement product for hip and knee replacement patients at a hospital with an annual operating revenue of $200 million and an annual Emergency Department capacity of 20,000 patients): Annual license fee for an effective e-communication product = $19,000 Medicare reimbursement penalty avoided = $31,250 (1/4 of $125,000 CMS average penalty for 2012)6 Increased bed capacity = $500 (assuming operating at or near capacity, with $1,000 per admitted patient vs. $500 per discharged patient)7 Additional patients able to be admitted from ED = $40,0007 (4% of 20,000 patients leave ER without being seen = 800 patients x 10% admitted = 80 x $500 per patient) Hospital operating revenue at risk based upon transitions of care measures = $20,000 (0.1% of $200 million)7 d" Patient"Education"and"Engagement" Increased)patient)education)has)been)shown)to:) ! Reduce)healthcare)providers)costs)due)to)fewer) readmissions)(these)are)direct)savings)for)ACOs).) ! Avoid)or)reduce)Medicare)reimbursement)penalties) (due)to)reduced)readmissions).) ! Increase)hospital)bed)capacity)(beds)that)were)being) used)for)readmitted)patients)could)be)used)for)more) profitable)patients)and)for)timely)transfers)from)the) Emergency)Department).) ! Reduce)Emergency)Department)wait)times)(avoiding) patients)leaving)without)being)seen).) ! Improve)patientDsatisfaction)ratings.) ! Improve)patient)careDquality)measures)(due)to) improved)compliance).) ! Reduce)adverse)events)(due)to)improved)compliance).) ! Improve)hospital)ratings)(attract)new)patients)and)staff) applicant)pool).) ! Reduce)medical)malpractice)costs.) ! Increase)payDforDperformance)reimbursements.) ! Increase)staff)satisfaction)(and)reduce)turnover).) !

4. ! 4!YOUR AUDIENCE IS EVERYWHERE, SHOULDNT UBI? ! Cost per readmitted patient = $2,0006 up to $60,0008 (applicable for ACOs and bundled payments) In addition to the financial benefit to the hospital, consider the improvements in patient perception and willingness to recommend the facility. These perceptions are likely to be reflected in improved HCAHPS scores. Higher HCAHPS scores not only improve hospital ranking in various Best Hospital reports, but represent 30% of the performance scores for incentive payments (CMS Value Based Purchasing Program). STAFF-PATIENT CONNECTIONS: TWO-WAY IMPACT Standardized, automated patient education and communications resulting in knowledgeable, compliant patients reduces stress on staff. This, too, can impact patient satisfaction. As noted in Healthcare HR and the Bottom Line, a 2012 white paper from Healthcare Source, happy employees help make patients happy. Therefore, when institutions provide a satisfying and supportive workplace for employees, patients are more likely to have a positive in-hospital experience. In other words, happy employees result in happy patients and HCAHPS scores go up.9 DEMONSTRABLE VALUE Hip and knee joint replacement procedures are ideal occasions for implementation of a measureable education and communication initiative. Provision of a unique, hospital-branded, compelling and time- relevant education tool to patients having an elective procedure can be used to demonstrate the value of this approach. Patient satisfaction scores should rise, outcomes should improve and, ultimately, the volume of patients choosing the hospital should increase. For example, New England Baptist Hospital (NEBH) learned from an ongoing survey of post-op hip and knee replacement patients (1,381 respondents) that 86% found the hospitals email education so valuable that it would be a factor in recommending NEBH to friends and family.10 Need more convincing? Consider these quotes from joint-replacement patients who have received email education in addition to attending pre-surgical classes: Being a nurse anesthetist, I have seen many knee replacements; therefore, I felt I had a good understanding of what to expect from the surgery standpoint. The emails kept me informed of post-op progress and I found them to be very helpful. I found the pre-op classes were good. ... I found several of the PT's tips on how to get around during early recovery very beneficial, especially since I had bilateral TKR. I am fortunate to have a medical background, but I still found that I didn't know everything and was glad to receive a lot of good information. I have recommended St. Vincent [Health System] to several friends who have had the same surgery.

5. ! 5!YOUR AUDIENCE IS EVERYWHERE, SHOULDNT UBI? ! The emails came just as I had questions about the next step. The emails were very useful to me and I have recommended New England Baptist Hospital to others. 11 Suzanne Nylander, O.D., B.S. is the director of business development and sales for UbiCare. Suzanne has worked with numerous health plans providing healthcare survey research focused on quality improvement. She has a Six Sigma Green Belt certificate in Healthcare and a Lean Six Sigma certificate. Her prior experience includes professional relations/education for medical device manufacturers, technical articles in ophthalmic publications and clinical practice. Betsy Weaver, Ed.D., is the CEO, President and Co-Founder of TPR Media (d.b.a. UbiCare) and is a nationally recognized innovator in patient education and healthcare communication. With the formation of TPR in 2002, Weaver created the first email services designed to enhance hospitals care connections with patients and streamline processes for staff. Building on this success, in 2010 Weaver created the first hub platform for healthcare, incorporating email, social media, text messaging and web services. UbiCare is an award-winning e-communications solutions company whose proprietary software creates connections that impact behaviors to change outcomes. UbiCares evidence-based customizable, timely and targeted products feature automated, mobile-optimized email newsletters, campaigns, surveys, microsites, text messaging and social media. Management tools and real-time reports make it easy to track ROI and make iterative changes as needs evolve. UbiCares unique technology enables its healthcare, education and nonprofit clients to build and sustain strong relationships with target populations. Achieving 57% open and 84% interaction rates, UbiCares solutions educate and engage while building brand loyalty. Contact UbiCare at info@ubicare.com or 617-524-8861 to learn how we can help you! Foot Notes: 1.) Doyle et al., A systematic review of evidence on the links between patient experience and clinical safety and effectiveness, BMJ Open 2013, e001570, p.4, http://bmjopen.bmj.com/content/3/1/e001570.full 2.) Pew Internet & American Life Project Surveys, Demographics of Internet Users, Post Election Survey, Nov. 14 Dec. 9 2012, http://www.pewinternet.org/Static-Pages/Trend-Data-%28Adults%29/Whos-Online.aspx 3.) Fox, S. and Duggan, M. Health Online 2013, Pew Internet & American Life, http://www.pewinternet.org/Reports/2013/Health- online/Summary-of-Findings.aspx 4.) Weaver, B., Care Connections, 2012: What Will Todays Trends Mean Tomorrow? UbiCare white paper, 2012, https://social.ubicare.com/whitepapers 5.) Press Ganey Performance Insights white paper, The Relationship Between HCAHPS Performance and Readmission Rates, 2012, http://healthblawg.typepad.com/files/performanceinsights_readmissions-12-12-2012.pdf 6.) Laderman, M. et al, The Effects of Medicare Readmission Penalties on Hospitals Efforts to Reduce Readmissions: Perspectives From the Field, The Commonwealth Fund Blog, Feb. 26, 2013, http://www.commonwealthfund.org/Blog/2013/Feb/The-Effect-of-Medicare- Readmissions-Penalties-on-Hospitals.aspx 7.) Project Boost: A Return on Investment Analysis, Society of Hospital Medicine, 2010, http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/PDFs/BOOST_ROI_Paper.final.pdf 8.) Donovan, P., Payment Bundling Requires Suspension of FFS State of Mind, Healthcare Intelligence Network, March 25, 2013, http://hin.com/blog/2013/03/25/payment-bundling-requires-migration-from-ffs-state-of-mind/ 9.) Healthcare HR and the Bottom Line: 5 Focus Areas for Improving HCAHPS Scores, Healthcare Source white paper, 2012, p. 5, http://bit.ly/17iXhav 10.) How Email Communication Impacts Patient Satisfaction, results of survey of 1,381 New England Baptist Hospital patients receiving UbiCares Joint Replacement Support Emails, June 2011 April 2013. 11.) Satisfaction surveys to recipients of UbiCares Joint Replacement Support Emails, June 2011 and June 2012. Contact Us | Meet the UbiCrew | Case Studies | Learn More