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Rethinking Chronic Care

Omada Health’s Virtual-First Care is rewriting the playbook for chronic care management.

Wei Li Shao of Omada Health

Some 133 million Americans live with diabetes, hypertension, or other chronic conditions, and the traditional health care model does not always serve them well.

“For such a long time, people believed that the battle against chronic conditions was fought in the doctor’s office,” says Wei-Li Shao, president of Omada Health. “We believe the battle, unfortunately, is most often lost in the vast amount of white space between doctors’ visits. People are left to their own devices, making decisions — some good, many bad — that affect their near-term and long-term health.”

Omada Health provides “virtual-first” care, integrating the expertise of dietitians, behavioral therapists, physical therapists, coaches, and others via digital tools that allow constant communication between members and their designated care team.Care plans are rooted in the science of behavior change, empowering people to embrace evidence-based habits that will help them meet their health goals.

A New Concert of Solutions to Combat Co Morbidities

Omada Health’s four programs — pre diabetes, diabetes, hypertension, and musculoskeletal care — can be deployed in concert, reflecting the prevalence of comorbidities.

“The unfortunate reality is that most Americans who suffer from one chronic condition suffer from another condition as well,” Shao says.

The Centers for Disease Control and Prevention estimates that 74% of adults with Type 2 diabetes have hypertension; 90% are overweight or obese.

“And if you’re overweight or obese, you’re likely to have back pain or joint pain,” Shao says.

Omada Health serves more than 1,700 clients, including 18 national and regional health plans, and dozens of employer entities across industries including Costco, Bacardi, Novo Nordisk, and the State of Alaska. All told, about 18 million U.S. adults have access to Omada Health through their insurers or employers; more than 640,000 have enrolled in an Omada Health program.

That includes a group of AmericanEagle Outfitters (AEO) employees. AEO chose Omada Health’s diabetes prevention program in 2019 because the company wanted to offer a personalized program that was easy to implement and promoted strong engagement and sustainable results, according to an Omada Health case study.

Omada provided each participant with a digital scale to track progress, matched them with a professional health coach and peer group for around-the-clock support, and offered interactive lessons via smartphone or laptop.

“Omada’s marketing includes some of the most engaging collateral that I have seen,” Anthony Jarusinski, AEO’s former benefits manager, said in the case study. “Our associates responded well to their various communication materials and were eager to enroll in the program.”

Indeed, 83% of targeted staff members enrolled. On average, participants in the program engaged with Omada 28 times every week and completed 76% of their lessons. A full 70% of employees who stuck with the program for at least 16 weeks lost weight, and 33% of participants lost 5% or more of their body weight.

Belief in a Better Way

When Omada was created 11 years ago by Sean Duffy and Adrian James, the San Francisco-based company was founded on the premise that the traditional U.S. health care system fails people who are overweight or obese.

“There was a belief in a better way,” Shao says. “And that belief was that things can be done, as Sean likes to say, ‘from afar.’ Things that don’t require a face-to-face visit but are proven to be effective without having a physician or other health care professional lay hands on a patient.”

Its original program focused on diabetes prevention. In 2018, Omada became the largest provider, in-person or virtual, to achieve full recognition from the Centers for Disease Control and Prevention for its diabetes prevention program. The recognition reflects the CDC’s approval of Omada’s curriculum, the level of participant engagement, the average participant weight loss, and other factors.

As the company has added programs and members, it is constantly learning about what works best to help members achieve their health goals.

“With every person who comes in, we utilize that data to hone our insights and our interventions more precisely for our new and existing Omada customers,” Shao says.

Omada has amassed more than a billion actionable health data points and adds another 25,000 datapoints every half-hour. They come from members who, on average, generate 31 data points each week from activity tracking, meal tracking, weigh-ins, log-ins, and group messages.

“We take all that, and we surface a set of care insights that drive customized interventions,” Shao says. “We know that when members experience those customized interventions delivered by a human care team, they are 2.5 times more likely to achieve positive outcomes.”

Addressing the Mental Side of Health

One insight pulled from Omada’s vast reservoir of data: 47% of its members show elevated behavioral health symptoms of anxiety and/or depression. That insight comes from validated mental health screening tools used as part of the intake protocol for all four Omada programs.

Shortly after closing on a new $192 million funding round in early 2022, the company announced plans to integrate mental and physical care in all its programs more thoroughly. Addressing depression and anxiety for people with medical conditions can improve treatment compliance, enhance overall health outcomes, and lower costs.

In addition to assessing mental health systems, Omada staff screen members for food insecurity, access to health care, and other social determinants of health; address specific behavioral challenges by providing sleep and stress-management lessons; and triage high-risk situations that require immediate intervention.

Every Omada member is assigned a care team that includes a health coach and the appropriate clinical specialists, such as certified diabetes educators and hypertension specialists.

“We can also pull in licensed clinical social workers who have special training in behavioral health,” Shao says. “And all individuals in our care teams are trained in behavioral health to the various degrees that match their licensure, so they can work not only on things such as dropping weight or dropping blood pressure, but also those signs and symptoms that impact the mental part of behavior change.”

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