Right Care Capitol Region University of Best Practices
Partnered Research with the
University of California Right Care
Initiative Research Team
Hector Rodriguez, PhD, MPH
Associate Professor of Health Policy and Management, UC Berkeley School of Public
Health
Janice F. Bell, PhD, MPH, MN
Associate Professor, Betty Irene Moore School of Nursing, UC Davis
August 12th, 2014
We are talking collaboration.
Which sectors are represented in the
room?
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Physician organizations/Clinic
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Hospitals/health systems
Health plans/payers
Patient/Consumer organizations
Technical assistance
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Government agencies
Universities/research
Pharmaceutical organization
Other
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1.
Agenda
1. Review UBP Capitol Region Collaborative Priorities
2. Describe two multisector pilot project ideas:

Regional stroke signs /symptoms recognition and early
response improvement campaign

Improve hypertension control using patient-centered
technology and team-based approaches in clinical vs.
non-clinical settings.
3. Weigh in on collaborative multisector approaches to
reduce heart attacks and strokes in the Capitol Region
Right Care Sacramento University of Best Practices
Collaborative Improvement Priorities
1. Education of highest risk patients and their families (for
instance for those who have experienced TIA) about
stroke signs and symptom recognition, the 3‐4.5 hour
time window of TPA, and the importance of calling
911/arriving at hospital via ambulance.
2. Intensification of provider efforts at CVD risk factor
mitigation for highest risk patients (proactive outreach
by clinical staff to high risk patients; adherence to
protocols; medication management by pharmacists, etc.).
3. Intensive effort on improving regional blood pressure
control through home blood pressure monitoring.
Mortality from Heart Disease and Stroke, by County (20072011)
(Age-Adjusted Deaths or Discharges per 100,000 Population)
Heart Disease Mortality
Stroke Mortality
250
200
150
100
50
0
CAStatewide
Yolo
Placer
El Dorado Sacramento
Sutter
Yuba
San Joaquin
Stroke Education Interventions
Key Findings
Title
Systematic review of mass media
interventions designed to improve
public recognition of stroke
symptoms, emergency response and
early treatment
(Lecouturier et al., BMC Public Health
2010, 10: 784)
Stroke education in clinical settings
(Chan et al., Journal of Stroke and
Cerebrovascular Diseases 2010, 19(3):,
209-215)
•
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Campaigns aimed at the public may raise
awareness of signs/symptoms but have
limited impact on behavior
Little to no change in intent to call EMS if
experiencing/witnessing stroke
Television but not newspaper improved
awareness of stroke signs
Participants receiving stroke education
(video, counseling, & printed materials)
consistently demonstrated better
knowledge than control group
Retention gradually declined over followup (after 1 & 3 months), but remained high
97% of intervention group shared info
with others
Intervention did not result in lifestyle
behavior changes
Home Blood Pressure Monitoring
Key Findings
Title
Home Blood Pressure Monitoring:
New Evidence for an Expanded Role.
PLoS Med 11(1): e1001592.
•
Electronic blood pressure measurement
(home or ambulatory monitoring)
improves the precision of HTN diagnosis
and is superior to clinic blood pressure
monitoring at predicting prognosis among
patients with hypertension.
•
Useful for risk stratification
(Caulfield, 2014)
Stratification by Self-Measured Home
Blood Pressure across Categories of
Conventional Blood Pressure: A
Participant-Level Meta-Analysis PLoS
Med 11(1): e1001591.
(Asayama etal. PLoS Med; 11(1) 2014)
Telehomecare and RemoteMonitoring:
An Outcomes Overview
http://www.viterion.com/web_docs/Telehomecarereport%20Diabetes%20and%20CHR%20Meta%20Analyses.pdf
“ . . .the results of studies to date are promising . . and
point to technology, infrastructure, access and
reimbursement issues that must be addressed for
maximal care quality improvement and cost savings.
These are multi-faceted issues that will require careful
and coordinated evaluation by payors, . . . government,
. . . care providers, . . . and employers, as well as an
assessment of technology needs. “
Hospitals and Clinics
Inpatient
Outpatient
Community Services
Hospice
Respite Care
Care Coordination
Challenge
Individual and
Caregivers
Many Touch Points
Multiple Transitions
Silos of Information
Unclear Accountability
Home Care
Multiple specialists
A Potential Solution: Technology-Enabled
Community Wide Care Coordination
•
•
•
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RN-led care coordination with community
health workers/health coaches
Personalized social network built around a
patient
Collaboration with clinicians, care team
members, caregivers, and others designated
by the individual
Person-centered health and healthcare
activities across a relevant community.
Technology-Enabled Community
Wide Care Coordination
Guiding Principles
• Engage participants,
caregivers and
families as equal
partners
• Evidence-based care
protocols to
coordinate care among
diverse care team
members and settings
•
Care experiences and
caring relationships
enabled through
technology
•
Measured outcomes
•
Evidence and cost
transparency for shared
decision making
Personal Health Network (PHN):
Key Features (Tiatros, Inc)
 Scalable
 Adaptable to
different chronic
conditions
 Cloud-based
 HIPAA Compliant
 Social-network
styled software
 “Carepod” of PHN
members
designated by the
patient
Kim, K.K., Bell, J., Reed, S., Joseph, J.G., Bold, R.,Cerrone, K., Altobello, D., Homchowdhury, J. A “Novel Personal Health
Network for Patient-Centered Chemotherapy Care Coordination,” in Proceedings International Conference on Collaboration
Technologies and Systems, Minneapolis, MN, 2014, pp.449-456.
Personal Health Network (PHN):
Key Features
 Patient generated data (e.g., BP), assessments and patientreported outcomes
 RN Assessments; Evidence-based protocols
 Shared Care Plan
 Appointment Reminders
 Medication Management
 Referrals
 Patient Education
 Secure Messaging; Video Chat
Multisector Collaboration Could Be Key to Effective
Implementation of Improvement Strategies

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Primary care providers: Integrate technology enabled team-based
approaches for patient education, care coordination and selfmanagement support
Hospitals/Health systems: Coordinate with outpatient providers to
provide information and training to high risk patients recently
discharged from the hospital
Health plans/payers: To support the real time monitoring of high risk
patients through care coordination reimbursement and support FAST
community awareness campaigns.
Technical Assistance Organizations: Align work with the regional
initiative as a primary objective, eg. Lead pilot improvement projects as
part of the regional initiative.
Governmental Agencies: Facilitate cooperation among local, state, and
federal agencies to support the community-wide campaign. Provide
instrumental support to the initiative through existing programs.
Universities: Monitor and evaluate the impact of the regional initiative
on public awareness, self-management of high risk patients, and timely
response.
Industry Partners: Instrumental and technical support and many ideas!
My organization would be interested in
contributing to a regional multisector
campaign to improve CVD outcomes:
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Yes, but I need to let
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Maybe, I need more
details!
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Which comes closest to your preferred
focus of the regional multisector
initiative to improve CVD outcomes?
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B.
Improving stroke
education and response for
high risk patients and
families
Improving CVD risks
(hypertension etc.) through
patient centered
technology and care teams
Both
I have a different idea and
I want to share it
No opinion/Other
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A.
Partnered Research to Reduce Heart Attacks
and Strokes in the Short vs. Long Term
•
•
•
We can start small
To ensure that the project will kick off, the UC
Right Care Initiative Research team can
support pilot data collection and analysis for a
multisector collaborative regional project
To examine the impact of interventions,
external funding would be required (eg.
Foundations, private organizations, federal
funding, etc.) and pilot data collection would
be instrumental to apply for funding.
Please Connect with Us
Right Care Initiative Research Team Contacts
Hector Rodriguez (Berkeley): hrod@berkeley.edu
Janice Bell (Davis): janice.bell@ucdmc.ucdavis.edu
Related Projects at UCD School of Nursing
Cancer Care Coordination for Patients Initiating
Chemotherapy (PI: Joseph)
Palliative Care Coordination (PI: Bell)
RN Usability and Fidelity Testing (PI: Bell)
Health Coaching at Golden Valley Health Center (PI: Kim)
Proposed: Front Door2, Care Management for Cardiometabolic conditions (PI: Kim); Technology Enabled Care
Coordination in Community Clinics for Cardio-metabolic
Conditions (UC-wide)