CMMI Project: San Diego – A Heart Attack and Stroke Free Zone Parag Agnihotri, MD Chair of the Healthcare Committee
San Diego: A Heart Attack and Stroke Free Zone Goal Reduce heart attacks and strokes by 50% Achieve 80% Achieve 80% medication blood pressure adherence control Save $5.8 M in avoided healthcare costs 2
Project Components: to reduce heart attack and stroke Provider Education Patient Wireless Health Monitoring Coaching Identification Medication Bundle 3
Hea ealthcare Tea eams 4
CMMI Be There San Diego HASFZ Study Sites 2016 Healthcare Teams: Arch Health Partners (4 sites) Neighborhood Healthcare (4 sites) North Coast Family Medical Group (1 site) North County Health Services (1 site) San Ysidro Health Center (3 sites) Scripps Clinic (2 sites) Sharp Rees-Stealy (15 sites) UC San Diego Family Medicine (3 sites) UC San Diego Internal Medicine (1 site) Vista Community Clinic (5 sites) 5
CMMI HASFZ Program Enrollment Criteria A s of May 28, 2015 Enroll patients age 50 to 85 years with any of the following criteria: • Average of two recent recorded BP > 140/90 • Recent BP recorded >160/100 • LDL cholesterol level > 100 • 10 Year ASCVD calculated Risk score > 7.5% for accurate ASCVD risk calculation the valid age range is 20 to 79 years. http://tools.cardiosource.org/ASCVD-Risk-Estimator/ • CAD or PAD not on Statin (no statin allergies) • CAD or PAD candidate for Aspirin and not on any antiplatelet agents • Diabetes and not on ALL Do not enroll (Not activated yet) No Hypertension Controlled Hypertension Controlled Hypertension and Incomplete medication bundle 10 year ASCVD Risk score less than 7.5% Patient 80-85 years controlled hypertension and unable to calculate ASCVD risk score. 6
Patient Demographics Enrolled Patient Race/Ethnicity Enrolled Participant Payer Category Two or More Race / Ethnicity… 8 Unknown Dual Eligible 2% American Indian/Native Alaskan 8 5% Native Hawaiian or Other Pacific… 19 Asian 170 Black or African American 191 Medicare Medicaid Advantage Hispanic or Latino 1016 26% 38% White 1674 Unknown 130 Medicare Fee for Service Enrolled Patient Gender 29% Female 1766 Male 1460 7
Enrollment Eligibility Elig ligib ibili lity Crit riteria ia Percen entage ge of of Pat atient nts Age ≥ 50 and and d diab abetes and and/or B BP ≥ 140/9 /90 and/ d/or LDL ≥ 100 75% Age > >18 and and hi history of of car ardiovascular diseas ase 9% Age > > 18 and and Risk Scor ore of of ≥ 7.5% (AS ASCVD, A ACC, o or AH AHA) A) 16% Patients may fit more than one eligibility criterion 8
Medication Bundle T Hypertensive Aspirin Lipid Lowering Thiazide - ACE* A 20mg Atorva/40mg Simva and > 50 yrs old 81 milligram 12.5mg/10mg L L *if African American consider Amlodipine/Thiazide Any History A of CVD L Aspirin Lipid Lowering Lisinopril 10 mg or 20mg Atorva/40mg Simva L 81 milligram any ACE Diabetic A and > 50 yrs old Aspirin L Lipid Lowering Lisinopril 10 mg or 81 milligram L 20mg Atorva/40mg Simva any ACE CVD Risk of 7.5% or A Aspirin Lipid Lowering Greater/yr by NHLBI or L 20mg Atorva/40mg Simva 81 milligram Framingham 9
Wireless Technology Applications Smart Wireless Pill Bottle Wireless Home Blood Pressure Monitoring 10
On-line Resources Betheresandiego.org Link to Education Video Benefits of Medications in Bundle 11
Health Coaching Health Coach Protocol Weekly Warm Initial Encounters Handoff Monthly Encounter for from Check-Ins Medication provider Adherence Questions Medication Community for goal Intensification Resources setting (provider) 12
Patient and Provider Tools 13
Health Coach Training ASK – EDUCATE - ASK ASK about the barriers • In order to start doing it/taking it regularly tomorrow, what problems, questions or concerns do you need to deal with now? EDUCATE around the point, then ASK about their next steps: But I’m curious, • What would work for you? • What will you do to make that happen? • What else? • What will you do NOW? [Teach back] 14
PDC- Medication Adherence 93% 90% 85% 76% Percentage of Patients 74% 67% 65% 59% Mar-May 2015 (Q3) June-Aug 2015 (Q4) Sept-Nov 2015 (Q5) Dec 2015-Feb 2016 (Q6) Mar-May 2016 (Q7) June-August 2016 (Q8) Quarter 15
Measuring Impact – Did we…? Reduc uce cardiov ovas ascul ular risk Reduce heart attacks and strokes Initiate medication bundle Improve medication adherence Increase home blood pressure monitoring and control Increase self-management and healthy lifestyle behavior Activate and engage patients, providers and communities Reduce costs Generate cost savi vings 16
Health Coaches in Action 17
TEAM BASED CARE COMMUNITY PARTNERSHIP 19
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