CMMI Project: San Diego A Heart Attack and Stroke Free Zone Parag - - PowerPoint PPT Presentation

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

2

Reduce heart attacks and strokes by 50%

Achieve 80% medication adherence Achieve 80% blood pressure control Save $5.8 M in avoided healthcare costs

Goal

Project Components: to reduce heart attack and stroke

Patient Identification

Provider Education Health Coaching Medication Bundle Wireless Monitoring

3

Hea ealthcare Tea eams

4

CMMI Be There San Diego HASFZ Study Sites 2016

5

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)

CMMI HASFZ Program Enrollment Criteria

As of May 28, 2015

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.

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

6

Patient Demographics

130 1674 1016 191 170 19 8 8

Unknown White Hispanic or Latino Black or African American Asian Native Hawaiian or Other Pacific… American Indian/Native Alaskan Two or More Race / Ethnicity…

Enrolled Patient Race/Ethnicity

7

1460 1766

Male Female

Enrolled Patient Gender

Medicare Advantage 38% Medicare Fee for Service 29% Medicaid 26% Dual Eligible 5% Unknown 2%

Enrolled Participant Payer Category

Enrollment Eligibility

8

Elig ligib ibili lity Crit riteria ia Percen entage ge of

• f 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

• f car

ardiovascular diseas ase 9% Age > > 18 and and Risk Scor

• re of
• f ≥ 7.5%

(AS ASCVD, A ACC, o

• r AH

AHA) A) 16% Patients may fit more than one eligibility criterion

Medication Bundle

9

Any History

• f CVD

*if African American consider Amlodipine/Thiazide Diabetic and > 50 yrs old CVD Risk of 7.5% or Greater/yr by NHLBI or Framingham Aspirin 81 milligram Lipid Lowering

20mg Atorva/40mg Simva

Lisinopril 10 mg or any ACE Thiazide - ACE* 12.5mg/10mg A L A L L T A L L A L L Aspirin 81 milligram Lipid Lowering

20mg Atorva/40mg Simva

Aspirin 81 milligram Lipid Lowering

20mg Atorva/40mg Simva

Lisinopril 10 mg or any ACE Aspirin 81 milligram Lipid Lowering

20mg Atorva/40mg Simva

Hypertensive and > 50 yrs old

Wireless Technology Applications

10

Wireless Home Blood Pressure Monitoring Smart Wireless Pill Bottle

On-line Resources

11

Link to Education Video Benefits of Medications in Bundle Betheresandiego.org

Health Coaching

12

Health Coach Protocol

Warm Handoff from provider Initial Encounter Weekly Encounters for Medication Adherence Monthly Check-Ins Questions for goal setting Community Resources Medication Intensification (provider)

Patient and Provider Tools

13

Health Coach Training

14 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]

PDC- Medication Adherence

67% 85% 74% 90% 65% 93% 59% 76% 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)

Percentage of Patients Quarter

15

Measuring Impact – Did we…?

• Reduc

uce cardiov

• vas

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

19

TEAM BASED CARE COMMUNITY PARTNERSHIP