CMMI Project: San Diego A Heart Attack and Stroke Free Zone. Parag Agnihotri, MD Chair of the Healthcare Committee

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1 CMMI Project: San Diego A Heart Attack and Stroke Free Zone Parag Agnihotri, MD Chair of the Healthcare Committee

2 San Diego: A Heart Attack and Stroke Free Zone Goal Reduce heart attacks and strokes by 50% Achieve 80% medication adherence Achieve 80% blood pressure control Save $5.8 M in avoided healthcare costs 2

3 Project Components: to reduce heart attack and stroke Provider Education Wireless Monitoring Patient Identification Health Coaching Medication Bundle 3

4 Healthcare Teams 4

5 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

6 CMMI HASFZ Program Enrollment Criteria As 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 > Year ASCVD calculated Risk score > 7.5% for accurate ASCVD risk calculation the valid age range is 20 to 79 years. 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 years controlled hypertension and unable to calculate ASCVD risk score. 6

7 Patient Demographics Enrolled Patient Race/Ethnicity Two or More Race / Ethnicity 8 American Indian/Native Alaskan 8 Native Hawaiian or Other Pacific 19 Enrolled Participant Payer Category Dual Eligible 5% Unknown 2% Asian 170 Black or African American Hispanic or Latino Medicaid 26% Medicare Advantage 38% White 1674 Unknown 130 Enrolled Patient Gender Medicare Fee for Service 29% Female 1766 Male

8 Enrollment Eligibility Eligibility Criteria Percentage of Patients Age 50 and diabetes and/or BP 140/90 and/or LDL % Age >18 and history of cardiovascular disease 9% Age > 18 and Risk Score of 7.5% (ASCVD, ACC, or AHA) 16% Patients may fit more than one eligibility criterion 8

9 Medication Bundle Hypertensive and > 50 yrs old Aspirin 81 milligram Lipid Lowering 20mg Atorva/40mg Simva *if African American consider Amlodipine/Thiazide Thiazide - ACE* 12.5mg/10mg T A L L Any History of CVD Aspirin 81 milligram Lipid Lowering 20mg Atorva/40mg Simva Lisinopril 10 mg or any ACE A L L Diabetic and > 50 yrs old Aspirin 81 milligram Lipid Lowering 20mg Atorva/40mg Simva Lisinopril 10 mg or any ACE A L L CVD Risk of 7.5% or Greater/yr by NHLBI or Framingham Aspirin 81 milligram Lipid Lowering 20mg Atorva/40mg Simva A L 9

10 Wireless Technology Applications Wireless Home Blood Pressure Monitoring Smart Wireless Pill Bottle 10

11 On-line Resources Betheresandiego.org Link to Education Video Benefits of Medications in Bundle 11

12 Health Coaching 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) 12

13 Patient and Provider Tools 13

14 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

15 PDC- Medication Adherence 93% 90% 85% Percentage of Patients 74% 67% 65% 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) Quarter 15

16 Measuring Impact Did we? Reduce cardiovascular 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 savings 16

17 Health Coaches in Action 17

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19 TEAM BASED CARE COMMUNITY PARTNERSHIP 19