Right Care Capitol Region University of Best Practices

1. Right Care Initiative 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

2. Physician organizations/Clinic organization • Hospitals/health systems • Health plans/payers • Patient/Consumer organizations • Technical assistance organizations • Government agencies • Universities/research • Pharmaceutical organization • Other We are talking collaboration. Which sectors are represented in the room?

3. 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 Agenda

4. 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. 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.). Intensive effort on improving regional blood pressure control through home blood pressure monitoring. Right Care Sacramento University of Best PracticesCollaborative Improvement Priorities

7. Stroke Education Interventions

8. Home Blood Pressure Monitoring

9. “ . . .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. “ Telehomecare and RemoteMonitoring: An Outcomes Overviewhttp://www.viterion.com/web_docs/Telehomecarereport%20Diabetes%20and%20CHR%20Meta%20Analyses.pdf

10. Care Coordination Challenge Hospitals and Clinics Inpatient Outpatient Individual and Caregivers Home Care Multiple specialists Many Touch Points Multiple Transitions Silos of Information Unclear Accountability Community Services Hospice Respite Care

11. A Potential Solution: Technology-Enabled Community Wide Care Coordination • RN-led care coordination with community health workers/health coaches • Personalized social networkbuilt around a patient • Collaborationwith clinicians, care team members, caregivers, and others designated by the individual • Person-centered health and healthcare activities across a relevant community.

12. Guiding Principles • Care experiences and caring relationships enabled through technology • Measured outcomes • Evidence and cost transparency for shared decision making • Engage participants, caregivers and families as equal partners • Evidence-based care protocols to coordinate care among diverse care team members and settings Technology-Enabled Community Wide Care Coordination

13. Scalable • Adaptable to different chronic conditions • Cloud-based • HIPAA Compliant • Social-network styled software • “Carepod” of PHN members designated by the patient Personal Health Network (PHN): Key Features (Tiatros, Inc) 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.

14. Patient generated data (e.g., BP), assessments and patient-reported outcomes • RN Assessments; Evidence-based protocols • Shared Care Plan • Appointment Reminders • Medication Management • Referrals • Patient Education • Secure Messaging; Video Chat Personal Health Network (PHN): Key Features

15. Primary care providers: Integrate technology enabled team-based approaches for patient education, care coordination and self-management 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! Multisector Collaboration Could Be Key to Effective Implementation of Improvement Strategies

16. Yes, and I can have ideas about how we can contribute • Yes, but I need to let think about how we can best contribute • Maybe, I need more details! • No My organization would be interested in contributing to a regional multisector campaign to improve CVD outcomes:

17. 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 Which comes closest to your preferred focus of the regional multisector initiative to improve CVD outcomes?

18. 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. Partnered Research to Reduce Heart Attacks and Strokes in the Short vs. Long Term

19. Right Care Initiative Research Team Contacts Hector Rodriguez (Berkeley): hrod@berkeley.edu Janice Bell (Davis): janice.bell@ucdmc.ucdavis.edu Please Connect with Us

20. 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 Cardio-metabolic conditions (PI: Kim); Technology Enabled Care Coordination in Community Clinics for Cardio-metabolic Conditions (UC-wide) Related Projects at UCD School of Nursing