Presbyterian Health utilized an existing population health model, along with systemwide data and infrastructure, to conduct proactive COVID-19 risk assessment and outreach, reduce disparities, and use remote monitoring for preventive care.
Presbyterian Health needed to identify and engage populations at risk for COVID-19 in order to reduce health disparities and adverse outcomes among diverse populations, help adapt virtual solutions for preventive care and disease management, and keep patients safe and out of the hospital.
Preventative care (eg, telehealth)
Individualized outreach (eg, medication delivery)
Chronic disease management (eg, healthy meal deliveries)
ED=emergency department; SDOH=social determinants of health.
Robran-Marquez D. Addressing patient and member needs during the pandemic: a robust population health framework is key. Becker’s Hospital Review Website. https://www.beckershospitalreview.com/care-coordination/addressing-patient-and-member-needs-during-the-pandemic-a-robustpopulation-health-framework-is-key.html.Published August 5, 2020. Accessed August 21, 2020.
Centura Health, a large accountable care organization, standardized workflows and streamlined communication channels to achieve significant clinical improvements in their highest-risk patients.
Centura Health wanted to improve quality metrics and the overall total cost of care of their chronic disease populations.
COPD=chronic obstructive pulmonary disease.
Milligan S. Reducing hospital admissions through the use of IT. Talk presented at: HiMSS16 Conference & Exhibition; February 29 - March 4, 2016. Las Vegas, NV. https://www.himssconference.org/sites/himssconference/files/pdf/QU3.pdf. Accessed April 21, 2020.
UC Davis Health includes a nationally renowned academic medical center and offers primary and specialty care outpatient services with offices located throughout the Sacramento region and on the UC Davis Sacramento campus.1-5
UC Davis Health recognized that COPD would be best managed with a multidisciplinary care team and wanted to develop a coordinated care approach that addresses COPD management across the inpatient and outpatient settings.6
Enrolled patients upon hospital admission6
Developed a preferred treatment plan based on the GOLD grade algorithm for each patient8
Provided one-on-one patient education in the inpatient setting and continued to support patients through postdischarge6,8
COPD=chronic obstructive pulmonary disease; EHR=electronic health record; GOLD=Global Initiative for Chronic Obstructive Pulmonary Disease; ROAD=Reversible Obstructive Airway Disease.
1. About us. UC Davis Health Website. https://health.ucdavis.edu/aboutus/index.html. Accessed March 11, 2021. 2. About UC Davis medical center. UC Davis Health Website. https://health.ucdavis.edu/medicalcenter/aboutus/about.html. Accessed March 11, 2021. 3. UC Davis Health primary care … in your neighborhood! UC Davis Health Website. https://health.ucdavis.edu/medicalcenter/cliniclocations/. Accessed March 11, 2021. 4. Comprehensive surgical services. UC Davis Health Website. https://health.ucdavis.edu/surgicalservices/. Accessed April 14, 2021. 5. UC Davis medical center again ranked one of California's top hospitals. UC Davis Health Website. https://health.ucdavis.edu/health-news/newsroom/uc-davis-medical-center-again-ranked-one-of-californias-top-hospitals/2018/08. Accessed March 11, 2021. 6. ROAD center program. UC Davis Health Website. https://health.ucdavis.edu/internalmedicine/pulmonary/road-center.html. Accessed March 11, 2021. 7. UC Davis comprehensive chronic obstructive pulmonary disease (COPD) clinic. UC Davis Health Website. https://health.ucdavis.edu/internalmedicine/pulmonary/pulm-COPD.html. Accessed April 14, 2021. 8. Data on file. Boehringer Ingelheim Pharmaceuticals, Inc.
In June 2017, Salmon Creek Medical Center began testing PIF in patients with In-Check DIAL G16. Based on those insights, they believed they needed to develop a new COPD approach that incorporated PIF assessment and patient/provider education.
Salmon Creek Medical Center wanted to integrate a standardized assessment tool into a care protocol for patients with COPD and educate patients on proper device technique.
Respiratory therapists measured PIF using In-Check Dial prior to the first dose of any dry-powder inhaler or metered-dose inhaler
Color-coded PIF reference sheets were placed by every dispensing machine for reference
COPD=chronic obstructive pulmonary disease; PIF=peak inspiratory flow.
Data on file. Boehringer lngelheim Pharmaceuticals, Inc.