THE DURHAM HEALTH INNOVATIONS PROJECT

__________________________ CARDIOVASCULAR TEAM: VASCULAR INTERVENTION PROJECT (VIP)

COMMUNITY CO-LEAD Sharon Elliott-Bynum, RN, MA, PhD, CAARE Inc. DUHS CO-LEAD Kevin L. Thomas, MD, FACC, FAAC, Duke University Medical Center

TEAM MEMBERS Nancy M. Allen LaPointe, PharmD, Duke University School of Medicine Monique Anderson, MD, Fellow, Duke University School of Medicine Margaret Bowers, RN, FNP, Duke University School of Nursing Khadijah Breathett, MD, Resident, Duke University Medical Center Cedric Bright, MD, VA Medical Center & Duke Medical Center Katrina Damon, MS, PhD, Project Coordinator Kristin Dossary, Project Manager, Duke Clinical Research Institute Olivia Fu, Duke School of Medicine Bradi Granger, RN, PhD, FAAN, Duke University Heart Center Elaine Hart-Brothers, MD, FACP, Metropolitan Durham Medical Group Karol Harshaw-Ellis, MSN, A/GNP, ACNP, Duke University School of Medicine Carolyn Lekavich, RN, ANP, MSN, MHS-CL, Duke University Medical Center John P. Middleton, MD, Duke University Medical Center Sahar Naderi, MD, Resident, Duke University Medical Center Eric D. Peterson, MD, FACC, Duke University Medical Center Beth C. Phillips, RN, MSN, CNE, Duke University School of Nursing Leanne Skipper, President, New Healthcare Solutions, LLC Maria Small, MD, MPH, Duke University Medical Center

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TABLE OF CONTENTS _____________________________________________________________________________________

HEALTH NEEDS & METRICS.......................................................................1

BUILDING THE TEAM & COMMUNITY ENGAGEMENT...............................3

MODELS OF CARE: CARDIOVASCULAR DISEASE.......................................6

CONNECTED CARE MODEL: KEY ELEMENTS FOR SUCCESS OF PROPOSED MODEL ....................................................................................14

REFERENCES..............................................................................................15

APPENDICES...............................................................................................17

Appendix A – ICD-9 codes .......................................................................................................... 17 Appendix B - DHI-VIP Data Tables & Maps............................................................................. 23 Appendix C – Figures & Tables................................................................................................... 31 Appendix E – Community Advisory Board (CAB) Organizations & Members..................... 34 Appendix F – CAARE, Inc. Model of Continuum Care............................................................ 35 Appendix G – Overview of Key VIP Stakeholders ................................................................... 36 Appendix H – Summary of Community Advisory Board Feedback........................................ 39 Appendix I – Summary of Community Conversations Feedback ............................................ 48 Appendix J – Surveys & Key Informant Interview Questions ................................................ 52 Appendix K – Survey Response Summaries............................................................................... 73 Appendix L – Key Informants ................................................................................................... 136 Appendix M – Cost/Benefit Summary, all stakeholders ....................................................... 137 Appendix N – VIP Logic Model................................................................................................. 138

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EXECUTIVE SUMMARY _________________________________________________________________________ Cardiovascular disease (CVD) is a top health concern for our country, state, and county. CVD causes millions of deaths each year and contributes to widening health care disparities. The Vascular Intervention Project (VIP) quantified the burden of hypertension, hyperlipidemia, and the vascular disease sequelae in Durham County, NC and found over 35% of the adult population to have some form of cardiovascular disease. Disparities in morbidity, mortality, utilization of services, and access to care were also observed. To respond to the health burden, the VIP team engaged in a comprehensive community engagement process to develop an innovative model of care that reflects the specific needs of the Durham community. The VIP gathered community feedback on a variety of proposed components of a comprehensive model of care. Through surveys, key informant interviews, a community advisory board, and a public forum, the Durham community voiced its support for a variety of innovative health care delivery models and strategies. With this feedback and evidenced-based approaches to health care delivery, the VIP proposes a care model that optimizes the potential of health information technology and virtual care delivery, connects patients with community spheres of influence for enhanced patient support and disease management, incorporates patient-centered care sites that are tailored to community needs, and increases the scope of nurses and Advanced Practice Clinicians (APCs) to build capacity in the health care workforce. At its foundation, a comprehensive primary care (or connected care) system is needed for long-term success of the VIP model. With key stakeholder support and investment, policy changes, and the essential components needed for sustainability, evidence strongly supports the potential for the VIP to improve health outcomes, increase efficiencies in health care delivery, and serve as a pilot for a national approach to health care reform.

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HEALTH NEEDS & METRICS Health Issue and National/State statistics

Approximately one out of every 3 people in the U.S.i has one or more types of cardiovascular disease (CVD). In 2005, cardiovascular disease (CVD) was the underlying cause of approximately 35% of deaths in the United States. End-stage kidney disease (ESKD) and chronic kidney disease (CKD) are conditions that are most commonly associated with high blood pressure and/or diabetes. Consequently, twenty-six million people had chronic kidney disease (CKD) that resulted in 85,790 deaths in 2006 (Rosamond, Flegal et al. 2007; Centers for Disease Control & Prevention 2008; American Heart Association 2009). Hypertension and hyperlipidemia, significant risk factors for CVD, are prevalent in 36.3% and 32.8% of Americans, respectively. Blood pressure and low-density lipoprotein (LDL) control have been proven to reduce mortality from cardiovascular and kidney disease, yet the incidence and sequelae of these risk factors continue to persist (Muldoon, Manuck et al. 1990; Chobanian, Bakris et al. 2003; Douglas, Bakris et al. 2003; Hajjar and Kotchen 2003; Rosamond, Flegal et al. 2008). Therefore, the prevention and treatment of hypertension and hyperlipidemia are critically important to reduce overall cardiovascular disease burden in the U.S.

Statewide, heart disease was the leading cause of death, accounting for approximately 26% of North Carolina’s deaths in 2002 and stroke was third, killing approximately 7%. Self-reported numbers suggest that almost 30% of North Carolina (NC) residents have hypertension and over 36% of those screened have high cholesterol (Centers for Disease Control & Prevention 2007; American Heart Association 2009). Health Needs: Durham, NC

Consistent with national and state trends, cardiovascular disease is the second leading cause of death in Durham County (Durham County Health Department 2007). Moreover, 500 Durham county residents currently have ESKD, requiring regular dialysis treatments and this number is increasing nearly 4% per year (Williams, Anstrom et al. 2007; CKD 2008). As part of the Durham Health Innovations (DHI) initiative to assess the health needs in Durham County, the Vascular Intervention Project (VIP) utilized International Statistical Classification of Diseases and Related Health Problems (ICD-9) codes, vital signs, and lab values to create the following cardiovascular disease-related categories: hypertension, hyperlipidemia (LDL≥130 mg/dL), myocardial infarction (MI), stroke, heart failure (HF), revascularization, chronic kidney disease (CKD), coronary artery disease (CAD), and other vascular disease (Appendix A – ICD-9 codes). The VIP team identified 75,777 Durham County residents in the Duke Support Repository (DSR) where approximately 38% had some form of CVD or CKD, 26% had hypertension, 19% had hyperlipidemia, 5% had CAD, 3% had HF, 3% experienced a stroke, 2% had CKD, 2.0% had MI, and 2.0% had other types of vascular disease (the denominator for all categories was total population in Durham county over the age of 18, 198,088) (U.S. Census Bureau 2008; DHI-VIP 2009). The three largest DHI-VIP cohorts of patients included those with hypertension (51,204), hyperlipidemia (36,581), and CAD (9,931). The mortality associated with CV disease varies across Durham County, with highest rates identified in 27706, 27710, and 27701 and the highest incidence of hypertension in 27706, 27701 and 27704 (DHI-VIP 2009). The mean age for the DHI-VIP cohort was 57.8 (sd±17.4), the median age was 58.0 (25th,75th percentile= 47,70), 38.9% were Duke employees/insured by Duke University, 37.1% had Medicare, 7.0% had commercial insurance/managed care insurance, 6.0% were self-pay/uninsured, 5.3% had Medicaid, 4.9% had insurance with a state agency, 0.8% had ‘other’ types of insurance. Of those categorized, 56% of DHI-VIP patients were white, 39.2% were African American, 2.6% were ‘Other’, 1.5% were Hispanic/Latino, and 43.9% were male. The DHI-VIP data does not capture individuals that did not receive care in the Duke University Health System (DUHS) between the referenced dates and thus likely underestimates the incidence of CVD in Durham County (Appendix B – DHI-VIP data tables & maps).

Disparities

Racial/ethnic minorities carry a disproportionately greater burden of CV related conditions (Rosamond, Flegal et al. 2008). Despite having a lower aggregate CVD death rate than the state overall, nonwhites in Durham County have approximately a 63% higher rate of death for this condition than whites (182.1/100,000 and

i all ages

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112.2/100,000 respectively) (Durham County Health Department 2007). Due to a myriad of factors including; language and cultural differences, immigration status, lack of medical research, lower rates of insurance and access to care, low education and literacy levels, less is known about the disease burden among Latinos ((Davidson, Moreno et al. 2007)). In 1999-2000, the death rate due to heart disease was 99.4 in Latino residents of NC; however, the NC Latino population is generally a younger population (SCHS 2002). Additionally, racial disparities exist among insurance status and utilization of services within the DHI-VIP population, where 76.1% of the self-pay/uninsured are nonwhite and racial/ethnic minorities are more likely to receive care only in the emergency department (DHI-VIP 2009). Therefore, it is essential that our model addresses barriers to care for these vulnerable populations.

Environmental Risk Factors

The VIP model proposes a dual risk stratification scheme for all Durham County residents based on two dimensions; the traditional clinical risk assessment (age, blood pressure, cholesterol, family history, etc.) and a novel component that incorporates neighborhood/environmental resources that impact health care delivery and outcomes. The environmental/neighborhood risk factors that are included in this second component include; access to transportation/proximity to health clinics, socioeconomic status, availability of safe areas to exercise (fitness facilities, parks, sidewalks, walking trails), proximity and access to health foods (vs. proximity to fast food restaurants), and crime rates (see Appendix C, Figure 1 – Environmental Risk Assessment and Figure 3 – Dual Risk Stratification). Based on clinical and environmental/neighborhood risk factors, Durham residents will engage in the VIP innovative model of care based on their cumulative risk. Health Metrics

The VIP will use the following health metrics and data extracted from the DSR to measure the current health status and efficacy of the VIP program:

1) a cross sectional assessment of the percentage of the Durham County population at target blood pressure (140/90 mmHg, systolic/diastolic) and cholesterol (LDL≥130 mg/dL) levels 2) incident rate of: stroke, MI, HF, CAD, CKD, revascularization, and vascular disease.

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BUILDING THE TEAM & COMMUNITY ENGAGEMENT

The goal for our community engagement process was to promote community participation, interest and

empowerment to design a model of care that improves the health of Durham County citizens. The process involved the formation of a skilled VIP core team and soliciting participation of a diverse group of community members, including representatives from existing health service organizations and care-related partnerships in Durham County. The specific components of our community engagement process involved: (a) assembling a community advisory board (CAB), (b) surveying patients, community leaders and providers, (c) interviewing key informants from the perspectives of patients, providers and community leaders, and (d) sponsoring a Community Conversations/Town Hall forum. Selection Process and Importance of Co-Leads & VIP Core Team Members

The selection process for the VIP team leaders required leaders with experiences in serving the community, clinical research, and cardiovascular care. Dr. Kevin L. Thomas and Dr. Sharon Elliott-Bynum, who represent DUHS and the Durham community respectively, serve as the VIP co-leads. VIP then created a collaborative, multidisciplinary team of individuals inclusive of community members and DUHS representatives. Team members were selected for their clinical expertise, involvement with community health care, knowledge of racial disparities, and participation in outcomes-based and community-based participatory research. Other team members were selected for their community connections, expertise with internet-based technologies, knowledge of and experience with non-traditional care models, and work with chronic disease management programs relevant to CV or CKD. The VIP core team created a structure to optimize the skills, interests, and talents of all team members (Appendix D – VIP core team structure). Community Advisory Board In concert with other DHI teams, the VIP team established an advisory board that represented ongoing efforts to improve health care delivery and outcomes in the community. Community leaders of existing health programs and services in Durham County were asked to participate. Given the similarities in intervention strategies and team goals for addressing the community, the VIP team partnered with the Cancer and Diabetes teams form a 3-team CAB. This collective working group selected CAB members and worked together through the planning process to manage CAB-related activities. The board consisted of a heterogeneous group of community members, including lay persons and a variety of health service organization representatives (Appendix E – CAB Organizations & Members). Community Advisory Board members were a central part of the planning process to ensure the community’s input was at the forefront of our model development. CAB members brought important information about community needs and perceptions about care delivery based on previous knowledge and experience in the Durham community with prior community projects. The goal of the CAB was to work as a team through a cooperative planning process to ensure accurate representation of the community’s needs and facilitate the short- and long-term success of the project. The primary objective was for community members, leaders, and providers to identify relevant, effective, and appropriate components of a comprehensive model of care that, if implemented, would improve health outcomes in a culturally relevant manner. Hence, the following were the roles and responsibilities: 1) to prioritize the challenges and barriers that impact the health status of our community and collaboratively identify ways to address these issues and 2) to develop a strategy to engage the community and identify potential community conversation sites in Durham County.

CAARE, Inc. is a private, non-profit, community-based organization that was a key community partner throughout the VIP planning process. CAARE is a multidimensional care clinic for at-risk community members who experience health and socioeconomic disparities. Through community-based supportive services, such as medical care (free to all users), transitional housing, preventative care, health education and information, nutrition and exercise counseling, community outreach events, testing and counseling for racially disparate health conditions, CAARE Inc. is able to provide holistic care to traditionally underserved populations that might otherwise go without medical and health services (see Appendix F – CAARE, Inc. Model of Continuum Care). Additional highlights about other key stakeholders, including the Community Health Coalition, Durham CAN, a Partnership for a Healthy Durham and important programs, resources and partnerships are noted in Appendix G.

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Some of the major contributions from the community advisory board that shaped our model development included: 1. Relationships and lessons-learned from previous community initiatives, such as the Diabetes Intervention

Project model, were helpful in ensuring prior mistakes were not perpetuated in our planning process. Early engagement and input from the community is critical for implementation and long-term success.

2. Recommendations from community-based organizations, e.g. PACs (Partners Against Crime), were critical in shaping the process in which we garnered community feedback. Rather than a traditional town hall approach, we utilized an informal “kitchen table talk” format that fostered greater participation and thought sharing by community participants.

3. It was evident that when conducting research in our community, it is very important to the community that researchers make the goals, objectives, and plans for sustainability of the project clear from the beginning. Our community was ready and willing to help provide information about how the changes can be made, and during this feedback process, it was apparent that evidence of implementation and commitment to change was very important to them. Based on this feedback, The VIP, Cancer, and Diabetes teams have a personal and professional investment in the community and, via this document, have communicated the importance of this investment.

Key themes were evident from community advisory board members’ comments during the 8-month planning process, including: 1) the importance of building trust in the community and being transparent about the process, 2) creating long-term relationships with implementation partners, 3) the most effective ways to gather feedback from the community require you to go where the people are (e.g. PAC meetings and community groups, councils, grassroots organizations/agencies, community gathering places), 4) how to build stronger models of care, including priorities such as a greater focus on prevention, the inclusion of best practices/evidence-based research, shared health information (including medication lists) for providers in the care of patients, education, and more effective mechanisms for screening-to-treatment; and 5) coordination and unification of health interventions, such as a “one stop shop [that] will maximize services to patients and community members”. The Community Conversations’ key themes emphasized developing solutions that: 1) target young people; 2) create effective health empowerment communication strategies to reflect the diverse communities; 3) provide access to affordable health care for the under-/uninsured and expanded access to clinics and transportation; 4) promote healthy behaviors and prevention; 5) increase funding for wellness centers; and 6) link community to existing resources. Appendix H and I summarize additional themes, feedback, and lessons-learned from the community advisory board and Community Conversations event. Broad-based community input: Surveys & Key Informant Interviews

Our team ensured broad-based community input and involvement through mixed data collection methods, using quantitative and qualitative approaches. With the help of our advisory board, the VIP created three surveys and sets of key informant interview questions to collect targeted feedback from patients, providers, and community leaders about proposed interventions and model components (see Appendix J for surveys and interview questions). We used random sampling to identify survey respondents and collected over 849 patient, 152 provider, and 20 community leader surveys. Surveys were administered in English and Spanish, electronically and via paper.

When asked what things would improve patients’ ability to better manage their health, patient survey response themes suggest a strong desire for 1) communicating with providers via email, text messages, and an internet health portal, 2) increased access to health care, exercise facilities/sidewalks/parks, and healthier foods, 3) a clinic in their neighborhood, 4) a clinic with non-business office hours (before 8am and after 5pm), 5) a provider that spoke their preferred language, 6) and a rewards/incentives program. Provider survey responses indicate that: group visits and community coachesii might be effective ways to improve patient health; email and an internet health portal are equally preferred patient communication methods but over 85% prefer using text messages the least; and providers need more time [than they can currently provide] for education and counseling on healthy

ii see explanation in next section

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behaviors and lifestyle modifications. Appendix K provides patient, provider, and community leader survey response summaries.

Purposeful sampling of diverse organizations and positions was used to identify key informants for the project. Seven community leaders, 9 providers, and 29 patients were identified and interviewed (see Appendix L - Key Informants). Recurrent themes emerged from key informant interviews across patients, providers, and community leaders. All three groups indicated that the main reasons patients have difficulty managing personal health are finances (lack of resources, insurance, money, access, transportation, unemployment) and incentives and rewards programs would be effective in improving patient compliance. Informants felt community coaches and group visits could improve patient provider communication and cultural sensitivity to ultimately improve patient education and engagement in their health. There was consistent support around developing a neighborhood clinic with a variety of innovative attributes and support services, including non-traditional business hours, care coordination planning for insurance, medication counseling, specialty referrals, appointment scheduling, exercise facilities, and point of care diagnostic testing - similar to model of care that CAARE, Inc. currently offers. Interviews revealed overall support of the use of internet health portals, email, and text messages for patient-provider communication with careful consideration given to privacy issues and the digital divide based on socioeconomic, education, and access strata that may exist.

Oversight Committee and Technical Assistance Core The Oversight Committee and Technical Assistance Cores were valuable in supporting the vision, mission, and the goals of the VIP. Consistent feedback about the 10-team vision for DHI allowed our team to continuously consider the project objectives. During presentations and meetings with Oversight Committee members, we received feedback on our model of care, data collection methods, recommendations about what partners and advisors to engage, and potential implementation and measurement strategies. Furthermore, standardized processes for DSR data acquisition, programming, geospatial mapping, and statistical analysis were provided by the technical assistance core during the planning process. Economic modeling was made possible with guidance from a group of DUHS health system business advisors.

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MODELS OF CARE: CARDIOVASCULAR DISEASE Current gaps and opportunities

Four obvious gaps in care delivery and access are evident. First, disproportionate access to care exists along socioeconomic and racial strata, resulting in differences in access between insured and under-/uninsured persons and minorities in the county. The second gap, fragmentation of health care delivery among health care providers/other components of the health care network (e.g. pharmacies, support services, safety net organizations) and lack of connectivity, affects patients along all socioeconomic and racial strata. Even among the insured population that has adequate access, the services received and available are systematically disconnected. The third gap, a deficiency in patient education about diseases and availability of community resources, provides significant challenges to individual-level empowerment for disease management. A final gap, continuity of care, requires a method to ensure that patients are not lost in the health care system. Therefore, despite the myriad of health professionals, facilities and community agencies, we witness how traditional models of care in Durham fail to meet the health care needs of the community. We propose to develop a novel, innovative model of care in Durham County that: recognizes cultural differences, allows for improved access, nurtures individual participation in plans of care, provides for the prevention and early identification of risk factors for CVD, tailors resources to individuals risk and neighborhood needs, integrates providers and care facilities, and modifies behavior through coordination with community workers. We expect this reorganization of care to lead to a predictable reduction in morbidity and mortality from vascular related diseases. What populations does your proposed model seek to serve?

We propose to target Durham County residents who have hypertension (systolic blood pressure >140, diastolic blood pressure >90) and hyperlipidemia (LDL-C >130). We will further stratify individuals with hypertension and hyperlipidemia by associated vascular events including; acute coronary syndromes (ACS), myocardial infarction (MI), coronary artery disease (CAD), heart failure (HF), stroke, chronic kidney disease (CKD), and other vascular conditions. Individuals who are currently engaged in the DUHS have been identified via the DSR and can be included in the VIP model through their current provider, referrals, and new VIP implementation practices. Individuals who are not engaged in the Duke University Health System will be identified through several channels. First, a social marketing campaign will be implemented, inclusive of radio, television, billboard, and internet advertisements, to increase awareness about hypertension and hyperlipidemia coupled with information about the DHI VIP program to engage new individuals. Secondly, community outreach efforts, including health fairs in diverse venues such as community/social gathering centers, faith-based institutions and shopping areas, will further target those that are not currently engaged in the health care system. In addition to screening, the health fairs will employ mechanisms to direct patients to health care portals and provide directed follow-up of all participants. Additionally, a strategic plan for providing access to the under-/uninsured must be developed with key community stakeholders (see further discussion under policy section below). Tiered-Risk Intervention

In the VIP model, individuals are assessed for their cumulative risk, inclusive of clinical and environmental factors, which will determine the resource allocation, the location and mode of care delivery, and respective treatment plans. Patients will be stratified into three levels; level 1 being the least vulnerable with little/no cardiovascular risk factors or disease and few environmental risks and the level 3 being the most vulnerable with multiple co-morbidities and numerous environmental challenges (see Appendix C, Figure 2 – Tiered Risk Intervention). Based on the DHI-VIP data (see Appendix B – Table 1.0), we estimate that 36,000-40,000 patients will have low-moderate risk (levels 1 & 2) and 40,000-45,000 patients will have moderate-high risk (levels 2 & 3), with obvious overlaps with the assignment of levels and the ability for patients to move in and out of risk categories as they improve their health status and learn to independently navigate their environmental barriers. Patients with low risk would design a health care delivery plan with their provider that is more telecommunications-based, less resource intensive, and requires less frequent follow-up. Conversely, a high-risk patient would develop a plan that requires more time with providers, group visits focused on education, assignment of community coaches, access to increase support and ancillary services, and has more intensive follow-up care. In summary, the tiered-risk intervention scheme will serve a range of Durham residents in different ways, starting from low risk consumers

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who have; comprehensive insurance, reliable means of transportation, access to health care providers, and are from the higher socioeconomic stratum to high risk patients who are under- or uninsured, have disproportionately less access to health care providers, advanced technologies and transportation, and are from lower socioeconomic strata. With a portfolio of innovative modes of care delivery, the patient and provider will be able to select the option that best suits the needs and risk of the patient.

What is the model of care that your team is proposing? Who will provide the services and what will they provide?

The VIP model is built on elements from the chronic care model as defined by Bodenheimer, et al (Bodenheimer, Wagner et al. 2002). Key components to community management of chronic illness is anchored by self management support, clinical information systems, delivery system redesign, decision support, health care organization and community resources. Moreover, within the VIP model are overarching principles that include the entire community, including public and private polices unique to the Durham community, identification and definition of all components of the health care system within Durham County, and integration of all facets of the delivery system including all networks of health care delivery in the county. The key elements of the VIP care model are: Telemedicine and Online tools RECORD: Centralizing patient health information is an important component in delivering health care. The VIP team, partnering with the American Heart Association, will provide a wellness program of online educational and disease management tools for patients/providers. This hypertension/hyperlipidemia patient education curriculum is designed to motivate patients to achieve blood pressure and cholesterol goals and could be easily expanded to include diabetes. The program will utilize a web-based health portal to engage patients in their continuum of care through online tools and resources. Primary focus will be on the Heart360 Cardiovascular Wellness Center® allowing patients to track and manage their blood pressure, cholesterol, weight and exercise progress online while using various report generating capabilities to share information with their healthcare providers. The Heart360 wellness center website will be designed to walk patients through the gamut of care opportunities and to improve patient education and engagement based on their current status. There will be multiple links to drive patients towards existing AHA educational resources on hypertension, diabetes and cholesterol disease prevention, treatment and management. The system will have the capacity to incorporate an email/pager/cellular contact strategy- generating automated messaging to providers, community coaches, or pharmacists based on specified milestones and patient status within the program (i.e. reminders to follow up with their healthcare provider office, updates about tools/resources not yet utilized, reminders to log daily blood pressure results, etc). Lastly, there will be a nurse directed phone consultation service available through the wellness center and the internet portal.

Access to Heart360 will be available through two modalities; computers stations with internet access and disease management kiosks located in various community venues (churches, major/retail pharmacies, office buildings, large retails stores, neighborhood clinics). The kiosks would offer the following: readings- ability to read blood pressures, weight, height; touch screen functionality- delivers the opportunity for dynamic delivery with guidance to additional resources and interactive instruction; printer capability- outputs can be printed at the kiosk; and back-end reporting – ability to report aggregate data from kiosk users to assess usage, frequency, health management outcomes in graphic form. Specific tools available through the wellness center will also include risk assessment tools for disease specific conditions (i.e. diabetes mellitus, hypertension, myocardial infarction) that allow patients to compute their risk, provide strategies to decrease their risk, goals that can be tracked longitudinally, and a discussion guide to utilize with providers. Medication lists will be created that can be automated/updated and linked with pharmacies to track refills, compliance, drug-to-drug interaction assessment, and message alerts for patients and providers. The RECORD menu of relevant products and functionalities include: Remote disease monitoring via computer-compatible blood pressure cuffs Electronic health records for personal health information management and longitudinal assessment Communication with providers and pharmacists via email/text messaging/portal, including automation of key

provider/patient functions (appointment calls and reminders, emails, letters, etc.) Online patient education and information tools/resources, including a web-based health services directory

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Risk assessment and risk-based intervention tools for care management goals (BP, weight, BMI, cholesterol and patient education) and portability.

Disease management, including kiosks with Heart360 access in a variety of settings (community clinics, barbershops, pharmacies, churches, work offices) for screening, education, and referrals to health services.

Telemedicine and internet-based resources, provide a portable way for patients to RECORD their health

information and receive individualized care in manner that is self-directed, convenient, and cost effective. The increased use of health information technology by providers, patients, pharmacists, and community coaches will reduce duplication of diagnostic testing, minimize inappropriate utilization of health care services, reduce medical errors and adverse drug events, enhance the efficacy of primary care and chronic disease management, and potentially reduce admissions/readmissions/acute care episodes. Furthermore, administrative tasks would also see great efficiency savings in the inpatient and outpatient settings, including transcription services, chart pulls, laboratory tests, drug usage, radiological processes, nursing time, and medical record documentation. On a national scale, savings could be as much as $346 - $813 billion per year (Hillestad, Bigelow et al. 2005). Telemedicine is an established method to improve the efficiency of patient care visits, clinical quality, and patient care outcomes. In a model defined by the University of Tennessee Telehealth Network, a recent case study suggested: improved patient access to primary and specialty care; reduced no show rates because patients experienced reductions in waiting time, time away from work, and travel time; more efficient patient care encounters; and clinical quality in chronic illness management demonstrating improved blood sugar, blood pressure and blood lipid results (McCarthy 2007). DHI Phone Consultation: DHI medical phone consultation service an innovation that is relevant to all disease management programs. A toll-free number would be made available to Durham County residents to address non-acute health-related questions and concerns. Access to medical consultation via telephone has been proven to 1) improve access, provide convenience to patients, 2) produce cost savings, 3) allow providers to provide equivalent quality of care to more patients, 4) yield high rates of public satisfaction, 5) reduce emergency department admissions, and 6) be comparable to face to face consultations in facilitating health promotional interventions, in triage, and in promoting access and delivery of routine health care to people with chronic disorders (Lattimer, Sassi et al. 2000; Car and Sheikh 2003; Pinnock, Bawden et al. 2003). A licensed practical nurse (LPN) or registered nurse (RN) would be staffed 24 hours a day/7 days a week to receive calls and triage patients accordingly. Patient-centered care sites: one-stop care delivery: The VIP proposes changes to the current infrastructure of health care delivery sites. Care sites that participate in the program will aim to create a patient-centered environment that addresses current barriers in the receipt of healthcare, particularly for minority populations including:

Non-traditional hours of operation Safe and free access to exercise facilities Computer and internet access to support the use of telemedicine and online resources/tools Connectivity with community resources: information and/or access to social and health services.

Community liaisons would be available to connect patients with resources as needed. Transportation- increased access to transportation services. Child care services Linguistically diverse clinical & non-clinical staff Short wait times and increased access to all services On-site pharmacy access

In a community-based intervention in Baltimore, the study team was able to demonstrate significantly improved lipid and blood pressure control among minority patients using many of the principles of the patient-centered coordinated care sites mentioned above (Becker, Yanek et al. 2005). The VIP model also addresses the issue of cultural concordance in which the number of racial and ethnic minority health professionals provides greater opportunity to minority patients to see a practitioner from their own racial or ethnic group and receive social support in managing chronic illness. Regarding cultural concordance, Health Resources and Services Administration (HRSA) completed and study in 2006, in which 55 studies were reviewed for service patterns, concordance and trust patterns, and the data suggest that 1) minority patients tend to receive better interpersonal

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care from practitioners of their own race/ethnicity, and 2) non-English speaking patients experience better interpersonal care, greater medical comprehension and greater likelihood of keeping appointments when they see a language concordant practitioner (HRSA 2006) . Patient Care Coordination through Community Coaches/Liaisons/Advisors/Liaisons: Community Community-based liaisons will be an integral part of the program to support patient disease management, keeping Durham residents connected in the health care system and compliant with their disease management programs. Once provided the necessary training, the coach would supply education to the community on lifestyle, diet, exercise, assist with medication adherence, and assist patients with medical appointment attendance and transportation. The principal goal of the community liaison is to help the patient navigate the health care system. These individuals will be recruited from various community organizations including churches, barbershops, faith-based organizations, community gathering centers or “social hubs”, and other community spheres of influence. The Patient Navigator/Community liaison, as defined by Harold Freeman (1995), enables patients to effectively negotiate the principle barriers encountered within the health care system such as communication, financial, misaligned health care systems and fear and distrust. The Patient Navigator model promotes timely diagnosis and treatment, creates seamless coordinated care and services, and assists patients and families in negotiating the health care delivery system (Freeman, Muth et al. 1995). The navigation model is based on the concept that people in communities trained as patient navigators can be effective in reducing and eliminating barriers within their own communities. As previously proven, patient navigators positively influenced the five-year survival rate of patients with breast cancer and demonstrated a shift from late stage breast cancer diagnosis to early detection (Oluwole, Ali et al. 2003). Group Visits: Advanced Practiced Clinicians (APCs) and select specialists (nutritionists, dieticians, and specialty educators) will engage moderate- to high-risk patients (and potentially low risk) in education, counseling, awareness, and self management specific to a variety of medical conditions and topics. Patients participate in group discussion, learning, and supportive dialogue and then see their health provider for individual clinical attention on a one-on-one basis. Group visit topics include: diet/nutrition, physical activity, medication management, high blood pressure, and high cholesterol. Group visits allow the delivery of comprehensive patient education, medication counseling, and health awareness while enriching the patient experience with a more supportive environment. Group visits in the context of chronic disease management have shown encouraging results. Van dam et al (2005) completed a systematic review of several studies that evaluated the impact of social support and group visits in the management of diabetes. The data suggest that patient group consultations with diabetes care providers, peer social support group sessions in or following diabetes education programs, and internet-based or telephone-based peer support and counseling programs showed favorable behavioral change in chronic illness management (van Dam, van der Horst et al. 2005). This review suggests that chronic illness metrics improve for patients involved in group visits conducted within community venues. Incentives and Rewards Program: Implementation stakeholders, including the VIP team, employers, insurers, pharmacies, providers, and the health system should partner to develop a patient incentives and rewards program. Employee wellness and patient incentives programs will aim to reward individuals that meet goals that are set by them and their provider. Based on survey and interview results from the VIP planning phase and the guidance of stakeholders, a variety of rewards and incentives might be considered and will largely depend on the target populations. Data supporting the use of incentives and rewards programs reside largely with employers and insurance companies (Alderman 2009). Earlier this year, the Affinia Group reported rewarding employees with gift cards for completing health risk surveys and larger rewards (annual insurance premium discounts and tax free reimbursement accounts) to patients that participated in blood pressure, cholesterol, blood sugar screenings and educational classes for these conditions (Appleby 2009). United Health gave discounts to members who refilled their prescriptions within 30 days to reward adherence (Loftus 2009). These programs are growing and are likely to have a large role in promoting patient responsibility and engagement for their health.

VIP Care Providers -Advanced Practice Clinicians (APCs): Advanced Practice Clinicians (NPs, PAs) at participating care sites will provide the majority of group visits and non-complex patient care. Low- to moderate-risk patients will receive the

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majority of their care from APCs. APCs would also serve as the responding-arm to the telemedicine/online disease management program. -Community Coaches/Liaisons/Advisors/Navigators: Role described above. -Physician: Internal Medicine, Family Practice (PCP’s), Specialists (cardiologists, nephrologists and endocrinologists.): Predominantly providing care to complex patients with vascular disease sequelae. -RN/LPN: Staff a 24-hour DHI phone consultation service. What volume of services is associated with your alternative model of care?

Assuming a high-risk population of approximately 15,000 patientsiii and a 150-patient case load for each community coach, approximately 90-110 community coaches will be needed for implementation of the VIP model of care. Approximately 2 Advanced Practice Clinicians/Mid-levels will be needed per care site (Lincoln, Walltown, Lyon Park, Holten, CAARE, Duke Outpatient clinic, and/or the Durham County Health Department), which necessitates a total of 10 APCs. One full-time physician per care site will be needed, totaling 5 and to staff the DHI phone service 7 days x 24 hrs/day (or 168 hours per 40-hours work week), approximately 4-5 LPNs/RNs will be necessary. And finally, 1 full-time pharmacist is required per care site, totaling 5 for all care sites. There will likely be opportunities to utilize existing providers at care sites or reallocate providers [within the county] to the new care sites as utilization patterns shift.

What are the estimated incremental costs of delivering your alternative model of care assuming that the primary connected care model is in place? Costs associated with the VIP model include:

Establishment of incentives/rewards/employee wellness programs ($$$$) Care sites*:

o Providers, as outlined above* ($$$) o Exercise facilities ($$) o Bilingual staff *($$) o Pharmacies*($$) o Child care provisions ($) o Computer stations for free access to online education/resources/tools* ($) o Education and training ($)

Print materials for patients Training for community coaches

o Disease Management Kiosks* ($$) o Ambulatory blood pressure cuffs ($) o DHI 24/7 phone consultation service* ($$) o Information Technology Infrastructure* ($$$$)

*indicates a shared cost if implemented in concert with other DHI teams

$ - modest cost, $$$$-significant cost Economic analysis – in current state of affairs, who bears the burden and what are the economic implications of the proposed changes in the model of care?

Currently, patients, providers, insurers/payers, and employers are bearing significant cardiovascular and vascular disease costs and burdens. Unmanaged disease and the complex nature of the current health system costs patients expensive out-of-pockets fees (co-pays, insurance premiums, deductibles), lost productivity at home and work, lost earning potential, and decreased quality of life with little time invested in improving their health (through education, exercise, and self-management). As a result of inefficiencies in the system and chronically ill populations, providers: experience decreased capacity, are unable to accept new patients without long waiting

iii based on data analyses that quantify the number of cardiovascular events with a CVD primary/secondary diagnosis

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periods, have insufficient time and resources to provide education and counseling related to chronic illnesses, and have no way to access and assess patient disease information, progress, and activities in a longitudinal and real-time fashion- which further restricts their ability to effectively manage their patients. As a result of the current reimbursement structure, a cost/benefit analysis suggests that cardiovascular admissions produce a positive margin for the health system, particularly those for hypertension and hyperlipidemia. On the other hand, gains are partially offset by the provision of un-/under-compensated care for the uninsured/under-insured in the inpatient and emergency department settings. Employers’ cost to provide health care benefits continues to increase. Employees, when chronically ill with cardiovascular disease, have reduced productivity and increased rates of absenteeism when they miss work due to their own illness or to care for sick family members. Lastly, the costs of chronic and cardiovascular diseases are very high for insurers, as they continue to see shrinking profits with increasing clinical encounters and payouts for the chronically ill.

With multiple stakeholder investment and implementation, the VIP model promises a net benefit for all stakeholders. Patients will be healthier, pay less out-of-pockets expenses for their health care, lead more productive lives at work and home, and experience a better quality of life. Insurers and employers will save on the costs of insuring their consumers and employees and providers will benefit from a plethora of opportunity costs when management of non-complex care is largely occurring in the community, including better management of their chronic disease patients, more time to deliver complex and new patient care, and the ability to measure and receive real-time information about their patients’ disease. How do the health metrics identified by your team align with your proposed alternative model of care? The principle health metrics for the VIP program completely align with our alternative model of care. Longitudinally, we will track blood pressures and cholesterol levels. We also plan to collect incident cases of stroke, MI, HF, dialysis/kidney disease, CAD, revascularizations, and vascular disease. Additionally we will monitor cross sectional prevalence of these conditions over time. Our new model will implement tools such as the internet-based Heart360 wellness center that will assist in tracking our defined health metrics in combination with the DSR.

What regulatory/policy changes (national/state/local) would facilitate your proposed alternative model of care?

In order to sustain the VIP model long-term, reimbursement structures for primary care and innovative care delivery methods will need to be addressed. Specific reforms include viable reimbursement rates for primary and preventative care (patient education, counseling, prevention, support groups) and reimbursement mechanisms for virtual care delivery (health care delivered via email, text messages, health portals, and phone). If integrated PHRs are to have an expanded role in patient care and communication, there must be business models supporting their use. So far, the systems’ costs are largely being underwritten by provider organizations, and the business case for their use in the fee-for service health care environment is weak. For PHR use to be sustainable, reimbursement policies must provide rewards for “non–visit-based” care that might improve health outcomes and lower costs by averting the need for clinical encounters and hospitalizations.

Secondly, a strategic plan needs to be developed to address access issues for the under-insured and uninsured in Durham County. Durham County, in concert with state policy leaders and key DHI stakeholders, should develop a county-wide plan to address insurance and access issues for all populations. Healthcare access for the uninsured/underinsured populations is paramount to the success of a redesigned health care system in Durham County and ultimate improvement in health outcomes.

Third, the public transportation system in Durham County must be redesigned (routes, times, connections etc.) to facilitate patient access to VIP care sites. We have received consistent feedback from the community that the public transportation system, in its current state, is a tremendous barrier to accessing health care in Durham County. How could the proposed model of care be evaluated in terms of processes, impact, and outcomes? In collaboration with Implementation stakeholders, the VIP team will identify the process, impact, and outcome evaluation questions that should be answered.

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Process questions will evaluate the VIP activities and operations and how well the program is functioning. Process evaluation questions might include:

Are VIP administrative and service objectives being met, including timely, culturally relevant/sensitive, and appropriate health care services?

Are sufficient primary care and cardiovascular services being delivered to the Durham residents with vascular risk factors and/or disease?

Are there un-served persons the VIP is not reaching? Once in service, do sufficient numbers of Durham residents complete and continue receiving services? Are Durham residents satisfied with the VIP services? Are VIP administrative, organizational, and personnel functions handled well, efficiently, and cost-

effectively? Impact measures will evaluate the extent to which the VIP program produces the intended improvements in cardiovascular health and social conditions in Durham County, or rather, are the desired outcomes attained and do the changes included unintended side effects (Peter H. Rossi 2004). The VIP impact evaluation questions might include:

Are the health outcomes, goals, and objectives being achieved? Do the services have beneficial effects on the recipients, in regards to personal/lifestyle, financial, and health

impacts? Do the services have (and to what extent) adverse side effects on the recipients, including decreased access,

health, satisfaction, or quality of care? Are some recipients affected more by the services than others and do disparities in care and health outcomes

persist, increase, or decrease? Is the problem or situation the services are intended to address made better and do we see a measurable

improves in health outcomes and disparities in Durham County? Outcomes will focus primarily on the desired health outcomes and efficiency of the program. For health outcomes, VIP will be evaluated on its ability to 1) reduce the percentage of the Durham County population that is over target blood pressure levels (140/90 – systolic/diastolic), 2) reduce the percentage of the Durham County population that is over target cholesterol levels (130 – LDL), and 3) reduce the incidence and rate of events of the hypertension and hyperlipidemia sequelae (stroke, MI, heart failure, kidney disease, vascular disease, coronary disease, and revascularization). Health outcomes will be evaluated based on data gathered from the Duke Support Repository (DSR), AHA tools and resources, and any other health information technology tools that are included in the implementation phase.

The efficiency assessments will take account of the relationship between the VIP costs and its effectiveness,

either through a cost-benefit analysis/cost-effectiveness analysis. The VIP efficiency evaluation questions will include 1) are resources used efficiently , 2) is the cost reasonable in relation to the magnitude of the benefits, 3) would alternative approaches yield equivalent benefits at less cost? Efficiency outcomes will be evaluated based on project financial reports and health outcomes data gathered from the Duke Support Repository (DSR) AHA tools and resources, and any other health information technology tools that are included in the implementation phase. A summary of VIP inputs, key processes, outputs, and outcomes of the model is provided in Appendix N – VIP Logic Model.

What are the critical components to the long-term sustainability of the proposed model of care?

Sustainability of community-based health interventions is dependent on well-established factors, which we have carefully and systematically included in the VIP intervention. Program interventions that have shown the greatest long-term impact on health outcomes in communities are those that use no paid staff (OR = 3.7; 95% CI, 1.8, 7.5), were modified to ‘fit’ community needs during implementation (OR = 2.7; 95% CI, 1.4, 5.0), included a good fit between local providers and the intervention (OR = 2.4; 95% CI, 1.2, 5.0), and included a program champion at each level of the intervention delivery (OR= 2.3; 95% CI, 1.2, 4.4) (O'Loughlin, Renaud et al. 1998). In the VIP intervention we have incorporated these principles via two primary mechanisms.

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Collaboration with existing health care providers, community organizations, safety net providers, networks, and other key partners will be essential. The community needs to be a part of the design and implementation and neighborhoods, churches, residents, and other groups need to have an opportunity to invest in this initiative. Durham has a rich history of experiences and unique challenges as it relates to health and healthcare initiatives, and therefore, inclusion of the key community stakeholders is essential to the successful implementation and sustainability of VIP (Appendix G). We have proposed a community health coach model that is driven by lay community leaders. This component of the model will evolve during implementation of the intervention to use local, voluntary charismatic authority to both sustain the existing mission of the intervention and to build capacity of the system for prolonged health effects(Hawe 1998). We have created new community partnerships that are built on existing relationships, such as the Duke and Durham community clinics, CAARE, and many other stakeholders (Appendix G), so that the intervention proposed is already part of the everyday life of providers caring for people in the Durham community. The fit between community providers and the intervention will be enhanced by the use of existing local events and health fairs for ongoing dissemination and measurement of outcomes of the intervention. These existing forums have been and will continue to be used as the mechanism for delivery of health information, to conduct preventive health care screenings, to provide appropriate therapeutic care, and to engage community participation in health and self-care initiatives. By using existing and ongoing venues that are currently organized and maintained by local community action groups and the local chapters of professional organizations (e.g. the American Heart Association and NAACP), our ability to continue the intervention beyond the immediate funding period is enhanced.

Providers, including community clinics (Durham Health Department, Lincoln Community Health Center, Walltown, Lyon Park, Holton, and CAARE, Inc), Duke Primary Care practices, and private practitioners must unite to formulate a shared DHI VIP vision. Whether it’s for the provision of care, implementation, and/or collaboration (e.g. referrals, connecting patients with resources), all providers need to be equally willing to invest, participate, and reap the numerous benefits that the VIP promises to provide.

Buy-in from employers, insurers, and businesses county-wide into a robust incentives/ rewards/employee wellness program is also essential to the long-term viability of the VIP. These key stakeholders include the Durham Chamber of Commerce, Blue Cross Blue Shield of North Carolina, Duke University (Human Resources Division), the state of North Carolina (state employees and Medicaid beneficiaries), and Centers for Medicare and Medicaid Services (CMS) (Medicare beneficiaries). Long-term commitment from these and all stakeholders is essential (Appendix G).

As mentioned previously, improved reimbursement schemes for primary care and virtual delivery of health care must be developed for our model to be sustainable.

Lastly, the VIP can not be sustained long-term without an information technology infrastructure that can measure and evaluate health outcomes, connect all providers (clinicians, pharmacies, volunteer organizations, safety-net organizations, health systems, health department, community coaches/navigators, social and support services) with critical patient health information, facilitate the efficient delivery of virtual health care, and ultimately reduce the cost for all stakeholders (patients, providers, employers, insurers/payers). Whether it’s a network of connectivity through health information exchanges (HIEs) or an internet-based health portal like the Heart360, a common tool must be developed.

Program champions have been confirmed at each level of the intervention, as described above. These champions successfully cross lay community membership, healthcare, finance and government. Using these ties and connections to mold the VIP project will ensure that the fit of the intervention evolves over time to meet the needs of the Durham residents whom we seek to serve. Furthermore we plan to engage champions from corporate and local businesses to invest in health reform and promote health and well being among their employees. Our business model outlines the positive impact of the intervention on local business and potential insurance premiums as we make improvements in the health of Durham employees.

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CONNECTED CARE MODEL: KEY ELEMENTS FOR SUCCESS OF PROPOSED MODEL

At the foundation of a connected care system is an integrated electronic medical record (EMR) and personal health record (PHR) that facilitates communication amongst all components of the health care delivery system. Access to basic patient information such as medication lists, allergies, vital signs at visits, laboratory values, family history, and social/environmental risk factors is essential to the management of chronic conditions.

During the planning phase of the DHI project the VIP team assessed the electronic medical records of health care facilities that provide the majority of health care in Durham County. Lincoln Community Health Center and its affiliate clinics (Lyon Park, Walltown, Holton Wellness Clinic, Hillside School), Durham County Health Department, Duke University Health System and affiliated practices, independent specialty clinics including Triangle Heart Associates and Durham Nephrology Associates, and the myriad of other clinics (including free clinics) that provide care to Durham residents all have independent EMRs without any interconnectivity. Like patients across the country, most Durham County residents receive care at multiple locations over time; therefore, the inability of these systems to connect produces fragmented care delivery that increases the cost of health care delivery and ultimately redundant, inefficient, and lower quality care.

In a truly connected system, patient health information would be protected but accessible to multiple players in their health care delivery system through a centralized electronic record that connects with each independent centers’ existing EMR infrastructure. With the individual patient’s consent, providers including physicians, APC’s, pharmacists, nurses, and community liaisons could access patient health information and history. As our model depicted, each of these aforementioned individuals would have a role in the management of patients that would necessitate access to clinical information. To this end, physicians and APC’s would review vital signs and lab values to adjust medications accordingly, achieve appropriate metrics, and to guide certain patient-level educational objectives; pharmacists would ensure that patients filled prescriptions and took medications, had accurate and up-to-date medication lists, and screen for drug interactions; community liaisons might have more limited access, but still connected so that pharmacists, physicians, and APC’s could maximize the potential these individuals have in keeping patients engaged in the system and compliant with management programs prescribed by their providers.

In addition to providing essential information to providers, a connected care system should provide easier access and information delivery for patients. The system should provide an online menu or directory of care options and resources, including: support groups, educational tools and information, care facilities, pharmacies, exercise facilities, support and ancillary services, etc. Moreover, patients should be able to schedule and change appointments electronically, review the results of their diagnostic tests, and have access to appropriate educational tools for their disease-specific conditions. For example, if an individual with no insurance wanted to see where they could receive care for their high blood pressure within the community, a list of free clinics that mange blood pressure would be provided through this online menu/directory. Furthermore, the EMR/PHR should allow patients to empower themselves through self management of their medication condition(s) as discussed in the VIP model described above.

In addition to a county-wide health information technology infrastructure and a web-based directory of resources, there are certainly several components of the VIP model that would simultaneously satisfy the requirements of an effective connected care system that is applicable to a variety of diseases. Community coaches, patient-centered care sites, and group visits would give patients support and keep them engaged; incentives/rewards would promote self management; and the use of online tools, telemedicine, groups visits, increased use of APCs, and one-stop shopping for health care would improve systemic efficiency.

A connected health care delivery system would improve patient health care delivery and outcomes while decreasing the cost of chronic disease management. There is the potential to decrease clinic visits, decrease hospitalizations for vascular-related chronic illnesses, and more importantly, empower patients to better manage their health conditions and promote better partnerships between health providers and their patients. Introducing a community liaison, connecting providers (of all types) – with each other and with community liaisons - with patient health information and connecting patients with health resources in the community will not only make a more efficient and effective primary care health system, but also keep patients engaged and ultimately healthier.

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REFERENCES Alderman, L. (2009). PATIENT MONEY; Getting Healthy, With a Little Help From the Boss New York Times.

New York. American Heart Association, A. (2009). Heart Disease and Stroke Statistics: 2009 Update At-A-Glance. Appleby, J. (2009). Firms offer bigger incentives for healthy living. USA Today. Becker, D. M., L. R. Yanek, et al. (2005). "Impact of a community-based multiple risk factor intervention on

cardiovascular risk in black families with a history of premature coronary disease." Circulation 111(10): 1298-1304.

Bodenheimer, T., E. H. Wagner, et al. (2002). "Improving primary care for patients with chronic illness." JAMA 288(14): 1775-1779.

Car, J. and A. Sheikh (2003). "Telephone consultations." BMJ 326(7396): 966-969. Centers for Disease Control & Prevention, C. (2007). "State Program: North Carolina Basic Implementation."

Retrieved October 31, 2009, from http://www.cdc.gov/DHDSP/state_program/nc.htm. Centers for Disease Control & Prevention, C. (2008). National Vital Statistics Reports 56. Chobanian, A. V., G. L. Bakris, et al. (2003). "The Seventh Report of the Joint National Committee on Prevention,

Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report." JAMA 289(19): 2560-2572.

CKD, T. F. o. (2008). Addressing Chronic Kidney Disease in North Carolina. Task Force on Chronic Kidney Disease, NC Institute of Medicine.

Davidson, J. A., P. R. Moreno, et al. (2007). "Cardiovascular disease prevention and care in Latino and Hispanic subjects." Endocr Pract 13(1): 77-85.

DHI-VIP (2009). DHI-VIP data tables. Douglas, J. G., G. L. Bakris, et al. (2003). "Management of high blood pressure in African Americans: consensus

statement of the Hypertension in African Americans Working Group of the International Society on Hypertension in Blacks." Arch Intern Med 163(5): 525-541.

Durham County Health Department, T. P. f. a. H. D. (2007) "Durham County Health Assessment." Freeman, H. P., B. J. Muth, et al. (1995). "Expanding access to cancer screening and clinical follow-up among the

medically underserved." Cancer Pract 3(1): 19-30. Hajjar, I. and T. A. Kotchen (2003). "Trends in prevalence, awareness, treatment, and control of hypertension in the

United States, 1988-2000." JAMA 290(2): 199-206. Hawe, P. (1998). "Making sense of context-level influences on health." Health Educ Res 13(4): i-iv. Hillestad, R., J. Bigelow, et al. (2005). "Can electronic medical record systems transform health care? Potential

health benefits, savings, and costs." Health Aff (Millwood) 24(5): 1103-1117. HRSA (2006). The Rationale for Diversity in the Health Professions: A Review of the Evidence. Lattimer, V., F. Sassi, et al. (2000). "Cost analysis of nurse telephone consultation in out of hours primary care:

evidence from a randomised controlled trial." BMJ 320(7241): 1053-1057. Loftus, P. (2009). UnitedHealth discounts some drug co-pays. Down Jones News wires. McCarthy, D. F., K. (2007). Case study: University of Tennessee Health Science Center’s Telehealth Networks. Muldoon, M. F., S. B. Manuck, et al. (1990). "Lowering cholesterol concentrations and mortality: a quantitative

review of primary prevention trials." BMJ 301(6747): 309-314. O'Loughlin, J., L. Renaud, et al. (1998). "Correlates of the sustainability of community-based heart health

promotion interventions." Prev Med 27(5 Pt 1): 702-712. Oluwole, S. F., A. O. Ali, et al. (2003). "Impact of a cancer screening program on breast cancer stage at diagnosis

in a medically underserved urban community." J Am Coll Surg 196(2): 180-188. Peter H. Rossi, M. W. L., Howard E. Freeman (2004). Evaluation: A Systematic Approach. Thousand Oaks, Sage

Publications, Inc. Pinnock, H., R. Bawden, et al. (2003). "Accessibility, acceptability, and effectiveness in primary care of routine

telephone review of asthma: pragmatic, randomised controlled trial." BMJ 326(7387): 477-479. Rosamond, W., K. Flegal, et al. (2007). "Heart disease and stroke statistics--2007 update: a report from the

American Heart Association Statistics Committee and Stroke Statistics Subcommittee." Circulation 115(5): e69-171.

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Rosamond, W., K. Flegal, et al. (2008). "Heart disease and stroke statistics--2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee." Circulation 117(4): e25-146.

SCHS, S. C. f. H. S. (2002) "Selected Data on the Health of the Latino Population in North Carolina." U.S. Census Bureau, P. D. (2008). "Population, Durham County, NC." van Dam, H. A., F. G. van der Horst, et al. (2005). "Social support in diabetes: a systematic review of controlled

intervention studies." Patient Education and Counseling 59(1): 1-12. Williams, J. E., K. J. Anstrom, et al. (2007). "Racial/ethnic variation in perceptions of medical information sources

in Durham County, North Carolina." N C Med J 68(6): 391-398.

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Maps

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Maps (2)

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Appendix C – Figures & Tables Figure 1 – Environmental Risk Assessment

Figure 2 – Tiered Risk Intervention

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Figure 3 – Dual Risk Stratification

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Appendix D – VIP Team Structure