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AllWays program finds at-risk patients, personalizes interactions

AllWays Health Partners is using advanced analytics to target patients with dangerously high blood pressure and cholesterol with personalized interventions.

AllWays—a Massachusetts-based health plan and member of Partners HealthCare —is using the approach to prevent heart attacks and strokes. It’s powered by an algorithm developed by Brigham Health’s Cardiovascular Medicine Innovation Group, and employs iHeart Champion, a remote medical management program.

According to Tony Dodek, chief medical officer at AllWays, the health plan piloted the program in 2015-2016 on approximately 1,000 Brigham Health patients, and the results were “quite striking,” he says.

iHeart Champion brought down blood pressure 20/10, with better outcomes and “patients and doctors loved it,” according to Dodek. Some 85 percent of the patients in the pilot were engaged in the program, and the result was an increase in medication compliance. The pilot program reported a 40 percent reduction in LDL cholesterol levels for patients in the program, who were treated with generic statins. iHeart Champion helped physicians know whether high blood pressure readings were a result of the patient being resistant to medication or if the patient just wasn’t complying.

Because the pilot was successful, AllWays has now extended the program to all 220,000 of its members, Dodek says. Patients who have not responded to diet and exercise interventions are identified by primary care physicians within the Partners system. iHeart Champion uses customized algorithms to scan electronic medical records to identify who would benefit from the program.

iHeart’s specially trained healthcare personnel, called “navigators,” serve as the point of contact between the patient and a team of pharmacists, nurse practitioners and a cardiologist assigned to their care. In addition to medication management, navigators also refer patients to AllWays Health Partners’ health coaches, who help members focus on a healthy lifestyle. “It’s a two-way referral network between the iHeart program and the health plan’s health coaches,” Dodek says.

According to Dodek, high blood pressure patients selected for the program get a blue tooth-enabled blood pressure cuff that sends the readings to the navigators, who use the program’s algorithms to make any needed adjustments via text and phone in the patients’ medications.

Efficiency is vastly improved in treating these patients, Dodek says. Normally, when patients are prescribed high blood pressure medicine, their physician has them keep a 12-week log and come back. If that’s not working, perhaps a second medication will be given for another 12-week trial period. iHeart Champion eliminates the months—and sometimes the years—that it takes to get blood pressure under control, he says. It also results in fewer medical appointments because management is done remotely.

The success of the iHeart Champion program is leading AllWays to consider similar remote programs for treating diabetes and congestive heart failure in the future, Dodek says. The health plan is also working on a way to give patients virtual physical therapy following knee replacement surgery.

This article was originally published by Health Data Management.

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