Healthfirst’s Best Life Initiative supports primary care teams to improve blood pressure, diabetes control among underserved patients

The Challenge

During the COVID-19 pandemic, people living with chronic conditions were at heightened risk of severe disease and mortality. These chronic diseases are commonly managed by primary care physicians (PCPs). However, PCPs and their teams are challenged by burnout and stress[3] and need additional support to help their underserved patients to reach their health goals.

Our Goal

We wanted to set up systems to reduce hypertension and improve diabetes management that would work in conjunction with our primary care teams, but outside of the clinic to reduce their workload and cognitive burden.

The Healthfirst Solution

The Best Life initiative was created to help primary care providers and their practices address the patients’ stress and social needs. If their primary care practices opted in to participate, Healthfirst would share detailed information concerning the health care access patterns of patients living with hypertension, diabetes, and obesity. Then, navigators from contracted community organizations would reach out to eligible Healthfirst members share relevant resources for each person such as health coaching and social services.

Population Health Improvements

Our pilot program showed promising exploratory results. Practices that enrolled in the initiative were more likely to control high blood pressure (69% vs. 57%) and meet hemoglobin A1C measures (56% vs. 45%) compared to practices that did not enroll. Notably, there was a change in blood pressure control among our enrolled Black members who began at 36% control (far below the Healthfirst average) and jumped to 62% control (exceeding the Healthfirst average).

Takeaway

Combining traditional in-patient primary care with health plan and community support systems may reduce provider burnout and lead to measurable improvements in the management of chronic disease for those at high-risk of disease progression. Healthfirst has identified this as rich area for additional research and intervention.

^[1] de Almeida-Pititto, Bianca, et al. "Severity and mortality of COVID 19 in patients with diabetes, hypertension and cardiovascular disease: a meta-analysis." Diabetology & metabolic syndrome 12 (2020): 1-12. Combining traditional in-patient primary care with health plan and community support systems may reduce provider burnout and lead to measurable improvements in the management of chronic disease among marginalized populations. Healthfirst has identified this as rich area for additional research and intervention.

^[2] Behavioral Risk Factor Surveillance System, 2015.

^[3] Arnetz BB, Goetz CM, Arnetz JE, Sudan S, vanSchagen J, Piersma K, Reyelts F. Enhancing healthcare efficiency to achieve the Quadruple Aim: an exploratory study. BMC Res Notes. 2020 Jul 31;13(1):362. doi: 10.1186/s13104-020-05199-8. PMID: 32736639; PMCID: PMC7393915

^[4] Nundy, Shantanu, Lisa A. Cooper, and Kedar S. Mate. "The quintuple aim for health care improvement: A new imperative to advance health equity." JAMA

327.6 (2022): 521-522.