UC San Diego Health (UCSDH) is the only academic health system in the region. UC San Diego Health has provided patient care, biomedical research, education, and community service for 5 decades. January 2018 UCSDH launched an MSSP Accountable Care Organization (ACO) Track 1+ model called UC San Diego Health Accountable Care Network. The Network consists of UCSDH Faculty Practice Group, Affiliated Medical Groups, Affiliated Hospitals and Skilled Nursing Facility partnerships. Within this network are value based contracts totaling approximately 45,000 member lives. Population Health (PH) Services Organization supports this Network and consists of a team of RNs and Social Workers, Physicians and Nurse Practitioners, Care Navigators and community partnerships. The PH leadership are certified and employs the standards and practices as a foundation for staff. We are building a unique team who supports our primary care team based care with a focus on the Quadruple Aim. We understand the value of certification to demonstrate high staff performance and adherence to common standards. With disparate electronic health systems, new physician affiliates, and a diverse payer mix, the task of building an integrated, patient centered value based case management team requires an engaged, knowledgeable team with strong analytic support. Our ACO results for 2019 showed 93% of patients highly rated ACO providers, 97.5% improved health and quality scores and stabilized cost by saving $1.07 million. Integrated Health Care Association awarded us the top 10% for Clinical Quality in 2019. Overall we reduced avoidable admissions from 330 / K to less than 240 / K in 2 years. During the pandemic we ramped up our telephone outreach to our high risk vulnerable senior population. We engaged nursing students to help with this effort with a focus on ensuring patients has what they needed to stay safe and we worked with our palliative care to ensure that patients wishes were documented. In addition, we expanded our digital health home monitoring to help patients engage in self care and help our providers with Telehealth. Our concurrent session will cover 3 key objectives and will include breakout sessions where smaller groups can share their experiences, successes and challenges making this a shared learning session with group engagement.

OBJECTIVES:

1. Describe the journey of building a CM team (SW and RN) using CMSA Standard of Practice and team learning with multi-tiered patient option approach.
2. Describe the development of remote patient monitoring to address patients with hypertension during COVID–19; innovations, opportunities and challenges.
3. Identify resources for social determinants of health, community partnerships and approach to end of life.