Hypertension, more commonly known as high blood pressure, remains a leading population health concern, as it affects nearly half of all adults in the United States. It increases the risk of heart disease and stroke, two leading causes of death in the United States.

Our Hypertension Management initiative identifies and shares best practices to support blood pressure (BP) control and develop tailored health care strategies for populations to reduce differences in outcomes.

Each UC site developed and has been implementing site-specific plans for improving blood pressure control and targeting differences in outcomes across populations. In addition, UC clinical leaders identified key education videos that help patients manage their blood pressure. These videos were translated into patients’ preferred languages and culturally tailored to make sure the health information is understandable and relevant.

Over the past four years, blood pressure control rates have improved by 16 percent. The UC-wide rate of blood pressure control is better than 85 percent of comparable institutions in California.

Diabetes represents another major population health concern. Diabetes affects approximately 38.4 million people in the United States, or approximately 11.6 percent of the population. Diabetes can also increase the potential for complications like heart disease, stroke, peripheral artery disease, eye problems and kidney disease.

The UC Diabetes Management initiative works to identify, recommend and implement interventions to improve diabetes care and advance health care equity. UC locations have been implementing strategies to enhance access to advanced medications and improve medication adherence, with a particular focus on targeting disparities across populations. Also, UC clinical experts selected key diabetes education videos for translation to make them culturally relevant and language-specific for patients.

Blood sugar control across all our populations has increased by 14 percent over the past four years. The UC-wide rate of blood sugar control is better than 95 percent of comparable institutions in California.

As both an important component of UC population health initiatives and in its own right, social drivers of health (SDOH) comprise the social, economic and environmental factors that may contribute to a patient’s health outcomes. Work in this initiative has led to several advancements across seven primary SDOH areas (food, housing, utilities, transportation, social isolation, loneliness and financial strain). Through the initiative, a new SDPH screening tool kit has been launched, which results in improved identification of health-related social needs in our patients.

In addition, the initiative took action on social needs by the integration of two social care referral platforms — FindHelp and 211 — to connect patients in need with valuable community resources. It also continued to enhance partnerships with community-based organizations to ensure patients are connected to trusted, local support services.

This initiative focuses on improving access to adult and child influenza vaccinations as well as participating in the American Medical Group Association’s Rise to Immunize® campaign for adult vaccines, including Influenza, Pneumococcal, Td/Tdap, and Zoster, along with expanded reporting to both Respiratory Syncytial Virus (RSV) and COVID-19.

As a result, UC academic health centers were recognized as ranking among the top performers nationwide across these immunizations. This collective achievement demonstrates the UC system’s strong commitment to preventive care and its measurable impact on promoting health.

This initiative has a mission to deliver a systemwide approach to discover best practices and care models, innovate care coordination and transform how care is delivered across UC’s academic health centers. Its areas of focus to include innovations for: 

• care at home services
• vendor partnerships
• advanced care teams
• electronic medical record optimization
• opportunities for enhanced revenue
• patient navigation of mental health services

So far, the team has identified 22 strategies and shared best practices through its ongoing work.

This team focuses on three key strategies:

• improve the affordability of pharmaceutical therapy for all stakeholders (patients, health plans, and providers)
• improve pharmacy-related quality of care metrics (for example, medication adherence)
• integrate pharmacists and pharmacy technicians into team-based care

A focus of the work has been increasing the adoption of prescription biosimilars across UC’s health system to increase access to advanced therapeutics and lower the significant barrier of these costly drugs. Since its introduction, we’ve witnessed a 120 percent increase in advanced therapeutic use of these biosimilars.

To support the engagement, adoption and integration of biosimilar drugs, the team has employed several strategies, including: 

• hosting systemwide education and training sessions for clinicians, led by UC clinical experts, on managing prescription biosimilar therapies
• leveraging a shared decision-making framework with a focus on patient preferences and social drivers of health to improve the quality and satisfaction of biosimilars use
• using UC pharmacies and physician-pharmacist dyads as part of a successful team-based model

To date, the overall total cost-of-care savings from the initiative is approximately $2.3 million.

The initiative’s goal is improving the quality of cancer care for all our patients through metric-based quality-of-care-related projects. The focus of these efforts has included establishing best practices for standardizing documentation for advance care planning and documentation of goal-concordant care. Robust outcome measurements have included looking at utilization patterns in the last few months of life. The initiative has introduced two new access metrics: the time for a new patient to be seen by a cancer specialist and the time from referral to receipt of cancer-directed therapy. Reducing the time for a new patient with cancer to be seen is now a systemwide goal.

UC academic health centers perform some of the most challenging and complex cardiac surgery cases. Annually, UC’s health locations perform 2,500 routine and complex cardiothoracic operations.

The Cardiac Surgery Consortium is an example of a specialty care collaboration to improve clinical outcomes and create value for patients and payors. For example, a recent focus has been on patients' length of hospital admission (“length of stay”) for these complex procedures. We’ve recorded a reduction in hospital stays by the equivalent of 380 days, resulting in an estimated $1.2 million improvement in financial performance. 

The newest population health initiative has a primary goal of preparing UC academic health centers for success in the evolving environment of value-based models of care by participation in various alternative payment model (APM) contracts. The initiative team uses lessons learned from APM participation at each site to inform successful approaches that are adopted more broadly within UC. This includes ensuring the needed capabilities and services are developed to improve patient care and outcomes at a lower cost to patients and payors. These value-based care experts also serve as critical thought leaders and partners with their health system’s financial and contracting teams.