There are six core tenets driving our approach.

These tenets merge several of the latest ideas coming out of health research. 

ONE>

The global non-communicable disease burden is growing.

These diseases, like hypertension and diabetes, have passed infectious diseases as the leading cause of death in the world.

THREE>

Technology and delivery can co-innovate.

These diseases, like hypertension and diabetes, have passed infectious diseases as the leading cause of death in the world.

FIVE>

Research on managing chronic cardiovascular disease focuses on a limited population.

These diseases, like hypertension and diabetes, have passed infectious diseases as the leading cause of death in the world.

TWO>

The new health care frontier is the community, not the hospital.

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FOUR>

Real-time analytics about delivery should be used to take action.

These diseases, like hypertension and diabetes, have passed infectious diseases as the leading cause of death in the world.

SIX>

There is an opportunity to move beyond traditional charity.

These diseases, like hypertension and diabetes, have passed infectious diseases as the leading cause of death in the world.

Where to start?

We propose establishing a community-based primary care system in villages in Punjab to template proactive detection and management of high blood pressure.

How will we do it?

We will train community health workers to use smartphones with an app that works with a bluetooth-enabled blood pressure cuff to conduct household level risk factor profiling and screenings for the entire adult population. The app will guide on the nuanced triage and management of cases based on the measured blood pressure. 

How does technology change case management?

Rather than binary ‘refer’ or ‘don’t refer’ decision support, the app will prompt different intervals of follow-up or referral based on evidence-based algorithms and integrated into a virtual cloud-based medical record for each patient. For cases that require repeat screening, the app will automatically schedule the follow-up visit.

For cases that require evaluation by a higher-level clinician for possible treatment, the app will guide the community health worker to refer the patient to the primary care clinic. If the patient is started on treatment, the platform will flag the community health worker to follow the patient up at the household level to ensure they are tolerating and adherent to the medications.

What about care in the community?

At the start, a specialist capable of treating high blood pressure and a nurse will staff the primary care clinic. The clinic will provide comprehensive primary care for all illnesses as well as manage referred cases of high blood pressure. Over time, the nurse or a non-specialist physician will use the app with a customized decision support algorithm to manage routine cases and only refer more complex and refractory cases to a specialist. If scheduled follow-up or clinic visits do not take place as scheduled, the cloud-based platform will flag the missed appointment to the community health worker and her supervisor so that patients can be proactively mobilized and do not slip through the cracks.

Where does patient data go?

Through the cloud-based platform, all patient-level epidemiological and systems-level process data will be captured and used to begin applying analytics to identifying where there are performance gaps, understanding how to customize implementation approaches, and delineating where unique strategies may be required for different segments of the population or particular types of patients.

What are the expected outcomes?

The initial pilot model will involve the clinic that provides comprehensive primary care and community health workers conducting household level screening and follow-up of hypertension. Once this model has been iterated and established, the community health workers can begin to take on additional diseases like diabetes and the clinic can begin to shift increasingly more routine management onto non-specialized staff.

Do you want to get involved? →

Across Sites

OPTIMIZE HEALTH

By cost-sharing and technical capacity building, Optimize Health can begin replicating and directly implementing similar approaches in others sites: contiguous villages in India, or other countries where the model could be adapted.

Healthcare Providers

CLINICIANS & INSURERS

Existing NGOs, private providers, and insurers to develop ways to scale up the work being done in the pilot site. These groups can be trained on the approaches being used and supported technically and managerially to implement strategies. 

Universal Coverage

PUBLIC & PRIVATE SECTOR

The Indian government is now initiating ‘Universal Health Coverage’ (UHC) pilots whereby, in select districts, public financing will be granted to non-governmental and private healthcare providers to deliver healthcare to the population. 

Dr. Ranvir Dhillon

JUGAAD

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