P10,000

Challenge

Despite significant advancements in medical science and technology, a considerable portion of the global population still grapples with limited access to essential healthcare services. Socioeconomic factors, geographical disparities, and systemic disparities create challenging conditions for people to manage their conditions, contributing to the widening gap in health outcomes. Ongoing global health challenges, such as the COVID-19 pandemic, have further underscored the vulnerabilities within existing healthcare infrastructures, emphasizing the need for a more robust and accessible system.

What’s more, the World Economic Forum estimates the global cost of chronic diseases will reach $47 trillion by 2037, further creating financial burdens on an already-strained system.

As we navigate the complexities of modern healthcare, it becomes increasingly evident that creating a resilient network for people to be healthy at home is not just a desirable goal but an essential one.

Solution

Recognizing the critical need for a more holistic and patient-centric approach to healthcare, JCHI — in partnership with UC San Diego Health’s Population Health — is supporting and promoting the development of several innovative solutions for healthcare monitoring, communication, and information dissemination.

Called Project 10,000 (P10,000), the program aims to enroll 10,000 patients on EHR integrated digital health solutions in the next five years. The multi-modal program currently encompasses 11 initiatives covering chronic conditions, behavioral health, and post-acute care. The goal is to foster a healthcare environment where individuals with chronic conditions and mental health challenges receive the comprehensive support they need, while empowering patients to take an active role in managing their chronic conditions.

P10,000 builds upon the success of Project 1,000, a team-based telemonitoring program for poorly managed hypertension.

How it Works

• By harnessing novel and market-leading wearables, passive sensors, AI, mobile apps, texting, telemedicine, and more, Population Health provides end-to-end support to identify, enroll, activate, and engage our connected patients.

• Patients are empowered with the data and tools to better understand their current health status and actionable next steps
  
  
• Real-time population dashboards identify patients that need intervention by PharmD, MA, RN, MD, or other clinical care team members.

• Population Health staff provide remote and in-home enrollment, activations, and home visits across San Diego County.

• Bi-directional dataflow is actively supported on 60+ devices with compatibility on thousands more.

Key Projects

• The MoM-Health project, part of the NIH’s Multi-Omics for Health and Disease Consortium, aims to understand high blood pressure during and after pregnancy using innovative biological measures. Expected to conclude in Spring 2028, with recruitment ongoing through 2027, the study involves participants using at-home blood pressure cuffs linked to electronic medical records. This data will help identify high blood pressure and hypertensive disorders during pregnancy and postpartum. The ultimate goal is to develop predictive strategies and preventative therapies to enhance maternal health and reduce long-term cardiovascular risks.

• The UCSD-at-Home Program utilizes all-in-one remote monitoring kits for ER patients to provide home-based treatment under the care of the MD, RN, and MA team.

• Hypertension and Diabetes monitoring: Patients utilize blood pressure cuffs, blood glucose meters, continuous glucose meters, and AI applications for self-guided and managed chronic care management programs. These programs aim to provide precision care, such as for patients with Type 1 and 2 diabetes via a host of innovative integrated platforms, including real-time clinical decision support (CDS).

• Mental Health Mobile App: A cloud-based solution for patient-centered health and wellness that enables participants to proactively manage their chronic condition(s) and improve their health and wellness. The platform leverages AI and cognitive services to augment care team analysis and understanding of each patient, and enables collaborative, team-based care across multiple care settings.

• Nightingale Sensors: A non-contact bed sensor for chronic disease monitoring. The device, placed under a patient’s bed, achieves adherence-independent non-contact longitudinal physiological monitoring of total body weight, high fidelity respiratory signals, and BCG-derived heart rates. It also includes a web and mobile dashboard for self-review​, ultimately reducing barriers to care. Home health monitoring devices such as this one have the potential to improve outpatient management of chronic cardiopulmonary diseases such as heart failure.

Launch

The initial project launched in March 2020.

Partners

UC San Diego Health Population Health Services Organization, UC San Diego Jacobs School of Engineering, UC San Diego Health Sciences

Related Paper

https://​www​.ann​fammed​.org/​c​o​n​t​e​n​t​/​2​1​/​S​u​p​p​l​e​m​e​n​t​_​3​/5179

Building a more resilient and inclusive healthcare landscape calls for a concerted effort to dismantle barriers, reimagine healthcare delivery, and ensure no patient is left behind in the journey to thriving in good health within the comfort and safety of their own homes. To join our efforts or learn about how JCHI can help further your organization’s digital health products and services, please contact Jeffrey Pan, Co-Director JCHI, at jep041@​health.​ucsd.​edu.