How ChristianaCare’s digital cardiac care program is closing racial gaps

March 25, 2024 - Healthcare organizations recognize that health inequities are detrimental to much-needed progress in clinical outcomes and care access nationwide. However, there is little agreement on how best to eliminate these inequities. Though virtual care technologies have been heralded for their ability to close some of the most trenchant care gaps, social determinants of health (SDOH) challenges and the digital divide can curb virtual care’s potential to make healthcare more equitable. Still, some organizations, like ChristianaCare, have successfully applied these tools to enhance clinical outcomes among underserved populations.

The Newark, Delaware-based health system announced last month that its digital hybrid care program has achieved its intended goal of improving heart failure and hypertension outcomes among Black patients.

The gap in cardiac care outcomes between Black and White populations is expansive. According to the US Department of Health and Human Services (HHS) Office of Minority Health, Black people were 30 percent more likely to die from heart disease than their White peers in 2019.

When it comes to heart failure and hypertension, this gap persists. Black patients have the highest risk of developing heart failure, and heart failure hospitalization rates within this population are two and half-fold higher than White patients, data published in 2022 reveals. Additionally, Black Americans are 30 percent more likely to have hypertension or high blood pressure than their White peers.

ChristianaCare saw similar disparities at the system level, stated Kirk Garrett, MD, medical director of the Center for Heart and Vascular Health and the John H. Ammon Chair of Cardiology at ChristianaCare.

“We had in the heart failure population the same phenomenon we see in almost every healthcare space, and that is marginalized people and folks of color have a much larger gap to fill than Caucasians,” he said in an interview with mHealthIntelligence.

This led the ChristianaCare Center for Heart and Vascular Health to partner with health technology services company Story Health to deploy a hybrid care approach that combines a digital platform and health coaches to support cardiac outcomes among the Black population.  

HEART FAILURE AND HYPERTENSION CARE FALLING SHORT

Heart failure occurs when the heart cannot pump enough blood and oxygen to support other body organs, according to the Centers for Disease Control and Prevention (CDC). While guideline-directed medical therapy (GDMT) is effective in reducing heart failure-related adverse events, it is underutilized among racial minority groups.

For instance, research shows that only 11 percent and 18 percent of eligible Black patients undergo GDMT with hydralazine and isosorbide nitrates and angiotensin receptor neprilysin inhibitors, respectively.

“Our performance with regard to getting patients with heart failure on to the medications that we knew would help them and getting them at doses of those medicines that we knew were needed…was superb, which is to say it was right in alignment with national averages, which is also a way of saying it was kind of awful,” Garrett said.

About 32 percent of ChristianaCare’s heart failure patient population identify as Black, making this health disparity significant.

Similar trends can be seen in hypertension care. The CDC states that hypertension, or high blood pressure (BP), occurs when the pressure of blood pushing against the walls of arteries increases. Hypertension can lead to heart disease, including heart failure and heart attacks.

Black patients have higher hypertension prevalence but lower blood pressure (BP) control rates compared to White patients. Data released in 2021 reveals that hypertension prevalence within the Black population was 45.3 percent versus 31.4 percent among White patients. However, BP control rates for Black patients averaged 39.2 percent compared to 49 percent among their White counterparts.

“We decided we needed to do better,” said Garrett. “We leaned into the tools that we had at our disposal, but we realized that the things that we had could get us a little further ahead on it, but they really weren't answering the call sufficiently.”

Thus, ChristianaCare struck a partnership with Story Health to employ a digital hybrid care approach to close the health disparity gap.

DEPLOYING A DIGITAL CARE PROGRAM TO CLOSE RACIAL GAPS

Managing chronic conditions like heart failure and hypertension typically involves frequent trips to the clinic to track health metrics and adjust medications and dosing as needed.

“It can take 12 steps of changes in order to get to the right treatment,” said Tom Stanis, co-founder and CEO of Story Health, in an interview with mHealthIntelligence. “Now, I can imagine, if you only see your cardiologist once every month to two months or something like that, [then it] is years before you can get to the right treatment, and even then, you may be hospitalized in between, and you're starting all over again. So, it's quite a challenge.”

This is the challenge Story Health’s digital hybrid care approach is designed to address. In this model, the clinician sets up a home treatment plan for the patient, using technology to connect with patients remotely. Clinicians can check in on patients virtually and adjust treatment plans as needed in addition to seeing them in the clinic.

Story Health also provides patients virtual access to health coaches who support them as they navigate their treatment plans. These coaches serve as an extension of the clinician, supporting medication adherence, coordinating lab work and transportation, and providing assistance with accessing prescriptions.

It is this human touch that makes the program successful, Garrett noted. While the technical pieces are crucial to facilitating interactions with patients, it is the interaction itself and the personal attention that boosts patient access, engagement, and outcomes.

“It’s the one-two punch of the improved access element,” he said. “The [Story Health] team is able to step in where my providers can't; they just don't have bandwidth or capacity to step in a way that this team does…And then the second is the tremendous help in arranging solutions to those impediments that exist for these patients.”

People experiencing SDOH challenges often face multiple hurdles to care. Stanis cited the example of one heart failure patient who was taking care of an elderly mother and a sister with cerebral palsy and working an hourly pay job. As a result, she could not come in regularly for her cardiology appointments. Instead of being labeled ‘non-compliant,’ which would have further hindered her access to care, the woman was enrolled in the digital hybrid care program. She became a model patient once the in-person clinic visit requirement was removed, Stanis said.

Furthermore, health coaches offer emotional support to patients having difficulty accepting their diagnosis or experiencing challenging side effects, Garrett said. This emotional support can help patients process their feelings and continue their care journey.

ChristianaCare and Story Health worked together to mitigate hurdles related to technology access and data sharing as they rolled out the program. To combat the former, communication with patients occurs over text messages. This alleviates the burden of patients having to download an app or figure out a new smartphone feature, Stanis said.

The Story Health platform is also integrated with ChristianaCare’s EHR so that progress made on the remote care side is reflected where health system clinicians can view it.

“That has been probably the biggest lift that we've had on the technology side in order to make sure that that's all one plan, not two separate things,” Stanis said.

The wraparound support from health coaches, continuous tracking of health metrics, and integration with the health system’s EHR to create a seamless care continuum were driving factors in ChristianaCare’s decision to partner with Story Health. And it appears to be paying off.

“We elected to develop this relationship with Story Health, and I think, as they say, the proof of the pudding is always in the eating,” said Garrett. “You see what results we're getting as a consequence of this relationship.”

CLINICAL OUTCOMES AMONG THE BLACK POPULATION

The digital hybrid care program targeting heart failure launched two and a half years ago. The results speak to the success of the approach, with increases in GDMT at appropriate doses among ChristianaCare’s Black heart failure patients.

The patients have achieved a six-fold improvement in target doses of beta blockers, a seven-fold improvement in target doses of angiotensin-converting enzyme/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitors, and a two-fold improvement in target doses of mineralocorticoid antagonists. The approach increased the appropriate use of sodium-glucose cotransporter-2 (SGLT2) inhibitors from 32 percent to 74 percent among Black patients.

Garrett further highlighted that the 30-day readmission rate for the Black population under the digital hybrid care program is less than half of the overall 30-day readmission rate for heart failure patients.

“I look at the data, and it's very difficult to avoid the conclusion that this program is extremely powerful in hitting important metrics for the organization as well as the patients,” Garrett said.

ChristianaCare is seeing similar improvements in hypertension outcomes among Black patients enrolled in the digital care program. Patients achieved a decrease of 17 mm Hg in average absolute systolic and 8 mm Hg in diastolic blood pressure levels after 120 days. These declines were more significant than the decreases of 8 mm Hg and 5 mm Hg among uncontrolled hypertension patients in another digital program after 12 months.

“And as a result of that, we'll see less heart failure,” Garrett said. “We'll see fewer heart attacks and strokes; we'll see less atrial fibrillation. Just a whole lot of things go away when we manage blood pressure.”

Though there has been some hesitation around adopting the digital hybrid care approach among ChristianaCare clinicians, particularly those outside the advanced heart failure care area, Garrett believes the clinical results will help drive broader buy-in. Not only that but digital care support and remote monitoring technologies can also alleviate chronic care burdens, which can, in turn, boost provider adoption.

As chronic disease management needs grow among the US population, particularly within underserved communities, Garrett notes that digital health approaches will be critical to expanding care access and enhancing outcomes.

“We've been able to see that in that group of minority patients — who historically really struggled to get to the levels of guideline-directed medical therapies that they need — we have been able to see remarkable results and really close the gap that has historically existed in that regard,” Garrett said.